bluuebunny/crossref_metadata_2025 huggingface dataset:
Factors determining the use of NOACs vs. Warfarin in a Kenyan cohort of patients requiring anticoagulation
Authors: Mucyo W , Jeilan M , Varwani M H , Ngunga M
Published: October 2022

Background

Non-Vitamin K oral anticoagulants (NOACs) are widely used for stroke prevention in atrial fibrillation (AF) and prevention and treatment of venous thromboembolism (VTE). Apart from conditions in which warfarin is still the anticoagulant of choice, other factors may influence the choice between NOACs and warfarin.

Purpose

This study aims to determine factors associated with the use of NOACs as compared to warfarin in Kenya.

Methods

The Heart Registry Kenya is a prospective record of patients from two public hospitals and one private hospital in Kenya, with acute coronary syndrome, heart failure, AF, and VTE from 2020 to date. Data of patients with AF and VTE was analyzed to determine if demographic, clinical, or other non-clinical factors influence the choice of anticoagulants. The Chi-Square test was used to identify statistically significant associations between independent variables and dependent variables (NOACs or warfarin), with a 95% confidence interval.

Results

Data was collected on 452 patients (165 with AF and 288 with VTE) from 3 centers; the mean age was 51 years, and 61.7% were female. The proportions of patients on NOACs among AF and VTE patients were 60.5% and 57.5%, respectively (χ2: 0.122, p: 0.727). Proportions of patients on NOACs at public hospital number 1, public hospital number 2, and private hospital, were 37%, 50%, and 87.7%, respectively (χ2: 45.2, p: <0.001). The use of NOACs in low, mid-low, mid-high, and high income groups was 50.4%, 31.3%, 75%, and 88.2%, respectively (χ2: 23.4, p: <0.0001). There was no statistically significant association between the choice of anticoagulant and age, gender, race, renal function, indication for anticoagulation, use of antiplatelets, or extended anticoagulation therapy.

Conclusion

Patients with high socioeconomic status, as determined by monthly income and treatment facility, were more likely to be discharged on NOACs than warfarin. This may signal socioeconomic disparities affecting the treatment of AF and VTE in Kenya.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research Fund - The Government of Kenya
Aspirin therapy on prophylactic anticoagulation for hospitalized patients with COVID-19: a propensity score-matched cohort analysis of the HOPE-COVID-19 registry
Authors: Santoro F , Nunez Gil I , Vitale E , Perez-Villacastin J , Fernandez-Ortiz A , Brunetti N D
Published: October 2022

Background

COVID-19 is an infectious illness, featured by an increased risk of thromboembolism. However, no standard antithrombotic therapy is currently recommended for COVID-19 hospitalized patients. Aim of this study was to evaluate safety and efficacy of additional therapy with aspirin over prophylactic anticoagulation (PAC) in COVID-19 hospitalized patients and its impact on survival.

Methods

8168 patients hospitalized with COVID-19 were enrolled in a multicenter-international prospective registry (HOPE COVID-19). Clinical data and in-hospital complications, including mortality, were recorded. 344 patients with incomplete data were excluded. Study population included patients treated with PAC or with PAC and aspirin. A comparison of clinical outcomes between patients treated with PAC and PAC and aspirin was performed using an adjusted analysis with propensity score matching.

Results

Of 7824 patients, 360 (4.6%) received PAC and aspirin and 2949 (37.6%) PAC. Propensity-score matching yielded 298 patients from each group. Mean age was 73±11 years, 67% were male, prevalence of hypertension and diabetes was 79 and 33% respectively and 7.5% underwent invasive ventilation.

In the propensity score-matched population, cumulative incidence of in-hospital mortality was lower in patients treated with PAC and aspirin vs PAC (15% vs 21%, Log Rank p=0.01, Figure 1). At multivariable analysis in propensity matched population of COVID-19 patients, including age, sex, hypertension, diabetes, kidney failure and invasive ventilation, aspirin treatment was associated with lower risk of in-hospital mortality (HR 0.62, CI 95% 0.42–0.92, p=0.018).

Conclusions

Additional therapy with aspirin over PAC in COVID-19 hospitalized patients was associated with lower mortality risk in a propensity score matched population.

Funding Acknowledgement

Type of funding sources: None.
The role of cardiac magnetic resonance-based feature-tracking strain analysis in the differential diagnosis and prognostic assessment of patients with left ventricular hypertrophy
Authors: Dohy Z , Szabo L , Pozsonyi Z , Csecs I , Toth A , Suhai F I , Czimbalmos C , Szucs A , Kiss A R , Becker D , Merkely B , Vago H
Published: October 2022

Background

Cardiac magnetic resonance (CMR) examinations have an essential role in the diagnosis of myocardial diseases with left ventricular (LV) hypertrophy; however, limited data are available from CMR-based feature-tracking strain analysis in this patient population. The aim of our study was to investigate the differential diagnostic and prognostic importance of feature-tracking strain analysis in patients with LV hypertrophy caused by myocardial disease.

Methods

We investigated 404 patients who underwent CMR examination and were diagnosed with myocardial disease causing LV hypertrophy. Hypertrophic cardiomyopathy (HCM) was detected in 330 patients, cardiac amyloidosis (CA) in 46 patients, Fabry disease (FD) in 12 patients, and endomyocardial fibrosis (EMF) in 16 patients. LV strain analysis was performed with feature-tracking. Global longitudinal (GLS), circumferential (GCS) and radial (GRS) LV strain parameters were measured. Strain values for the six basal, six midventricular, and five apical segments were averaged to obtain regional longitudinal and circumferential strain values (basal LS, midventricular LS, apical LS, basal CS, midventricular CS, apical CS). The apex-to-base regional LS and CS ratios were calculated as apical LS/basal LS and apical CS/basal CS, respectively. To assess global dyssynchrony, mechanical dispersion (MD) was measured. The all-cause mortality of the patients was analyzed.

Results

In the differentiation of CA from HCM, GLS had the highest sensitivity with a cutoff of more than −23%, and basal LS and basal CS had the highest specificity with a cutoff of more than −16% and −38%, respectively (p<0.001). FD patients had the lowest longitudinal and circumferential MD values, meaning that compared to that of other patients with LV hypertrophy, global dyssynchrony is least pronounced in this patient population (p<0.01). EMF patients had impaired global and regional CS and the lowest apex-to-base CS and LS ratios. CA patients had the highest apex-to-base CS and LS ratios, suggestive of apical sparing (p<0.001). CA patients had the worst prognosis; the significant independent predictors of mortality were a diagnosis of CA, the LV stroke volume index and basal LS (p<0.01).

Conclusions

Myocardial diseases with left ventricular hypertrophy have remarkable differences in CMR-based strain characteristics which can be helpful in the differential diagnosis and provides incremental information on adverse outcomes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Development and Innovation Fund of Hungary, Ministry for Innovation and Technology in Hungary
Short dual antiplatelet therapy duration in high bleeding risk patients undergoing PCI for non-ST-elevation acute coronary syndrome
Authors: Cao D , Valgimigli M , Sartori S , Spirito A , Snyder C , Mehran R
Published: October 2022

Background

Patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) remain at increased risk of recurrent ischemic events. An abbreviated dual antiplatelet therapy (DAPT) duration as short as 1 month has been suggested for those at high bleeding risk (HBR). Whether the benefits of 1-month DAPT are preserved in HBR patients presenting with non-ST-elevation ACS (NSTE-ACS) is subject of debate.

Purpose

To assess the impact of NSTE-ACS presentation on the ischemic and bleeding outcomes of HBR patients undergoing PCI with a cobalt-chromium everolimus-eluting stent followed by a 1-month versus 3-month DAPT.

Methods

The XIENCE Short DAPT Program encompasses three prospective, international, single-arm studies evaluating the safety and efficacy of a 1-month (XIENCE 28 USA and Global) or 3-month (XIENCE 90) DAPT duration. The program enrolled HBR patients who had undergone successful XIENCE stent implantation for acute or chronic coronary syndrome (excluding ST-elevation ACS). Event-free subjects discontinued DAPT at 1 or 3 months post-PCI. The primary endpoint was the composite of all-cause death or myocardial infarction (MI), while the key secondary endpoint was Bleeding Academic Research Consortium (BARC) type 2–5 bleeding between 1 and 12 months post-PCI. Ischemic and bleeding events associated with 1-month versus 3-month DAPT were assessed according to clinical presentation using propensity-score (PS) adjustment.

Results

Out of 3,364 HBR patients (n=1,392 on 1-month DAPT and n=1,972 on 3-month DAPT), 1164 (34.6%) underwent PCI for NSTE-ACS. At 12 months, the risk of death or MI was similar between 1- and 3-month DAPT in patients with (adjHR 1.12, 95% CI 0.73–1.70) and without NSTE-ACS (adjHR 0.92, 95% CI 0.65–1.29; p-interaction = 0.33). Landmark analysis between 1 and 3 months post-PCI showed significant treatment effect modification according to clinical presentation (p-interaction = 0.03) with greater benefit of 1-month DAPT in stable patients. BARC 2–5 bleeding was consistently reduced in both NSTE-ACS (adjHR 0.58, 95% CI 0.38–0.90) and stable patients (adjHR 0.86, 95% CI 0.63–1.18; p-interaction = 0.15).

Conclusions

Among HBR patients undergoing PCI with an everolimus-eluting stent, 1-month compared with 3-month DAPT was associated with similar 1-year risk of ischemic events and reduced bleeding, irrespective of clinical presentation. Between 1 and 3 months post-PCI, however, stable patients seemed to derive greater net benefit from 1-month DAPT compared to those with NSTE-ACS.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott
CYP2C19 loss-of-function alleles and the use of omeprazole or esomeprazole increase the risk of cardiovascular outcomes in patients using clopidogrel – a real-world study
Authors: Ritvos M S , Rasanen M , Hayrynen S , Kiiski J I , Niemi M , Sinisalo J
Published: October 2022

Background

Patients carrying loss-of-function (LOF) variants of CYP2C19 or using the CYP2C19-inhibitors omeprazole or esomeprazole cannot fully bioactivate clopidogrel, and thus are lacking optimal thrombosis prevention. However, clopidogrel is a relevant alternative to ticagrelor due to its lower incidence of hemorrhagic events and lower cost.

Purpose

The purpose of this study was to investigate in a real-life prospective patient cohort how loss-of-function (LOF) CYP2C19 variants and omeprazole or esomeprazole influence the incidence of cardiovascular events (cardiovascular deaths, reinfarction and strokes) in patients using clopidogrel.

Methods

A cohort of prospective patients (N=1972) with acute coronary syndrome (ACS) (N=1302) or symptomatic chronic coronary disease (N=670) were followed for 365 days. Information of purchased prescription drugs, hospital discharge, and death registry was available for all patients. The patients were retrospectively genotyped for the CYP2C19*2, CYP2C19*3, and CYP2C19*8 LOF variants.

Results

A total of 608 (30.8%) patients carried CYP2C19 LOF alleles. During the 365 days follow-up, 252 patients had a recurring ischemic vascular event, either myocardial infarction (N=189), stroke (N=24) or cardiovascular death (N=39). Vascular events were significantly more frequent among carriers of CYP2C19 LOF alleles [14.8% (95% CI 11.7–17.8] than in non-carriers [10.8% (95% CI 9.0–12.6)], p=0.016. Omeprazole or esomeprazole use was similar among the LOF allele carriers and non-carriers, but inclusion of their use in the analysis strengthened the association. Vascular events were significantly more common in a composite group of carriers of CYP2C19 LOF alleles and non-carriers who were using omeprazole or esomeprazole than in non-carriers who were not using omeprazole or esomeprazole 14.8% (95% CI 12.2–17.3) vs 9.9% (95% CI 8.0–11.9) p=0.002. There was a tendency towards lower risk of hemorrhagic complications in carriers of LOF alleles than in non-carriers (p=0.07).

Conclusions

Patients with impaired clopidogrel bioactivation due to loss-of-function CYP2C19 variants or concomitant omeprazole or esomeprazole use are at increased risk of cardiovascular events. For relevant patient care both genetics and concomitant medication should be considered both in everyday patient care and further randomised studies.

Funding Acknowledgement

Type of funding sources: None.
Patents experiences of in-hospital telemetry monitoring
Authors: Holm M , Falun N , Bendz B , Fridlund B , Langorgen J , Norekval T M
Published: October 2022

Background

Telemetry monitoring is a cornerstone of care in in-hospital arrhythmia monitoring. Annually, a large number of patients experience arrhythmias that need to be monitored and treated during hospital stay. However, studies focusing on patients' experiences of telemetry monitoring are scarce.

Purpose

To explore and describe adult patients' experiences of in-hospital monitoring in a non-intensive care unit setting.

Methods

In-depth interviews with an inductive, explorative and descriptive design were performed before hospital discharge at two university hospitals in Norway. Twenty patients were purposefully selected. Inclusion criteria were; monitored for more than 72 hours, with at least one serious arrhythmia registered. A qualitative content analysis according to Graneheim and Lundman was performed revealing categories at a manifest level.

Findings

Patients were 25–83 years (mean 62), and had spent an average of 9 days on telemetry (3–14). Patients were monitored due to primary arrhythmia (9), STEMI (2), syncope (2), TAVI (1), acute heart failure (1), heart transplant (1), GUCH (1) and non-cardiac causes (3). Four main categories were revealed from the analysis. Firstly, patients' experienced to receive limited information related to the purpose and results of the monitoring. Communication with the staff and immediate response to arrhythmias were important factors to feel safe and taken care of during hospital stay. Secondly, patients experienced the monitoring system to be troublesome. The device and the wires attached made it challenging to maintain adequate hygiene. Patients also experienced sleeping problems related to both wires and disturbing alarms, and described pain in the neck due to the weight of the telemetry unit. Thirdly, patients' experienced a restricted range of activity. Patients experienced the restricted radius of movement as a feeling of security, even though patients also described uncomfortable feelings like “wearing an ankle brace”. Fourthly, patients' experienced uncertainty at hospital discharge as the telemetry monitoring was discontinued, especially if they still experienced arrhythmias.

Conclusion

The information provided to patients on telemetry monitoring is poor and there is need for a better system to carry the telemetry in order to ease mobilisation and facilitate good sleep. Patients need to be informed about the results of the telemetry monitoring, to help them to be familiar with their arrhytmia, and increase the experience of security after discharge.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): 1 Department of Health and Social Sciences at Western Norway University of Applied Sciences, Norway2 Department of Heart Disease, Haukeland University Hospital, Norway
Quality of life in patients with heart failure and improved ejection fraction: one year changes and prognostic implication
Authors: Gonzalez B , Zamora E , Rivas C , Pulido A , Crespo E , Velayos P , Diaz V , Altabella M , Bares D , Codina P , Domingo M , Santiago-Vacas E , Cediel G , Lupon J , Bayes-Genis A
Published: October 2022

Background

Inconsistent and controversial results have been reported about the association of quality of life (QoL) and left ventricular ejection fraction (LVEF) in patients with heart failure (HF). The 2021 universal definition of HF specifically describes the criteria for the patients with HF and improved LVEF (HFimpEF): HF with a baseline LVEF ≤40%, a ≥10 point increase from baseline LVEF, and a second measurement of LVEF >40%.

Purpose

1) To assess whether patients with HF and reduced LVEF (HFrEF) at first visit in an outpatient HF Clinic that fulfil the HFimpEF criteria one year later presented a higher improvement in QoL assessed by the Minnesota Living With Heart Failure Questionnaire (MLWHFQ) than those patients that did not fulfil HFimpEF criteria. 2) To assess the prognostic role of QoL on outcomes in HFimpEF patients.

Methods

In a prospective registry of real-life HF outpatients LVEF and QoL evaluated by MLWHFQ were assessed at first visit at the HF Clinic and at one year of follow-up.

Results

From August 2001 to August 2021, baseline and one year LVEF and MLWFQ scores were available in 1040 patients with an initial LVEF ≤40%. Table 1 shows baseline demographic and clinical characteristics of patients. In summary, mean age was 65.2±11.7 years, 75.9% of the patients were men, the main aetiology was ischaemic heart disease (52.9%) and patients were mostly in New York heart Association (NHYA) class II (71.1%) and III (21.6%). Baseline LVEF was 28.5% ± 7.3 and baseline MLWHFQ score was 30.2±19.5. At one year, mean LVEF increased to 38.0±12.2 while MLWHFQ scores improved to 17.4±16.0. There were 361 patients that fulfilled the HFimpEF criteria (34.7%). These patients significantly and markedly improved both LVEF (from 28.7±6.6 to 50.9±7.6, p<0.001) and QoL (from 32.9±20.6 to 16.9±16.0, p<0.001). Although in patients that did not fulfil the criteria of HFimpEF both LVEF (from 28.4±7.6 to 31.1±7.9, p<0.001) and QoL (from 28.7±18.8 to 17.6±15.9, p<0.001) also significantly improved, the improvement in QoL was significantly higher in HFimpEF patients (−16.0±23.8 vs. −11.1±20.3, p=0.001), taking into account that baseline MLWHFQ score was worse in HFimpEF patients (p=0.001). However, at one year QoL was similar when both groups were compared (p=0.50). MLWHFQ score at one year proved to be superior to QoL improvement (using a cut-off of at least 5 points) from the prognostic point of view.

Conclusions

QoL improved both in patients with and without HFimpEF criteria, and QoL perception at one year was similar in both groups, suggesting the influence of other factors other than LVEF in QoL perception. QoL at one year revealed to be superior to QoL changes from baseline from the prognostic point of view.

Funding Acknowledgement

Type of funding sources: None.
How to screen frailty in outpatients with heart failure: multimodality assessment vs. the Vulnerable Elderly Survey 13 (VES-13) scale
Authors: Roig T , Gonzalez B , Lopez Y , Rivas C , Arderiu A , Pulido A , Crespo E , Velayos P , Diaz V , Altabella M , Bares D , Barcelo E , Domingo M , Lupon J , Bayes-Genis A
Published: October 2022

Background

During two decades we have been screening fragility in outpatients with heart failure (HF) with a multimodality assessment using several geriatric scales, showing that frailty or fragility is frequent in HF patients, even in young patients, and we demonstrated that this identified fragility played an important prognostic role. Frailty is a medical syndrome with multiple causes and contributors that increases outpatients' vulnerability so a minimal stress can cause functional impairment, with a major risk of dependency, even death. Frailty can be reversible or attenuated by interventions. Nowadays several specific scales for fragility or frailty detection are widely available. One of them, the Vulnerable Elderly Survey 13 (VES-13) has scarcely been used in HF.

Purpose

To assess the prevalence of fragility in an outpatient HF Clinic at first visit using both the VES-13 scale and a multimodality assessment that includes Barthel index, OARS scale, Pfeiffer test, and abbreviated Yesavage Geriatric Depression Scale of 4 items (GDS), and compare the two approaches

Methods

Nurses fulfilled the scales with the patients at their first visit. An scoring ≥3 in the VES-13 scale and the presence of one of the predefined criteria in the multimodality assessment (Barthel <90; OARS score <10 in women and <6 in men; Pfeiffer Test score >3±1, depending on educational level; one positive depression response in abbreviated GDS; and age >85 years or nobody to turn to for help) were considered to have fragility for the purpose of the study.

Results

From March 2021 to December 2021, 136 patients were evaluated with the two fragility screening modalities (mean age 68.8±10.8 years, 64% men, 46% from ischaemic aetiology, 65.4%/27.9% in NYHA class II/III, LVEF 39.5% ± 13.4). VES-13 identified 51 (37.5%) patients with fragility, while the multimodality assessment detected 45 (33.6%) patients. Barthel index and depressive symptoms in the GDS were the most altered items (19 and 20 patients respectively) in the multimodality assessment. Concordance between VES-13 and multimodality assessment was 83.8%, but Cohen's Kappa was 0.65, not reaching the suitable level of 0.70.

Conclusions

VES-13 was capable of identifying a higher number of patients with fragility at first visit in the routine screening performed in an outpatient HF clinic, than the multimodality assessment used in the last decades. Follow-up of patients and further analysis will allow evaluating which of these two approaches adds more value for outcomes prediction.

Funding Acknowledgement

Type of funding sources: None.
The effects of illness perceptions on health-related quality of life in patients with atrial fibrillation
Authors: Holmlund L , Hornsten C , Hornsten A , Olsson K , Valham F , Hellstrom Angerud K
Published: October 2022

Background/Introduction

Health-related quality of life (HRQoL) in patients with atrial fibrillation (AF) is lower compared with the general population, healthy controls, and patients with other cardiovascular diseases. Many factors influence HRQoL in patients with AF negatively. Illness perceptions have been shown to be related to HRQoL in a number of diseases, but, the role of the effect of illness perception on HRQoL in patients with AF is lacking.

Purpose

The aim was to explore the relationship between illness perceptions and HRQoL in patients with AF.

Methods

The present study with a cross-sectional design included 167 patients with AF. Patients scheduled for cardioversion at a University hospital in Sweden, filled in self-reported, validated questionnaires. Illness perception was measured with the Revised Illness Perception Questionnaire (IPQ-r) and HRQoL was measured with the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmias (ASTA). The illness perception part of IPQ-r consists of seven dimensions (Timeline acute/chronic, Consequences, Emotional Representations, Personal control, Treatment control, Illness coherence, and Timeline cyclic). Dimensions of the IPQ-R with significant correlations with HRQoL were included in a multiple regression model.

Results

The participants consisted of 69.5% men and the mean age for the group was 68,8±10,4. The correlations for the dimensions of illness perception are presented in Table 1. The multiple regression analysis (Table 2) showed that Consequences (p<0,001) and Emotional Representations (p=0,003) were significantly associated with and adversely affected HRQoL. The model explained 35% of the total variance in HRQoL (R2= 0,350, p=0,001).

Conclusion(s)

Emotional representations such as anger, anxiety, depression, and the consequences that patients experience that the condition has on daily life, negatively affect patients with AF. The relationship between illness perception and quality of life, indicates that efforts to change illness perceptions can be useful in improving HRQoL. In addition to information, patients need to be given the opportunity to talk about the disease, about their feelings, and about the consequences that the disease has on daily life. A challenge for healthcare will be to design support for each unique individual based on their illness perceptions.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Forskningslyftet, Umea UniversityStrategic Research Area Health Care Sience (SFO-V)
Using a co-designed, self-delivered, Avatar-based patient discharge education application to improve acute coronary syndrome patient knowledge
Authors: Zhang L , Gallagher R , Du H , Barry T , Foote J , Clark R
Published: October 2022

Background

30-day rehospitalisation following heart event among acute coronary syndrome (ACS) patients remains high and is largely contributed by poor disease-related knowledge and self-management, especially in the disadvantaged patient groups such as those with low education levels and inadequate health literacy. Traditional patient education methods fail to address these issues.

Purpose

This study aimed to test a unique consumer co-designed discharge education application (app) on patients' knowledge and its acceptability.

Methods

ACS patients (unstable angina, non-STEMI or STEMI) were recruited from Royal Adelaide Hospital at South Australia during admission, provided with the app via tablet for one-month self-delivered education. The app has undergone a rigorous development process with the substantial engagement of consumers (Figure 1). App content includes the Heart Foundation Six Steps to Cardiac Recovery including disease-related knowledge, risk factor management, and ACS responses, assessed at baseline, followed by first use at discharge and one month later. Patients and cardiac nurses rated the acceptability of the app.

Results

Among 22 Participants 81.8% were male (n=18), with a mean age of 59.7 (10.3) years, 45.5% (n=10) had not completed high school and nearly a quarter of the participants had marginal or below marginal health literacy. The diagnosis included STEMI (n=16, 72.7%) and non-STEMI (n=5, 22.7%). The majority of participants underwent percutaneous coronary intervention (PCI) (n=21, 95.5%)

Significant improvements were observed for overall coronary artery disease knowledge at one month (p=0.003) and the exercise and nutrition domains at discharge (p=0.029; p<0.001) and one month (p=0.02; p=0.003) (Figure 2). Significant improvements were also observed for ACS knowledge and beliefs at discharge (p=0.008; p=0.038) and one month (p<0.001; p=0.025) when ACS response attitude was also significantly improved at one month (p=0.036). Overall acceptability was high at 7.7/10 (n=22 nurses) and 8.3/10 (patients). The participants described the app as `clear, simple, easy to understand, as well as stimulating and interactive, better than a live person'.

Conclusion

This novel, self-delivered Avatar-based ACS discharge education App has the potential to provide discharge education for ACS patients even for those who have low education levels or inadequate health literacy. Results need to be confirmed in a randomised controlled trial.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The National Heart Foundation Australia
Is there an inter-manufacturer difference in generic clopidogrel response?
Authors: Hall S , Xia Y , Ahmed H , Iskhakov D , Alviar C , Berger J , Keller N , Bangalore S
Published: October 2022

Background

Differences in platelet aggregation response to generic clopidogrel by manufacturer has not been investigated.

Purpose

Compare rates of clopidogrel response among patients receiving medication produced by two different manufacturers after acute coronary syndrome and/or percutaneous coronary intervention.

Methods

This quality improvement project included 515 adult patients receiving clopidogrel for acute coronary syndrome or ischemic heart disease and referred for coronary angiography/percutaneous coronary intervention at a large, public hospital. The project was divided into two phases: 1. retrospective collection of baseline data; 2. two 12-week, prospective phases in which all clopidogrel in the hospital was restricted to a single manufacturer at a time. The primary outcome was clopidogrel response measured by platelet function testing defined as ADP response <40% on light transmission aggregometry between two manufacturer groups. Aspirin response defined as arachidonic acid response <20% was also measured.

Results

Of 515 total patients included in both phases (mean [SD] age, 64.5 [11.4] years; 351 [68.2%] men; 450 [87.4%] ACS), 52% were found to be clopidogrel responders based on results of platelet function testing (Table 1 – select variables). Among 135 patients in the prospective phase, there was a significantly lower proportion of patients who were clopidogrel responders in the Manufacturer 1 group compared to the Manufacturer 2 group (34.8% vs. 55.1%, p=0.03) (Table 2 – select variables). After adjustment for age, sex, BMI, aspirin response, therapeutic hypothermia, LHC indication, clopidogrel loading dose, time between loading dose and lab measurement, and manufacturer, aspirin response (OR [95% CI]: 0.96 [0.95–0.97], p<0.001) and manufacturer (OR [95% CI]: 2.45 [1.18–5.22], p=0.02) were associated with clopidogrel response.

Conclusions

In a large public hospital, we observed that pharmacodynamic response to clopidogrel varied by drug manufacturer. Further investigation and/or regulation is needed to minimize inter-manufacturer variability.

Funding Acknowledgement

Type of funding sources: None.
Incremental prognostic value of stress CMR for cardiovascular risk stratification after a cryptogenic ischemic stroke
Authors: Pezel T , Toupin S , Sanguineti F , Kinnel M , Hovasse T , Unterseeh T , Champagne S , Garot P , Garot J
Published: October 2022

Background

One-third of ischemic strokes are “cryptogenic” without clearly identified etiology. Although coronary artery disease (CAD) is the main cause of death after stroke, the interest of CAD screening in patients with cryptogenic stroke is still debated.

Purpose

The aim of the study was to assess the incremental prognostic value of stress cardiovascular magnetic resonance (CMR) beyond traditional risk factors for predicting cardiovascular events in patients with a prior cryptogenic ischemic stroke.

Methods

Between 2008 and 2021, consecutive patients with prior cryptogenic strokes referred for stress CMR were included and followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction (MI). Univariable and multivariable Cox regressions were performed to determine the prognostic value of unrecognized MI and silent ischemia.

Results

Of 542 patients (55.2% male, mean age 71.4±8.8 years) who completed the follow-up (median 5.9 years), 66 (12.2%) experienced MACE. Silent ischemia and unrecognized MI were detected in 18% and 17% of patients, respectively. Using Kaplan-Meier analysis, silent ischemia and unrecognized MI were associated with the occurrence of MACE (hazard ratio, HR: 8.43 [95% CI: 5.11–13.9]; HR: 7.87 [95% CI: 4.80–12.9]; respectively, p<0.001). In multivariable analysis, silent ischemia and unrecognized MI were independent predictors of MACE (HR: 8.08 [95% CI: 4.21–15.5]; HR: 6.65 [95% CI: 3.49–12.7]; respectively, p<0.001). After adjustment, stress CMR findings showed the best improvement in model discrimination and reclassification above traditional risk factors (C-statistic improvement: 0.13; NRI=0.428; IDI=0.048).

Conclusions

In patients with prior cryptogenic stroke, stress CMR findings have an incremental prognostic value to predict MACE over traditional risk factors.

Funding Acknowledgement

Type of funding sources: None.
The association between fitness measurement and cardiac rehabilitation completion
Authors: Alotaibi J , Doherty P
Published: October 2022

Background

Assessing functional capacity for patients entering a CR programme is strongly recommended by various organisations. Based on the result of this assessment, the intensity of exercise is prescribed, the risk is stratified and by the end of the programme, the effectiveness of the exercise intervention is evaluated [1]. However, despite the recommendations relating to assessing patients' level of functional capacity prior to the programme and following it, less than one -third of CR patients undertook this test [2].

Aims

The aim of this study was to examine the association between whether the patient's fitness is measured at bseline assessment and the completion of their Cardiac Rehabilitation (CR) programme.

Method

A retrospective observational study using data from 102 CR centres from January 2015 to April 2016 was conducted to address this aim. Logistic regression was used to investigate the association and taken into account some factors including age, gender, Body Mass Index (BMI), employment status, total number of comorbidities

Results

Data relating to 31,433 patients (mean age of 65.20±11.80 years, 73% of whom were male) was analysed. Out of the total number of patients, 9,785 (31%) undertook a fitness assessment at baseline. Patients whose fitness was measured were 48% more likely to complete their CR programme compared to those whose fitness was not measured.

Conclusion

Patients are more likely to complete CR if their fitness is measured at baseline which represents one the largest modifiable service-level characteristics reported in CR

Funding Acknowledgement

Type of funding sources: None.
Incremental prognostic value of stress CMR in symptomatic patients with coronary stenosis on CCTA
Authors: Pezel T , Hovasse T , Lefevre T , Sanguineti F , Champagne S , Benamer H , Neylon A , Toupin S , Garot P , Chevalier B , Garot J
Published: October 2022

Background

Noninvasive functional imaging is often performed in patients with obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CCTA). However, the prognostic value of stress cardiovascular magnetic resonance (CMR) is unknown in patients with coronary stenosis of unknown significance on CCTA.

Purpose

To assess the prognostic value of stress CMR in symptomatic patients with obstructive CAD of unknown significance on CCTA.

Methods

Between 2008–2020, consecutive symptomatic patients without known CAD referred for CCTA were screened. Patients with obstructive CAD (at least 1 ≥50% stenosis on CCTA) were further referred for stress CMR and followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction.

Results

Of 2,210 patients who completed CMR, 2,038 (46.5% male, mean age 69.8±12.2 years) completed follow-up (median 6.8 [IQR 5.9–9.2] years); 281 experienced a MACE (13.8%). Inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with MACE (HR: 4.51, [95% CI: 3.55–5.74]; and HR: 3.32, [95% CI: 2.55–4.32], respectively; p<0.001). In multivariable Cox regression, number of segments with >70% stenosis, with noncalcified plaques and number of vessels with obstructive CAD were prognosticators (p<0.001). The presence of inducible ischemia and LGE were independent predictors of MACE (HR: 3.97, [95% CI: 3.43–5.13]; HR: 2.30, [95% CI: 1.52–3.33]; p<0.001). After adjustment, stress CMR showed the best improvement in model discrimination and reclassification above traditional risk factors and CCTA (C-statistic improvement: 0.04; NRI=0.421; IDI=0.047).

Conclusions

In symptomatic patients with obstructive CAD of unknown significance on CCTA, stress CMR had incremental prognostic value to predict MACE.

Funding Acknowledgement

Type of funding sources: None.
Can artificial intelligence prediction of successful atrial fibrillation catheter ablation therapy be interpretable?
Authors: Ogbomo-Harmitt S , Muffoletto M , Zeidan A , Qureshi A , King A , Aslanidi O
Published: October 2022

Background

Radiofrequency catheter ablation (RFCA) therapy is the first-line treatment for atrial fibrillation (AF), the most common type of cardiac arrhythmia globally. However, the procedure currently has low success rates in dealing with persistent AF, with a reoccurrence rate of ∼50% post-ablation. Therefore, artificial intelligence (AI), particularly deep learning (DL), has increasingly been applied to improve and optimise treatments for AF. However, AI is limited by its black-box nature. Therefore, a factor hindering the broad clinical application of DL in AF is the lack of assurance that the DL model is using physiological relevant features when making its prediction. In order to provide this assurance, its decision process needs to be interpretable and have biomedical relevance.

Aim

This study aims to explore interpretability in DL prediction of successful ablation therapy for AF and evaluate if pro-arrhythmogenic regions in the left atrium (LA) were used in its decision process.

Methods

LA models with segmented fibrotic tissue were derived from 122 late gadolinium-enhanced magnetic resonance (LGE MR) images of persistent AF patients. To increase the dataset size, an additional 199 synthetic LA tissue models were generated from the LGE MR images. Two ablation strategies were simulated: fibrosis-based ablation (FIBRO) and a rotor-based ablation (ROTOR). RFCA strategy success was determined by its ability to terminate persistent AF in 2s with less than 40% of the tissue ablated [1]. A convolutional neural network (CNN) was developed to predict the success of each RFCA strategy, and gradient weighted class activation maps (GradCAM) were used to assess if the CNN was using locations of pro-arrhythmogenic regions in its decision process on an independent test set of 50 LA tissue models.

Results

For predicting the success of the FIBRO strategy, the CNN model had an AUC (area under the receiver operating characteristic curve) of 0.92±0.02, recall of 0.89±0.03 and precision of 0.82±0.02. For the ROTOR strategy, the AUC was 0.77±0.02, the recall was 0.93±0.04 and the precision was 0.76±0.02. Finally, the independent test set's GradCAM saliency maps showed that 62±25% and 71±13% of ablation lesions (known from the LA model simulations, but unseen by the CNN during training) coincided with informative regions in the saliency maps for the FIBRO and ROTOR strategies, respectively (Figure 1).

Conclusion

The most informative regions of the saliency maps coincided with the successful ablation lesions, suggesting that the DL model was able to identify ablated pro-arrhythmogenic regions by leveraging structural features of LGE MR images. In the future, this technique could provide a clinician with a decision support tool and increase confidence in the AI prediction.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): UK Medical Research Council
Neuronal nets and logistic regression analysis provide improved prediction of infective endocarditis compared to the modified Duke Score: a post-hoc analysis of the prospective PRO-ENDOCARDITIS study
Authors: Vogel L , Dykun I , Totzeck M , Rassaf T , Mahabadi A
Published: October 2022

Introduction

The modified Duke score is the currently recommended diagnostic algorithm in suspected infective endocarditis (IE). The categorization in major and minor criteria enables an easy clinical application, but may not optimally utilize individual patient's information. In contrast, detailed statistical evaluation of multiple characteristics using artificial intelligence and logistic regression report improved prediction of various cardiovascular diseases over conventional clinical strategies. We tested the hypothesis that neuronal nets and logistic regression analysis would provide improved prediction of IE as compared to the modified Duke score.

Methods

This post-hoc evaluation of the prospective observational PRO-ENDOCARDITIS study was conducted at the West German Heart and Vascular center between December 2017 and May 2019 and includes 261 patients. Duke criteria and clinical characteristics were prospectively collected. Transesophageal echocardiography (TEE) imaging was evaluated by a blinded cardiologist at a central core-lab. IE as primary endpoint was adjudicated by an independent clinical endpoint committee. The database was divided into a training (70%) and validation cohort (30%). We compared the value of the Duke score, neuronal nets and logistic regression analysis for prediction of the primary endpoint.

Results

The mean age was 60.1±16.1 years, 37.2% were female. In 47 cases, IE was present. The modified Duke score achieved an AUC of 0.863 in the training cohort and 0.913 within the validation cohort. The logistic regression and the neural net exceeded the predictive value in both cohorts (training cohort: 0.992 and 0.986; validation cohort: 0.964, 0.957; for logistic regression and neuronal nets, respectively, Figure 1). Without the use of TEE, the remaining Duke criteria only poorly predicted IE (training cohort: 0.771, 0.951 and 0.938; validation cohort: 0.835, 0.862 and 0.780, for the Duke score, logistic regression and neuronal nets, respectively).

Discussion

Logistic regression analysis and neuronal nets provide improved prediction of IE as compared to the clinically established modified Duke score. Further studies on larger databases are needed to confirm our results and provide algorithms for clinical routine.

Funding Acknowledgement

Type of funding sources: None.
Deep learning-based electrocardiogram analysis detecting paroxysmal atrial fibrillation during sinus rhythm in patients with cryptogenic stroke: validation study using implantable cardiac monitoring
Authors: Jeon K H , Kwon J M , Lee M S , Cho Y J , Oh I Y , Lee J H
Published: October 2022

Background

Atrial fibrillation (AF) is the most cause of cardioembolic source causing cryptogenic stroke. In these, anticoagulation therapy could reduce recurrence of stroke. However, paroxysmal AF would not be detected even by 24 hours Holter monitoring. Deep learning-based electrocardiogram (ECG) analysis models were recently developed to detect AF during sinus rhythm.

Purpose

We aimed to develop a deep learning algorithm (DLA) to detect AF during sinus rhythm and validate the model in patients with cryptogenic stroke who underwent implantable cardiac monitoring (ICM) to diagnose paroxysmal AF.

Methods

This cohort study involved three hospitals (A, B, and C). We developed a DLA to detect AF using sinus rhythm 10 s 12-lead ECG. We included adult patients aged ≥18 years from hospital A and B. We used development data from AF adult patients who had at least one atrial fibrillation rhythm in the study period (Jan 2016 to Dec 2021) and non-AF patients who had no reference to AF in the ECG and electronic medical record. DLA was based on convolutional neural network (CNN) using 10 s 12-lead. For external validation, the ECGs from 217 patients (hospital C) with cryptogenic stroke who underwent ICM were analyzed by using the DLA for validating the accuracy in the real-world clinical situations.

Results

We included 10,605 AF adult patients and 50,522 non-AF patients as development data. During the internal validation, the area under the curve (AUC) of the final DLA based on CNN was 0.793 (95% Confidence interval 0.778–0.807). In external validation data from cryptogenic stroke patients, the mean ICM duration was 15.1 months, and AF >5 mins was detected in 32 patients (14.5%). The diagnostic accuracy of DLA was 0.793 to detect AF during sinus rhythm, and AUC was 0.824. The sensitivity, specificity, positive predictive value, and negative predictive value of the model were 0.844, 0.784, 0.403, and 0.967, respectively, which outperformed other conventional predictive methods based on clinical factors, such as CHARGE-AF, C2hest, and HATCH.

Conclusions

In this study, DLA accurately detected paroxysmal AF using 12-leads normal sinus rhythm ECG in patients with cryptogenic stroke and outperformed the conventional models. The DLA could be used as a screening tool to identify the cause of stroke in the future.

Funding Acknowledgement

Type of funding sources: None.
PMHnet-alpha: development and validation of a neural network based discrete-time survival model for mortality prediction in ischemic heart disease
Authors: Holm P , Haue A D , Westergaard D , Banasik K , Koeber L , Brunak S , Bundgaard H
Published: October 2022

Background

Current risk prediction models in ischemic heart disease (IHD) use a small set of well-known risk factors, have limited predictive capabilities, and are largely the same as they were twenty years ago.

We developed and externally validated PMHnet-alpha, a neural-network based survival model for risk-stratification in ischemic heart disease that leverages the multitude of clinical features available in modern electronical health records.

Methods

We included 39,746 IHD patients from the regional Heart Registry that had been subjected to a coronary angiography between 2006 and 2017 with confirmed coronary artery disease.

Clinical data was extracted from the Danish National Patient Registry, and electronic health records.

595 different features, consisting of diagnosis codes, procedure codes, biochemical test results, and clinical measurements were used as model inputs.

Prior to model development, patients were randomly divided into a training set (n=34,746) and a tesing set (n=5,000).

The testing set was not used for model development.

Model performance was evaluated at six months, one years, three-, and five years of follow-up using time-dependent ROC curve analysis and Harrels' C-index.

Lastly, we also assessed the calibration of the model.

We benchmarked the performance of PMHnet-alpha against the GRACE Risk Score 2.0, which is widely considered to the best-performing model in current clinical use.

We explored the importance of individual features using SHAP values on the trained models.

Findings

PMHnet-alpha had very high model discrimination on the testing data with time-dependent AUCs of 0.88 (95% CI 0.86–0.90) at six months, 0.88 (95% CI 0.86–0.90) at one year, 0.84 (95% CI 0.82–0.86) at three years, and 0.82 (95% CI 0.80–0.84) at five years.

The discrimination of the benchmark model GRACE2.0 on the same data was considerably lower, 0.77 (95% CI 0.73–0.80) at six months, 0.77 (95% CI 0.74–0.80) at one year, and 0.73 (95% CI 0.70–0.75) at three years.

PMHnet-alpha is undergoing external validation in other nordic countries.

We identified that on-average, age, coronary pathology and smoking status were the most impactful features.

Interpretation

Here we present a significant improvement of the state of the art in cardiac risk prediction.

PMHnet-alpha supports better and optimized use of available healthcare data, signified by the vast improvement compared to GRACE2.0.

This also signifies an important paradigm shift in which data-driven strategies are necessary to transform the increasing amount of data generated in the modern healthcare system into evidence-based clinical decision making.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Novo Nordisk Foundation, NordForsk