bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of antiarrhythmic drugs on atrioventricular conduction in patients with preexisting bundle branch block
Authors: Kochav S , Chen R.C , Dizon J.M.D , Reiffel J.A.R
Published: November 2020

Background

Theoretical concern exists regarding AV block (AVB) with class I antiarrhythmics (AADs) when bundle branch block (BBB) is present. Whether this is substantiated in real-world populations is unknown.

Purpose

To determine the relationship between type of AAD and incidence of AVB in patients with preexisting BBB.

Methods

We retrospectively studied all patients with BBB who received class I and III AADs between 1997–2019 to compare incidence of AVB. We defined index time as first exposure to either drug class and excluded patients with prior AVB or exposed to both classes. Time-at-risk window ended at first outcome occurrence or when patients were no longer observed in the database. We estimated hazard ratios for incident AVB using Cox proportional hazards models with propensity score stratification, adjusting for over 32,000 covariates from the electronic health record. Kaplan-Meier methods were used to determine treatment effects over time.

Results

Of 40,120 individuals with BBB, 148 were exposed to a class I AAD and 2401 to a class III AAD. Over nearly 4,200 person-years of follow up, there were 22 and 620 outcome events in the class I and class III cohorts, respectively (Figure). In adjusted analyses, AVB risk was markedly lower in patients exposed to class I AADs compared with class III (HR 0.48 [95% CI 0.30–0.75]).

Conclusion

Among patients with BBB, exposure to class III AADs was strongly associated with greater risk of incident AVB. This likely reflects differences in natural history of patients receiving class I vs class III AADs rather than adverse class III effects, however, the lack of worse outcomes acutely with class I AADs suggests that they may be safer in BBB than suspected.

Funding Acknowledgement

Type of funding source: None
Prevalence of drug-drug interactions for oral anticoagulant drugs in patients with atrial fibrillation and relationship with outcomes: a population-based cohort study
Authors: Proietti M , Cortesi L , Spagnoli F , Nobili A , Marengoni A
Published: November 2020

Introduction

The introduction of non-vitamin K antagonist oral anticoagulants (NOACs) changed the treatment of atrial fibrillation (AF) patients, promising a better safety profile and a lower chance of interaction with drugs than vitamin K antagoniste (VKA).

Aim

To evaluate the prevalence of possible drug-drug interactions (DDIs) in a cohort of newly anticoagulated AF patients, their impact on outcomes and possible differences between VKA and NOACs users.

Methods

We performed an analysis derived from administrative databases in Lombardy Italian region. All patients ≥40 years admitted from 01/06/2013 to 30/06/2018 with an AF diagnosis that were VKA or NOACs new users were included in this analysis. Possible DDIs were evaluated according to the prescription of OAC therapy, on the basis of current available evidence. Stroke, intracerebral hemorrhage (ICH), any bleeding and all-cause death were the study outcomes.

Results

Among the 122816 patients included in the analysis, mean (SD) age 76.3 (9.6) with 47.3% females, a mean (SD) CHA2DS2-VASc of 3.5 (1.4) was found. A total of 70180 (57.1%) patients were prescribed with VKA and 52636 (42.9%) with NOACs. A possible DDI was recorded in 63273 (51.5%). Patients exposed to DDIs were older and less likely female (both p<0.0001) and with a higher mean (SD) CHA2DS2-VASc (p<0.0001). Rate of stroke, ICH, any bleeding and all-cause death were higher in those patients exposed to DDIs (all p<0.001). After full adjustment, exposure to possible DDIs was associated with an increased risk for any bleeding (HR: 1.08, 95% CI: 1.05–1.12) and all-cause death (HR: 1.10, 95% CI: 1.07–1.13), with no differences for stroke and ICH. Comparing VKA and NOACs patients exposed to possible DDIs, we found that VKA users exposed to possible DDIs, after adjustments, were at higher risk for all the outcomes (Table).

Conclusions

In a large cohort of AF patients newly prescribed with OAC, possible DDIs were largely prevalent, in particular in VKA users. Presence of a possible DDI is associated with an increased risk of any bleeding and all-cause death. VKA users exposed to a possible DDI were at higher risk for any outcome than NOACs users exposed to a possible DDI.

Funding Acknowledgement

Type of funding source: None
Association between digoxin use and sudden cardiac death in individuals with the rs10494366 variant of the NOS1AP gene
Authors: Soroush N , Aarnoudse A , Shokri F , Van Den Berg M , Ahmadizar F , Stricker B
Published: November 2020

Background

Digoxin is one of the oldest cardiovascular medications still used to treat heart failure and atrial fibrillation. Due to its narrow therapeutic window, it is associated with life threatening intoxication and arrhythmias, and with QTc-shortening. Common genetic variation in the nitric oxide synthase-1 adaptor protein (NOS1AP) has been associated with QTc interval prolongation.

Purpose

We investigated whether the rs10494366 variant of the NOS1AP gene modified the risk of SCD in patients using digoxin.

Methods

In a prospective population-based cohort study, we included data of the three cohorts, started as of January 1st, 1991 until January 1st 2014. Digoxin current use on the date of cardiac death in cases and the same day of follow-up in the remainder of the cohort was a time-dependent exposure. The main outcome was SCD defined as sudden and unexpected death as a result of cardiac causes, according to international criteria. Identification and adjudication of SCD was performed independently, before the start of this study. We used Cox proportional hazard regression analysis to investigate the associations between NOS1AP rs10494366 variant and incident SCD among digoxin users compared to non-users. Associations were adjusted for age, sex (model 1) in addition to BMI, prevalent diabetes, myocardial infarction, baseline hypertension and smoking status (past, current, never) (model 2).

Results

We included 14,594 individuals, with a mean age of 65.3 (SD 10.3) years. Almost 59% were female. The cumulative incidence of SCD was 9.5% (609 cases) by the end of follow up. Among them, 98 (16%) individuals were exposed to digoxin at the time of death.

In model 1, NOS1AP rs10494366 variant was not associated with SCD in the total study population. However, an interaction term of the gene with the daily dose of digoxin was significantly associated with increased risk of SCD (p-value 0.0001). In model 2, the risk of SCD in current users of digoxin was 4.2 [95% CI 1.3–13.8] for the GG genotype; 2.1 [95% CI 1.1–4.2] for the GT genotype, and 1.5 [95% CI 0.7–3.2] for the TT genotype.

Conclusion

NOS1AP rs10494366 variant modified the risk of sudden cardiac death in users of digoxin. Our study suggests that individuals with the homozygous minor GG allele have a fourfold increased risk of sudden cardiac death.

Funding Acknowledgement

Type of funding source: None
Work environment and nurse outcomes: a secondary analysis from the RN4CAST@IT study
Authors: Zanini M , Bagnasco A , Dasso N , Catania G , Sasso L
Published: November 2020

Introduction

Nursing care in cardiology requires advanced skills, continuity of care and global care of the chronic patient. The relationship with the patient requires a psychological and moral commitment which, combined with time-pressure and high workloads, increases the risk of negatively impacting nurses' well-being. Emotional exhaustion in nurses has negative consequences on care, therefore nursing leaders should monitor this outcome and ensure that its incidence is limited.

Purpose

To test the relationship between the nursing working environment and emotional exhaustion among nurses in cardiology wards.

Methods

The data are drawn from the database of the larger study, RN4CAST@IT. This was a multi-center and multi-level study.

A convenience sample of nurses providing bedside care was included. For the analyses presented here, the data relating to nurses working in Cardiology wards were extracted.

The data were collected through a web survey between September and December 2015.

The questionnaire investigated several topics about nursing staff including nurse-patient ratios, skill mix, working environment measured with PES-NWI, and emotional exhaustion with the Maslach Burnout Inventory.

Descriptive statistical analyses were conducted to describe the sample and variables taken into consideration; a binomial logistic regression model was built to test the relationships between the dependent variable “high Emotional Exhaustion;' and the independent variables “PES-NWI composite score”, “workload” and “skill mix”.

Results

Responses by 291 cardiology nurses were analysed. Binary logistic regression, adjusted for skill mix and staffing, showed that, better working environment conditions reduced the risk that nurses working in the cardiology develop high Emotional Exhaustion by 96% (OR 0.038; 95% CI 0.011–0.136).

Conclusions

Considering the relationship that these analyses have shown between a favourable working environment, capable of involving professionals, of providing adequate resources and leadership, and the risk that professionals may develop a high level of emotional exhaustion, we need to reflect how it impacts on patients. These results are the starting point for analysing the organization of clinical contexts, with their peculiarities, to make them more and more suitable for people, both patients and professionals.

Funding Acknowledgement

Type of funding source: None
Pharmacological Restoration of mOod in HEART Failure: outcomes of the PRO-HEART trial
Authors: Hare D.L , Toia D , Stewart A.G , Toukhsati S
Published: November 2020

Background

Depression is common in chronic heart failure (CHF) patients and is associated with increased morbidity and mortality. Anti-depressant medication has shown benefits in coronary artery disease but efficacy has not been demonstrated in CHF patients.

Purpose

To assess whether escitalopram is more effective than placebo in treating major and/or minor depression in patients with CHF.

Methods

This was a randomized, placebo-controlled, double-blind, parallel group study. Adult patients with systolic CHF (NYHA Class ≥2, nadir LVEF <40%) were screened for depression using the Cardiac Depression Scale (CDS) for a score ≥95 (sensitivity 97% at 85% specificity for major Depression (MDD)) followed by a clinical diagnosis of major or minor depression using the SCID interview. Patients were randomised to active escitalopram or matching placebo for 6 months, stratified for major or minor depression. Blinded therapy started with 5mg with automatic uptitration to 10mg after 2 weeks and further uptitration to 20mg at 2 months if CDS score remained ≥95. The primary end-point was change in CDS score over 6 months with secondary end-point change in Hamilton Depression Rating Scale (HAM-D).

Results

Of 28 CHF patients (males = 25; mean age = 63.61±10.32), mean CHF diagnosis 5.8 years, ischaemic aetiology (n=18), entry LVEF 42.2±9.6%; eGFR 61.8±15.4, 14 were diagnosed with major and 14 with minor depression. Two-way Mixed Model ANOVA showed a significant improvement from baseline to 6 months in both CDS (F(1,25)=18.76, p<0.001) and HAM-D (F(1,25)=17.32, p<0.001), but no significant interaction between condition and change over time. Three-way Mixed Model ANOVA showed no interaction between baseline depression diagnosis (Major or Minor) and response to treatment by condition. There were 7 SAEs for hospitalisation, unrelated to study medications and no differences between groups on AE/SAEs.

Conclusions

Patients showed a significant improvement in depression with both placebo and active drug but with no benefit of escitalopram over placebo. This suggests that there is no additional benefit from antidepressant therapy for CHF patients beyond that conferred by placebo. Further research is needed to explore whether greater benefits might be achieved by combination therapies or in particular subgroups of depressed CHF patients.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): National Heart Foundation of Australia, Beyond Blue
Opportunities to reduce the risk of stroke in AF: the REVIEW AF study
Authors: Gallagher C , Wong C.X , Hendriks J.M , Nyfort-Hansen K , Rowett D , Bednarz J , Elliott A.D , Linz D , Middeldorp M.E , Mahajan R , Lau D.H , Sanders P
Published: November 2020

Background

Stroke is one of the most devastating complications of atrial fibrillation (AF) and is associated with poor patient outcomes. Recent registry data has demonstrated improved use of stroke prevention therapy with the advent of direct-acting oral anticoagulants, but little data exists in the Australian health care setting.

Purpose

To examine the use of oral anticoagulant therapy in a cohort of individuals presenting to the emergency department (ED) due to AF.

Methods

A total of 437 consecutive individuals who presented to the ED with a primary diagnosis of AF to three tertiary hospitals in our city in South Australia between March 2013 and March 2014 were included. Data were collected retrospectively from electronic medical record review. CHA2DS2-VASc and HAS-BLED scores were calculated and any documented contraindications to the use of oral anticoagulation (OAC) taken in to consideration.

Results

Mean age was 69±15 years and 49.9% were male. A total of 244 (55.8%) individuals had a prior diagnosis of AF at index presentation. 179 (73.4%) of these individuals recorded a CHA2DS2-VASc score of ≥2. A total of 124 of these individuals were appropriately anticoagulated (69.3%) whilst 37 individuals were not treated with OAC and did not have a documented contraindication (20.7%). Anticoagulation status was unknown in 18 individuals due to a lack of documentation (10.0%). A CHA2DS2-VASc score of 0 was recorded in 25 individuals with a prior diagnosis of AF at index presentation with 3 individuals (12%) inappropriately overtreated with OAC. The remaining 193 individuals (44.2%) presented with a first episode of AF. In 129 (66.8%) of these individuals a CHA2DS2-VASc score of ≥2 was recorded and only 10 individuals had a documented contraindication to the use of OAC. In 119 (61.7%) individuals there were no documented contraindications to the use of OAC. In 74 (62.2%) of these presentations OAC was not commenced, whilst in 45 (37.8%) individuals OAC was prescribed.

Conclusions

Significant opportunity exists to improve the use of stroke prevention therapy in AF. Despite repeated opportunities to commence this therapy within the hospital setting, it remains frequently underutilised in individuals at high risk of stroke.

Funding Acknowledgement

Type of funding source: None
Impact of radial compression protocols on the compression time and radial artery occlusion
Authors: Takamatsu S , Kagiyama N , Shiomi T , Mizobuchi M , Sone N , Tougi K , Yamauchi S , Yuri T , Fukuyama S , Shibata M , Nakazawa R , Ii N , Masutani M , Hirohata A
Published: November 2020

Background

Trans-radial access (TRA) has been established as a safe and established approach for invasive coronary catheter procedures. However, protocols for post-procedural hemostasis varies depending on institutes and an evidence-based protocol is lacking.

Purpose

The objective of this study was to investigate the clinical implications of procedural hemostasis.

Methods

Consecutive patients who were referred to outpatient catheter examination before and after April 2018 were treated with an old and a new protocol, respectively. In both protocols, we used the same commercially available hemostasis band with injecting an air of 16 ml for hemostasis. In the old protocol, the amount and timing of deflation were fixed, whereas the air was removed as much as possible for every 30 minutes in the new protocol. Time to complete hemostasis, the rate of major bleeding, and the rate of radial artery occlusion (RAO) at 6 months after the catheter examination were compared between the protocols.

Results

Total of 1,843 (71±10 years old, 77% male) patients was included in the study. Between patients in the old and the new protocol group (n=1,000 and 843, respectively), there was no significant difference in age, gender, body size, or systolic blood pressure. The new group had significantly higher prevalence of diabetes (47% vs 39%, p=0.002), slightly larger sheath size (4.1±0.3 vs 4.0±0.2 Fr, p<0.001), and lower rate of dual antiplatelet therapy (DAPT: 24% vs. 35%, p<0.001). Time for complete hemostasis was about one-third with the new protocol compared with the old protocol (65±32 vs. 190±16 min, p<0.001) and there was no major bleeding in either group. The rate of radial artery occlusion was 0.7% and 9.8% in the old and the new group (p<0.001). Multivariate analysis showed that the significant predictor of prolonged hemostasis time were the old protocol (odds ratio: OR 80.5, p<0.001) and the prescription of DAPT (OR 2.9, p<0.001), while the factors associated with higher risk of radial occlusion were the old protocol (OR 13.9, p<0.001), the number of previous TRA (OR 1.1, p<0.001), and smaller body size (OR 0.127 per 1 m2 increase p=0.005).

Conclusions

Our new protocol for hemostasis after TRA was strongly associated with shorter hemostasis time and a lower rate of radial artery occlusion. This approach will decrease the post-procedural hospital time with even fewer complication rates.

Study outline

Funding Acknowledgement

Type of funding source: None
Psychosocial factors predict type 2 diabetes mastery
Authors: Ski C , McGuigan K , Hill A , Coates V , Thompson D.R , O'Kane M , McCay D
Published: November 2020

Background

Psychosocial aspects of chronic diseases such as Type 2 diabetes (T2D) and cardiovascular disease (CVD) are increasingly recognised as impacting effective self-management. Until now, little was known regarding the moderating effects of empowerment and depression on the relationship between diabetes-specific distress and mastery.

Purpose

To evaluate the potential mediating role of diabetes empowerment and depression on the relationship between diabetes-specific distress and mastery.

Methods

Sample comprised 131 participants diagnosed with T2D, mean [SD] age 62.3 [8.8]; 59.5% male. Mean time since diagnosis was 10.4 years. Assessments included: emotional distress (Problem Areas in Diabetes Scale; PAID); depression and anxiety (Hospital Anxiety and Depression Scale; HADS); mastery (Pearlin Mastery Scale); and empowerment (Diabetes Empowerment Scale – Short Form; DES-SF). Data were examined using SPSS: PROCESS a logistic regression-based path analytical framework for multiple mediator models.

Results

Regression coefficients for the model identified distress (b=−0.249, t(5,112)=−3.71, p<0.001), empowerment (b=0.280, t(5,112)=3.02, p<0.001) and depression (b=−0.980, t(5,112)=−5.73, p<0.001) were all statistically significant predictors of mastery. The PROCESS model assessed ΔR2 as a result of the interaction between distress and depression, which indicated a significant increase (ΔR2=0.08) in variance explained due to the inclusion of both moderators: F(2,112)=16.88, p<0.001, ΔR2=0.14. Also identified were interaction effect sizes: at low levels of empowerment, increasing depression led to increasing levels of distress predicting overall levels of mastery. This held true at moderate and high levels of empowerment; increasing levels of depression led to increasing distress predicting mastery.

Conclusions

These findings elucidate the impact of empowerment and depression on the association between distress and mastery in a diabetes cohort. The evidence suggests that the psychosocial interventions likely to have greatest impact on mastery are those that target key moderators such as empowerment and depression.

Funding Acknowledgement

Type of funding source: None
Reliability of low electrocardiogram sampling frequencies for short-term heart rate variability analysis to estimate transient psychophysiological stress induced by car driving
Authors: Brisinda D , Fenici R
Published: November 2020

Background

Heart rate variability analysis (HRVa) is increasingly used to evaluate stress-induced adaptation of the autonomic nervous system (ANS), basing on electrocardiogram (ECG) recorded with novel wearable wireless devices (WWD) for physiological monitoring. However, in order to transfer ECG data to mobile phones efficiently, WWD use low sampling frequency (SF), usually ∼100 Hz, thus much lower than the 0.5–1 kHz, previously suggested to optimize R–R intervals detection, precise enough for HRVa in the time-domain (TD), frequency-domain (FD) and with nonlinear (NL) methods. Moreover, the latter are sensitive to SF as a function of data length.

Aim

Aim of this study was to quantify the relative error (RE%) of HRVa, when calculated from ECG downsampled at 100 Hz, compared with that digitized at 1 kHz, considering different data lengths.

Methods

ECG of four healthy professional pilots was continuously recorded with a WWD (Vi-grade, Udine), at 1 kHz SF, while driving a professional simulator, inducing different degree of psychophysiological stress by changing suddenly the vehicle's behavior without advising the driver.

TD, FD and NL HRV parameters were calculated (Kubios 3.0.2, Finland), from time intervals of 300, 120, 60 and 30 seconds, of ECG downsampled at 100 Hz SF from original recordings acquired at 1 kHz SF (assumed as goldstandard). The RE% and the intraclass correlation coefficient (ICC) were calculated.

Results

A good correlation (ICC ≥0.79–0.84) was found for the majority of HRV parameters, in both driving conditions, for all selected intervals lengths. The average RE% ranged between zero and 3%, increasing if the length of the interval selected for HRVa was lower than 60 second (Table 1). However higher RE was occasionally found. In Figure 1, an example of HRVa calculated from 2 minutes tachogram's segments, at 100 Hz (left) and at 1 kHz SF (right) is shown.

Conclusions

Compared to 1 kHz SF, downsampling ECG at 100 Hz doesn't affect significantly HRVa for data lengths between 5 and 1 minutes. However, for shorter time intervals the RE increases. This must be taken into account if HRVa is used to track transient short-lasting changes of ASN modulation induced by acute stress.

Figure 1

Funding Acknowledgement

Type of funding source: None
Distinguishing sinus rhythm from atrial fibrillation on single-lead ECGs using a deep neural network
Authors: Oudkerk Pool M , De Vos B.D , Wolterink J.M , Blok S , Schuuring M.J , Bleijendaal H , Dohmen D.A.J , Tulevski I.I , Somsen G.A , Mulder B.J.M , Pinto Y , Bouma B.J , Isgum I , Winter M.M
Published: November 2020

Background

The growing availability of mobile phones increases the popularity of portable telemonitoring devices. An atrial fibrillation diagnosis can be reached with a recording of 30s on such telemonitoring devices. However, current commercially available automatic algorithms still require approval by experts.

Purpose

In this research we aimed to build an artificial intelligence (AI) algorithm to improve automatic distinction of atrial fibrillation (AF) from sinus rhythm (SR), to ultimately save time, costs, and to facilitate telemonitoring programs.

Methods

We developed a deep convolutional neural network (CNN), based on a residual neural network (ResNet), tailored to single-lead ECG analysis. The CNN was trained using publicly available single-lead ECGs from the 2017 PhysioNet/ Computing in Cardiology Challenge. This dataset consists of 60% SR, 9% AF, 30% alternative rhythm, and 1% noise ECGs. The 8528 available ECGs were divided into a training (90%) and validation set (10%) for model development and hyperparameter optimization.

Results

The trained CNN was applied to an independent set containing single-lead ECGs of 600 patients equally divided into two groups: SR and AF. Both groups comprised of 300 unique ECGs (SR; 60% male, 63±11 years, AF; 38% male, 56±14 years). In distinguishing between AF and SR, the method achieved an accuracy of 0.92, an F1-score of 0.91, and area under the ROC-curve of 0.98.

Conclusion

The results demonstrate that distinguishing SR and AF by a fully automatic AI algorithm is feasible. This approach has the potential to reduce cost by minimizing expert supervision, especially when extending the algorithm to other heart rhythms, like premature atrial/ventricular contractions and atrial flutter.

Figure 1. ROC curve

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Dekkerbeurs - Hartstichting
Deep-learning-based artificial intelligence algorithm for detecting anemia using electrocardiogram
Authors: Jeon K.H , Kwon J.M , Kim K.H , Kim M.J , Lee S.H , Baek S.D , Jeung S.M , Park J.S , Choi R.K , Oh B.H
Published: November 2020

Background

Anemia changed the morphology of electrocardiography (ECG), and researchers suggested that mismatching oxygen demand and supply in the myocardium affects the ECG

Purpose

A deep-learning-based algorithm (DLA) that enables non-invasive anemia screening from electrocardiograms (ECGs) may improve the detection of anemia.

Methods

A DLA was developed using 57,435 ECGs from 31,898 patients and was internally validated using 7,369 ECGs from 7,369 patients taken at one hospital. External validation was performed using 4,068 ECGs from 4,068 patients admitted at another hospital. Three types of DLA were developed using 12-lead ECGs to detect hemoglobin levels of 10 mg/dL or less. The DLA was built by a convolutional neural network and used 500-Hz raw ECG, age, and sex as input data.

Results

During internal and external validation, the area under the receiver operating characteristics curve (AUROC) of the DLA using a 12-lead ECG for detecting anemia was 0.941 and 0.904, respectively. Using a 90% sensitivity operating point, the specificity, negative predictive value, and positive predictive value of internal validation were 0.889, 0.998, and 0.151, respectively, and those of external validation were 0.785, 0.994, and 0.166, respectively. The predicted Hgb level based on the DLA was correlated with the actual Hgb level (r=0.891, 95% CI 0.890–0.893, P<0.0001). 57 patients of moderate to severe anemia were treated with appropriated blood transfusion and predicted DLA score of most patients who received transfusion decreased after transfusion according to increase in hemoglobin level.

Conclusion

In this study, using raw ECG data, a DLA accurately detected anemia. The application of artificial intelligence to ECGs may enable screening for anemia.

Correlation between DLA and actual Hb

Funding Acknowledgement

Type of funding source: None
Comparison of wavelet continuous transform and signal averaged ECG for high frequency content and late potential detection in healthy individuals
Authors: Garcia Iglesias D , Rubin Lopez J.M , Perez Diez D , Moris De La Tassa C , De Cos Juez F.J , Calvo Cuervo D
Published: November 2020

Introduction

The Signal Averaged ECG (SAECG) is a classical method forSudden Cardiac Death (SCD) risk assessment, by means of Late Potentials (LP) in the filtered QRS (fQRS)[1]. But it is highly dependent on noise and require long time records, which make it tedious to use. Wavelet Continuous Transform (WCT) meanwhile is easier to use, and may let us to measure the High Frequency Content (HFC) of the QRS and QT intervals, which also correlates with the risk of SCD [2,3]. Whether the HFC of the QRS and QT measured with the WCT is a possible subrogate of LP, has never been demonstrated.

Objective

To demonstrate if there is any relationship between the HFC measured with the WCT and the LP analyzed with the SAECG.

Methods

Data from 50 consecutive healthy individuals. The standard ECG was digitally collected for 3 consecutive minutes. For the WCT Analysis 8 consecutive QT complexes were used and for the SAECG Analysis all available QRS were used. The time-frequency data of each QT complex were collected using the WCT as previously described [3] and the Total, QRS and QT power were obtained from each patient. For the SAECG, bipolar X, Y and Z leads were used with a bidirectional filter at 40 to 250 Hz [1]. LP were defined as less than 0.05 z in the terminal part of the filtered QRS and the duration (SAECG LP duration) and root mean square (SAECG LP Content) of this LP were calculated. Pearson's test was used to correlate the Power content with WCT analysis and the LP in the SAECG.

Results

There is a strong correlation between Total Power and the SAECG LP content (r=0.621, p<0.001). Both ST Power (r=0.567, p<0.001) and QRS Power (r=0.404, p=0.004) are related with the SAECG LP content. No correlation were found between the Power content (Total, QRS or ST Power) and the SAECG LP duration. Also no correlation was found between de SAECG LP content and duration.

Conclusions

Total, QRS and ST Power measured with the WCT are good surrogates of SAECG LP content. No correlation were found between WCT analysis and the SAECG LP duration. Also no correlation was found between the SAECG LP content and duration. This can be of high interest, since WCT is an easier technique, not needing long recordings and being less affected by noise.

Funding Acknowledgement

Type of funding source: None
The value of a novel model of remote monitoring alert classification of cardiac implantable devices
Authors: Mendez Zurita F , Grande Osorio M , Gonzalez Matos C , Rodriguez Font E , Guerra Ramos J , Alonso Martin C , Campos Garcia B , Moreno Weidmann Z , Ramirez De Diego I , Bote Collazo M , Paz Jaen E , Velasco Nieves A , Mogro Carranza J , Garcia Mancebo S , Vinolas Prat X
Published: November 2020

Introduction

Remote monitoring (RM) is commonly used in the follow-up of patients with cardiac implantable devices (CID). However, there are a significant amount of automatic alerts of low clinical relevance. An alert classification model designed to optimize the management of RM alert in CID receivers can improve the analysis.

Purpose

Assess the effectiveness of a local protocol for review and classification of MR alerts.

Methods

Retrospective study, single center. We included all patients with ICD +/− CRT in the RM program between september 2016 and december 2019. All transmission received were analyzed. The priority of the transmissions was established based on clinical criteria and device parameters, classified into 3 categories from lowest to highest priority: green, yellow and red. Each category involved a specific action protocol (Figure 1). The categorization by colors was initially carried out by a remote support center, based on data from the devices; and later, reviewed by arrhythmia nurse team who incorporated clinical information data. In case of discrepancy, the alert was again evaluated together with the cardiologist. The degree of concordance in the categorization of alerts was analyzed, as well as the transmission response time (TRT): support center- care team.

Results

In our center a total of 1013 patients were included (68±14 years old, 76% male), who completed 8755 remote transmissions. The initial classification of transmissions by the support center was: 6890 (78.7%) green, 1497 (17.1%) yellow and 368 (4.2%) red. Only 0.62% of transmissions required reclassification by the healthcare team. No alert initially classified as yellow or green should be reclassified to red. The TRT was 3.35 hours for the red transmissions and 5.6 hours for the yellow ones.

Conclusion

The categorization of alerts in our RM system allows an efficient and safe organization of assitance to patients with CID.

Funding Acknowledgement

Type of funding source: None
Cuffless systolic and diastolic blood pressure estimation at the wrist via an optical device: comparison to intra-arterial measurements
Authors: Pellaton C , Vybornova A , Fallet S , Marques L , Grossenbacher O , De Marco B , Chapuis V , Olivero E , Bertschi M , Alpert B.S , Sola J
Published: November 2020

The diagnosis and management of hypertension usually requires the estimation of blood pressure (BP) by means of an inflatable cuff. This procedure generates discomfort and limits patient compliance. Cuffless devices capture BP readings without performing any arterial occlusion. We believe that comfortable and cuffless BP monitoring devices can significantly aid in the fight against hypertension and support the expansion of ambulatory and remote patient monitoring programs, provided that these devices provide reliable BP readings.

The purpose of this study was to compare the systolic (S) and diastolic (D) blood pressure (BP) estimations from a new optical device at the wrist (figure) against invasive measurements performed on patients scheduled for radial arterial catheterization. The first results from this study were recently published and demonstrated good agreement for the overall study population. Here we report expanded statistical analyses for different population subgroups such as gender, age, body mass index (BMI) and skin color.

The study protocol consisted of the simultaneous recording of reflective photo-plethysmographic signals (PPG) from the optical device, and BP values recorded by a contralateral radial arterial catheter. The PPG signals were processed to generate estimates of SBP and DBP. Agreement of paired BP estimations was further calculated in terms of standard deviation (SD) of differences. The mean of differences were systematically zero because BP estimations from the optical device were calibrated for each patient.

The table shows that, for the overall population, both SBP and DBP differences SDs were smaller than 8 mmHg (as already published). Furthermore, across different population groups, both genders, all BMIs and all skin colors also resulted in SDs smaller than 8 mmHg. Only patients whose age was above 65 years were associated with a higher SD.

For the overall population and most subgroups the new optical technique appears to be capable of replacing more traditional methods of BP estimation. Only the SBP differences for the subgroup of older patients were larger. Additional studies are needed to confirm and expand these very encouraging results.

Table 1. SD of measured BP differences Population N SD of SBP differences SD of DBP differences (mmHg) (mmHg) All 16 7.1 2.9 Gender Male 10 6.4 2.8 Female 6 8.0 3.1 Age (years) <65 7 4.0 2.3 >65 9 *9.3 3.4 BMI (kg/m2) <26 10 7.9 2.9 >26 6 5.7 2.8 Skin Color (Fitzpatrick) 2 13 7.7 3.0 3 3 4.5 2.6 *Only subgroup with a SD larger than 8mmHg.

Figure 1. The investigational device

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Aktiia SA
A novel approach using hand-held echocardiography to guide the diagnosis of heart failure in pregnant women in a low-resource setting; Maternal and Perinatal Health Research Collaboration
Authors: Alsharqi M , Arnold L , Dockerill C , Baigent C , Leeson P , Nair M
Published: November 2020

Background

Point of care imaging devices are promising tools for cardiovascular imaging in low-resource settings.

Purpose

Our aim was to determine whether hand-held echocardiography scans performed by obstetricians can help to identify the cardiac phenotypes in pregnant women with heart failure in India.

Methods

In November 2018, eighteen obstetricians from 10 hospitals across the states of Assam, Meghalaya and Uttar Pradesh were given 2 days of hands-on training in image acquisition using Philips Lumify devices. Obstetricians were asked to follow a simplified protocol of image acquisition and optimisation designed by the Oxford Cardiovascular Clinical Research Facility team. The protocol includes 3 key echocardiography views; parasternal long axis, parasternal short axis, and apical four chamber. Remote supervision and constructive feedback on performance was provided to improve image quality. Echocardiographic images of 269 pregnant women (with and without suspected heart failure) were acquired by the trained obstetricians, between February 2018 and January 2020. The first 147 scans were transferred with end-to-end encryption to the University of Oxford Research Echocardiography Core Laboratory (ORECL). Image interpretation and formal quality assessment was performed by 2 experienced echocardiographers.

Results

Parasternal long axis image quality was assessed as good in 78.3%, and was superior to both the parasternal short axis view (76.5%) and the apical 4-chamber view (61.9%). Image depth and gain optimisation was the main reason for loss of quality. The acquisition quality was related to reported clinical disease severity, and advanced pregnancy status. Left ventricular systolic function was impaired in 32 participants (21.9%), and 23.3% of the cohort had a dilated left atrium. Rheumatic heart disease was found in 12 participants (8.3%), in which the mitral valve was stenotic; 10 severe and 1 moderate. Mitral regurgitation was reported in 29 cases (20.8%); 6 severe, 7 moderate and 16 mild. Tricuspid and aortic valve abnormalities were also detected. Pericardial effusion was reported in 45 participants (30.8%).

Conclusion

Obstetricians with supervised training, using hand-held echocardiography have demonstrated acceptable image acquisition quality which could be assessed through core laboratory analysis to detect cardiac abnormalities. Such an approach could be useful to guide the diagnosis of heart failure in pregnant women in low-resource settings. Further training for the obstetricians and image quality assurance have been implemented in the ongoing MaatHRI study with plans to conduct a validation analysis.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Medical Research Council (MRC), UK Fellowship for M Nair.
Innovation in health care: continuous wireless monitoring to improve management of critically ill atients: LIMS study preliminary results
Authors: Pietrantonio F , Alessi E , Pascucci M , Delli Castelli M , D'Amico R , Ronchetti M
Published: November 2020

Background

Wireless vital parameter continuous monitoring (WVPCM) is compared to regular nurse monitoring in order to provide data on the clinical and economic impact of critically ill patients (CIPs) in Internal Medicine Units (IMU).

Study Design

Pilot prospective randomized controlled open-label multi-center study with WIN@Hospital wearable wireless system creating alerts on portable devices (ipad). Experimental Arm: CIPs with MEWS (Modified Early Warning Score) ≥3 and/or NEWS (National Early Warning Score) ≥5 at admission underwent WCPCM over the first 72 h. Active Comparator: CIPs with MEWS ≥3 and/or NEWS ≥5 at admission undergoing regular nurse monitoring.

Method

Primary outcomes: Reduction of major complications (MC) from 15% to 5%. Secondary outcomes: One day reduction in length of stay (LOS); reduced nurse monitoring time; accurate patient stratification and definition of end stage disease.

Results

Preliminary results: Enrolled 145 and evaluable 125 patients (51 M/74 F), mean age 80.5 years, Comorbidity: Cumulative Illness Rating Scale CIRS-CI: 4, CIRS SI: 1.8. About 38% scored a BRASS (Blaylock Risk Assessment Screening Score) ≥20 indicating need for discharge planning requiring step-down care. More than 50% of patients present IIA index >3 indicating high dependency from nursing assistance. Nurses saved a minimum of 49,6 minutes to a maximum of 58,1 minutes on time spent monitoring each patient per day. A trend towards reduction of major complications in the experimental group appears to be seen (31% versus 45%). Decrease in re-admissions (7% versus 11%) and mortality (7.3% versus 23.9%) has been observed. Arrhythmic and ischemic complications detection doubled in the experimental arm. More than 30% of the patients meet the criteria defining end stage disease.

Conclusion

WVPCM, detecting early deterioration in CIPs, may facilitate timely response in at-risk patients, increasing safety and reducing costs.

Telemedicine Network

Funding Acknowledgement

Type of funding source: None
Implication of real-time telemonitoring system in the diagnostics of cardiac diseases
Authors: Petrov I , Boichev B , Garvanski I
Published: November 2020

Objectives

We assessed the implication of a live telemonitoring system Check Point Cardio with real-time remote diagnostics in the diagnosis of a wide range of cardiac diseases- from rhythm disturbances to ischaemic heart disease.

Methods and results

In the period between 10.01.2017 and 10.01.2019 a total of 14172 patients were monitored. The mean monitoring period for the whole group was 7.76 (±4.5) days. The primary indication for real-time monitoring was rhythm and conduction abnormalities (66%) and ischemia detection (34%). In 2087 (14,8%) of the patient a clinically significant pathological finding was observed. A total of 603 (4,3%) patients were referred to a planned hospitalization with the most common reasons- ST segment deviation (450 pts), clinically significant bradycardia due to AV block- (21 pts); Sinus arrest/SA block (90 pts) and pacemaker malfunction in 20 patients, wide complex tachycardia was observed in 7 patients.

In addition to that 42 patients were referred to an emergent hospitalization after a contact by our team. From those patients 30 were with ST segment elevation, 10 were with ST- segment depression and 2 were with sustained wide complex tachycardia.

Conclusion

Real-time telemonitoring accompanied with real-time remote diagnostics is a reliable method for diagnosis of wide-range cardiac diseases. The possibility of immediate diagnosis and contact with the patient, combined with GPS localization, allows a fast reaction in case of an emergent situation.

Funding Acknowledgement

Type of funding source: None
Building a predictive model for warfarin dosing via machine learning
Authors: Tan O , Wu J.Z , Yeo K.K , Lee S.Y.A , Hon J.S , Chiang P , Lau Y.H , Moh R , Fam J.M
Published: November 2020

Background

Warfarin titration via International Normalised Ratio (INR) monitoring can be a challenge for patients on long term anticoagulation due to its multiple drug interactions, long half life and patient's individual reponse, yet critically important due to its narrow therapeutic index. Machine learning may have a role in learning and replicating existing warfarin prescribing practices, to be potentially incorporated into an automated warfarin titration model.

Purpose

We aim to explore the feasibility of using machine learning to develop a model that can learn and predict actual warfarin titration practices.

Methods

A retrospective dataset of 4,247 patients with 48,895 data points of INR values were obtained from our institutional database. Patients who had less than 5 visits recorded, invalid or missing values were excluded. Variables studied included age, warfarin indication, warfarin dose, target INR range, actual INR values, time between titration and time in therapeutic range (TTR as defined by the Rosenthal formula).

The machine learning model was developed on an unbiased training data set (1,805 patients), further refined on a handpicked balanced validation set (400 patients), before being evaluated on two balanced test sets of 100 patients each. The test sets were handpicked based on the criteria of TTR (“in vs out of range”) and stability of INR results (“low vs high fluctuation”) (Table 1). Given the time series nature of the data, a Recurrent Neural Network (RNN) was chosen to learn warfarin prescription practices. Long-short term memory (LSTM) cells were further employed to address the problem of time gaps between warfarin titration visits which could result in vanishing gradients.

Results

A total of 2,163 patients with 42,622 data points were studied (mean age 65±11.7 years, 54.7% male). The mean TTR was 65.4%. The total warfarin dose per week as predicted by the RNN was compared with actual total warfarin dose per week prescribed for each patient in the test sets. The coefficient of determination for the RNN in the “in vs out of range” and “low vs high fluctuation” test sets were 0.941 and 0.962 respectively (Figure 1).

Conclusion

This proof of concept study demonstrated that a RNN based machine learning model was able to learn and predict warfarin dosage changes with reasonable accuracy. The findings merit further evaluation of the potential use of machine learning in an automated warfarin titration model.

Funding Acknowledgement

Type of funding source: None
Virtual reality, the start of a new era for patient education in cardiology?
Authors: Hooglugt J.Q , Oudkerk Pool M.D , Mulder B.J.M , De Winter R.J , Bouma B.J , Winter M.M
Published: November 2020

Background

Anxiety, perceived in patients undergoing percutaneous cardiac intervention is a known problem, which is negatively correlated with quality of life, adherence to recommended clinical practice and medication, health promoting behavior, hospitalization, and patient experience and satisfaction. Hence, preprocedural interventions to alleviate anxiety are interesting. While preoperative education interventions were proven to be effective as anxiety reduction modality, especially those modalities that provide immersive experience appeared to be even more effective within this context. Given the non-invasive nature of these modalities and the introduction of innovative techniques such as Virtual Reality (VR), the question arises whether VR can be successfully introduced as an effective tool to alleviate anxiety in cardiology patients undergoing PFO or ASD closure.

Purpose

The purpose of the study was to alleviate pre-procedural anxiety in patients undergoing percutaneous PFO or ASD closure using a VR film as an innovative and immersive patient education modality.

Methods

Patients were randomized to either the VR-group or the control group. The control group received traditional patient information by their cardiologist. The intervention group additionally viewed a 4-minute VR-film, that was designed to create a representative patient-experience of the day of the procedure. The primary outcome was patient anxiety in the VR group compared to the control group, as measured with anxiety scores derived from the State Trait Anxiety Inventory (STAI) questionnaire. Measurements were performed directly after the informed consent visit and one week prior to the procedure. Secondary outcome measure was the duration of anesthesia during the procedure.

Results

In total 40 patients have been included (mean age = 45 yrs ± 11, male = 21), mean FU duration = 37 days ± 23). So far, 27 patients (VR-group n=14; Control group n=13) completed follow-up. At baseline the control and intervention group were equally anxious (37±9 vs 38±14). During follow-up we found a significant increase in anxiety in the control group (37±9 vs 46±12; p=0.034; figure 1), whereas anxiety in the VR-group remained unchanged (38±14 vs 36±9; figure 1). One week prior to the procedure, the control group was significantly more anxious compared to the VR group (+ 11±4; p=0.012; figure 2). The mean duration of the anesthesia was significantly shorter within the VR-group in comparison with the control group (57±10 min vs 71±18 min; p=0,029). This may be an indication that decreased anxiety could have beneficial effects on the complete duration of anesthesia.

Conclusion

Our results demonstrate that immersive VR patient education is both innovative and effective in alleviating anxiety prior to a cardiological procedure and may have beneficial effects on patient experience and anesthesia duration.

Funding Acknowledgement

Type of funding source: None