bluuebunny/crossref_metadata_2025 huggingface dataset:
Pregnancy related inappropriate sinus tachycardia: a distinct arrhythmia?
Authors: Sharp A , Patient C , Pickett J , Belham M
Published: November 2020

Background

The syndrome of inappropriate sinus tachycardia (IST) is well recognized and affects ∼1% of the population. We believe IST in pregnancy is a relatively frequent yet under-recognized phenomenon that may represent a distinct arrhythmia. To date, there are only three case reports in the literature.

Purpose

To further understand the natural history of IST in pregnancy, and to explore maternal outcomes.

Methods

A retrospective, observational cohort analysis.

Results

19 pregnant women presented to our institute with a definitive diagnosis of IST (as defined by task force criteria) between January 2016 and January 2017. Symptom onset was 4–36 weeks gestation (mean 20 weeks). Of those in their second or subsequent pregnancy (n=8), 50% described symptoms compatible with IST in previous pregnancies. 42% attended the emergency department on ≥1 occasion with symptoms of IST. 32% required hospital admission. 26% required pharmacological therapy (beta-blockers in all). There were no maternal deaths, instances of heart failure or acute coronary syndrome, no thromboembolic or haemorrhagic complications during pregnancy. Rates of Caesarean section were similar to the background rate of our unit; however, rates of induction were notably elevated (58% vs 25%), with 55% of these women being induced purely for symptoms of IST. Following delivery, symptoms resolved within one week for 17 of the women in the cohort, 1 had symptoms resolve after 4 month and 1 had persistent symptoms as she became pregnant again.

Conclusion

IST in pregnancy likely represents a distinct arrhythmia; the majority of individuals here had symptoms only during pregnancy, which resolved rapidly postpartum. Additionally, half of the women in a second or subsequent pregnancy had suffered IST symptoms during previous pregnancies, with no symptoms in between pregnancies. It is biologically plausible and may represent an exaggerated cardio-autonomic response to the physiological changes of pregnancy such as increased sympathetic tone and change in baroreceptor reflex sensitivity. Recognition of the condition is important given it is associated with significant morbidity, the distressing nature of symptoms leading to high rates of hospitalization and induction of labour.

Funding Acknowledgement

Type of funding source: None
Effects of evolocumab on plasma levels of proprotein convertase subtilisin/kexin type 9 and lipoprotein(a) in acute myocardial infarction
Authors: Nakamura A , Kanazawa M , Kagaya Y , Kondo M , Sato K , Endo H , Nozaki E
Published: November 2020

Background

There are two types of circulating proprotein convertase subtilisin/kexin type 9 (PCSK9), mature and furin-cleaved. Most types of lipoprotein(a) [Lp(a)], an independent risk factor of cardiovascular events, bound to mature PCSK9.

Purpose

This study examined the effects of monoclonal anti-PCSK9 antibody on plasma PCSK9 and Lp(a) levels in acute myocardial infarction (MI).

Methods

Acute MI patients (n=36) were randomly divided into evolocumab (140 mg; n=17) and non-evolocumab (n=19) groups. Changes in plasma PCSK9 and Lp(a) levels were monitored before and 1, 3, 5, 10, and 20 days after evolocumab administration.

Results

In the non-evolocumab group, plasma levels of mature PCSK9, furin-cleaved PCSK9, and Lp(a) (236.4±57.3 ng/mL, 22.4±5.8 ng/mL, and 19.2. ± 16.5 mg/dL, respectively) significantly increased by day 3 (408.8±77.1 ng/mL, P<0.001; 47.2±15.7 ng/mL, P<0.001; and 39.7±21.3 mg/dL, P<0.005, respectively) and returned to the baseline by day 10 or 20. In the evolocumab group, mature PCSK9 significantly increased by >1000 ng/mL with a simultaneous decline of furin-cleaved PCSK9 below the measurement sensitivity level after day 3. The incremental area under the curve for plasma Lp(a) levels was significantly smaller in the evolocumab group compared with the non-evolocumab group (P=0.038).

Conclusion

Mature and furin-cleaved PCSK9 are transiently upregulated after MI onset. Evolocumab significantly increases mature PCSK9 and decreases furin-cleaved PCSK9 and might inhibit transient increase of plasma Lp(a) in acute MI.

Figure 1

Funding Acknowledgement

Type of funding source: None
The effect of in-hospital high-dose vs. low-dose intensive statin in patients with non-ST segment elevation acute coronary syndrome
Authors: Chen P , Liu Y , Duan C , Fan H , Zeng L , Guo W , Jiang L , Xue W , He W , Tao S , Guo Z , Chen J , Tan N , He P
Published: November 2020

Background

Statins remain a standard treatment for acute coronary syndrome (ACS) patients. We aimed to determine the association between different dosages of in-hospital statins and the prognoses among patients receiving percutaneous coronary intervention (PCI).

Methods

NSTE-ACS patients were retrospectively enrolled from January 2010 to December 2014 from five centres in China. Patients receiving either atorvastatin or rosuvastatin during their hospitalizations were included. All the patients were categorized into high-dose statin group (40mg atorvastatin or 20mg rosuvastatin) or low-dose statin group (20mg atorvastatin or 10mg rosuvastatin). In-hospital events and long-term all-cause death was recorded.

Results

Of the 7,008 patients included in the study, 5,248 received low-dose intensive statin (mean age: 64.28±10.39; female: 25.2%), and 1,760 received high-dose intensive statin (mean age: 63.68±10.59; female: 23.1%). There was no significant difference in in-hospital all-cause death between the two groups (adjusted OR, 1.27; P=0.665). All-cause death was similar between the two groups during the long-term follow-up period (30-day: adjusted HR, 1.28; P=0.571; 3-year: adjusted HR, 0.83; P=0.082). However, there was a robust association between the high-dose statin and the reduction in in-hospital dialysis (adjusted OR, 0.11; P=0.030).

Conclusions

The in-hospital high-dose intensive statin is not associated with lower risks of in-hospital or follow-up all-cause death in NSTE-ACS patients undergoing PCI. Considering the robust beneficial effect of in-hospital dialysis, an individualized high-dose intensive statin can be rational in specified populations.

Univariate and multivariate analyses

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Science and Technology Planning Project of Guangzhou City athe China Youth Research Funding
Efficacy and safety of PCSK9-Inhibitors in the real-world: data from a clinical registry
Authors: Saba P.S , Murgia A , Gazale E , Terrosu P , Sanna G.D , Parodi G
Published: November 2020

Background

To date, little information is available on the real impact of PCSK9 inhibitors in terms of reducing cholesterolemia, events and the actual tolerability in the so-called “real world”. This lack of information is substantially related to the fact that these drugs have only been marketed recently. In Italy, few centres are licensed to prescribe these drugs. This, on the one hand, limited the number of patients to whom the new therapy was offered but, on the other hand, “concentrated” the observations in a few centres, making it possible to more easily collect the few data currently available. The Cardiology Unit of our university hospital is the only prescribing centre in the North Sardinia and therefore represents the natural collector of all the prescriptions of this drug in this wide geographical area.

Purpose

The aim of the study was to evaluate the efficacy and tolerability of PCSK9 inhibitors in the current clinical practice.

Methods

Data were collected reviewing all Alirocumab and Evolocumab prescriptions provided by the Cardiology Unit of our university hospital included in the Italian National Drug Agency (AIFA) registry from February 2017 to October 2019. In order to collect complete clinical information, all patients were interviewed regarding their health status, the on-treatment cholesterol levels and the possible appearance of side effects or cardiovascular events.

Results

In the reference period, 111 patients (58.9% males, age 63±10 years) received PCSK9-Inhibitors prescription (52.7% Evolocumab, 47.3% Alirocumab), 86.5% as secondary prevention. Statin intolerance was the indication for PCSK9-Inhibitors in the majority (73.3%) of patients. LDL cholesterol at eligibility evaluation was 175±50 mg/dl and reduced to 87±44 mg/dl (p<0.0001) at last follow-up assessment (median 12.3 IQR 6.8–21.4 years). Maximal per cent variation of LDL-cholesterol was achieved already after 6 months of therapy (−45±3% vs basal). No attenuation in LDL-cholesterol lowering was observed; conversely, LDL levels continued to reduce during treatment (p for linear trend = 0.01; Figure 1). During follow-up, 8 patients (7.2%) stopped PCSK9 inhibitors: 2 subjects (1.8%) for side effects certainly related to the drug (flu-like syndrome, allergic reaction), 4 for possible side effects (myalgia, abdominal pain), the remaining for other reasons.

Conclusions

Clinical use of PCSK9 inhibitors confirms its efficacy and safety also in the “real world” setting. LDL reduction occurs early during the treatment and shows a significant trend in further reduction during the observation period. More than 90% of subjects tolerate and persist in PCSK9 inhibitors treatment in the long-term follow-up.

Figure 1

Funding Acknowledgement

Type of funding source: None
REDUCE-IT: outcomes by baseline statin type
Authors: Bhatt D , Miller M , Steg P.G , Brinton E.A , Jacobson T.A , Ketchum S.B , Doyle R.T , Juliano R.A , Jiao L , Granowitz C , Tardif J.-C , Ballantyne C.M
Published: November 2020

Background

REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial) randomized 8,179 statin-treated patients with elevated triglycerides and increased cardiovascular (CV) risk to either icosapent ethyl (IPE), a pure, stable prescription form of eicosapentaenoic acid, 4g/day or placebo. IPE significantly reduced time to first occurrence of the primary composite endpoint of major adverse CV events (CV death, nonfatal myocardial infarction [MI], nonfatal stroke, coronary revascularization, or hospitalization for unstable angina) (HR 0.75, CI 0.68–0.83) and key secondary endpoint events (composite of CV death, nonfatal MI, or nonfatal stroke) (HR 0.74, CI 0.65–0.83) versus placebo (all p<0.0001). A modest reduction in placebo-corrected LDL-C was observed (−6.6%; p<0.0001). The mechanisms for the CV benefit of icosapent ethyl are not fully understood.

Purpose

Explore the impact of statin type and lipophilic/lipophobic category on outcomes, and on LDL-C, to further consider the possible relevance of LDL-C pathways to the observed CV benefit of icosapent ethyl.

Methods

Primary and key secondary endpoint analyses and LDL-C changes from baseline were explored by individual statin type (atorvastatin, simvastatin, rosuvastatin, or pravastatin) at baseline, and then by categorizing these statins into lipophilic (i.e., hydrophobic: atorvastatin, simvastatin) and lipophobic (i.e., hydrophilic: rosuvastatin, pravastatin) statin groups; 96.1% of patients fell within these individual statin groups.

Results

CV outcomes were similar across statin types (interaction p=0.61) and lipophilic/lipophobic categories (interaction p=0.51) (Figure). Statin type and category had a similar lack of meaningful impact on the modest placebo-corrected median LDL-C changes from baseline to one year, which ranged from −5.8 to −8.4% (all p≤0.0003).

Conclusion

No meaningful treatment differences in the primary or key secondary endpoints across statin type or lipophilic/lipophobic category were observed. A similar lack of treatment difference was observed in LDL-C changes from baseline to one year. Therefore, the LDL-C changes and CV risk reduction in REDUCE-IT appear independent of the type of concomitant statin therapy. These data provide clinicians with additional insight regarding concomitant statin therapy considerations when prescribing icosapent ethyl and suggest there are important mechanisms of action for the substantial CV risk reduction observed with icosapent ethyl that are distinct from the LDL receptor pathway.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The study was funded by Amarin Pharma, Inc.
Natriuretic effect of 2 weeks of dapagliflozin treatment in patients with type 2 diabetes and preserved kidney function: results of the DAPASALT trial
Authors: Scholtes R , Muskiet M.H.A , Van Baar M.J.B , Greasley P.J , Karlsson C , Hammarsterdt A , Arya N , Van Raalte D.H , Heerspink H.J.L
Published: November 2020

Background

Sodium glucose co-transporter 2 (SGLT2) inhibitors reduce the risk for heart failure hospitalization, potentially by inducing sodium excretion, osmotic diuresis and plasma volume contraction, leading to more favorable systemic hemodynamic function. However, this hypothesis has never been formally investigated as no studies have assessed cumulative sodium excretion with SGLT2 inhibition during standardized sodium intake.

Methods

We conducted a mechanistic open label study in patients with type 2 diabetes mellitus (T2D) with preserved kidney function, who were receiving a standardized sodium intake (150 mmol/day) to evaluate the acute effects (average day 2–4), effects at steady state (average day 12–14) and effects during three days wash-out of dapagliflozin on sodium balance and blood pressure. Primary outcome measure was 24-hr sodium excretion during the acute phase. Secondary outcomes included 24-hr glucose excretion and 24-hr blood pressure at each time period and sodium excretion at steady state and during follow-up.

Results

Seventeen patients with T2D were enrolled (64.7% male, mean ± SD age 64.24±7.33 years, weight 99.54±17.36 kg, eGFR 94.53±10.10 mL/min/1.73m2, HbA1c 7.20±0.63%). Average sodium excretion at baseline was 147±32 mmol/24 hr, which did not significantly change during treatment (Change at day 2–4 [95% CI]: −5.21 [19.54, 9.12] mmol/24 hr; Change at Day 12–14 [95% CI]: 3.69 [−24.82, 32.20] mmol/24 hr). However, sodium excretion was reduced following washout compared to end of treatment (Change at Day 15–17 [95% CI]: −16.72 [−34.11, 0.66] mmol/24 hr). Glucose excretion was significantly increased throughout the study. Systolic blood pressure was 127.0±10.3 mmHg at baseline and significantly reduced at Day 3 [95% CI]: −5.27 [−8.55, −1.99] mmHg and Day 14 [95% CI]: −7.10 [−10.04, −4.16] mmHg compared to baseline and remained lower following washout.

Conclusions

This study shows that, during a standardized sodium intake, the SGLT-2 inhibitor dapagliflozin acutely reduces blood pressure without altering sodium excretion, indicating possible direct vascular effects independent of sodium balance.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Astra Zeneca
Periprocedural anticoagulation in AF cryoballoon ablation in a nationwide registry: no difference in complication rates between strategies
Authors: Zubkova P , Lubimceva T , Topchian A , Davtyan K , Artiykhina E , Tarasiyk E , Kosonogov A , Kryzhanovsky D , Sagitov I , Chetverikov S , Nechepurenko A , Poleshchenko Y , Vavilova T , Lebedev D , Mikhaylov E
Published: November 2020

Background

Standard treatment for patients with atrial fibrillation is pulmonary vein isolation (PVI). There are two widely adopted methods for PVI - cryoballon ablation (CBA) and radiofrequency (RF) ablation. There are several randomized studies evaluating different periprocedural anticoagulation strategies in patients undergoing PVI, and those mainly related to RF ablation procedures. However, there is a lack of data on safety of different anticoagulation strategies in CBA.

Purpose

To analyze the current anticoagulation approaches in patients undergoing cryoballoon ablation, the incidence and types of hemorrhagic and thromboembolic periprocedural events. The analysis was performed on data from the National cryoballoon AF ablation registry (NCT03040037).

Methods

Nineteen centers prospectively entered data into a web-based platform. The full data on AC therapy was available in 719 subjects. The specialists evaluated ischemic events clinically, and those included stroke, transient ischemic attack, pulmonary embolism or extracranial systemic embolism. Major bleedings were registered and classified according to the ISTH criteria.

Results

The mean CHA2DS2-VASc score was 2.0±1.4; mean BMI 29.5±4.8; mean GFR 92±28.9 ml/min. Periprocedurally, 574 (79.8%) subjects received direct oral anticoagulants (DOACs), 113 (15.7%) anti-vitamin K drugs (mainly warfarin); 16 (2%) patients received antiplathelet therapy. Uninterrupted DOAC therapy was used in 251 (34.9%) cases. Uninterrupted warfarin therapy was used in 36 (2%) patients. Bridging therapy was used in 325 (45.2%) patients. The total number of major adverse events was 25 (3.5%): 24 of them hemorrhagic and 1 transient ischemic attack (1 female patient on rivaroxaban with bridging). Five (0.7%) patients had hemopericardium: 3 - on uninterrupted rivaroxaban, 1 – rivaroxaban with bridging, 1 – interrupted apixaban. Seventeen (2.5%) patients had groin vascular complications and 1 -hemoptysis. Three patients died within 30 days following CBA from non-cardiovascular causes. There were no statistically significant differences in complications between patients receiving different periprocedural anticoagulation.

Conclusions

About 45% of patients referred for CBA receive bridging anticoagulation therapy in the periprocedural period. Although this is not in line with the current guidelines, we found no meaningful difference in complication rates between different anticoagulation approaches. CBA might be associated with different from RF ablation safety profile and requires randomized trials on periprocedural anticoagulation.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): RF President's council grant
Comparing clinical outcomes following 1 year of dual antiplatelet therapy in patients risk stratified by the PRECISE-DAPT and DAPT scores
Authors: Boudreau R , Fu A , Barry Q , Tran U , Perry-Nuygen D , Simard T , Le May M , Labinaz L , Dick A , Glover C , Froeschl M , Hibbert B , Chong A , So D
Published: November 2020

Background

Dual antiplatelet therapy (DAPT) is the standard of care following PCI. DAPT reduces ischemic events but increases bleeding risk. Duration of DAPT following PCI remains controversial. Current guidelines recommend duration be individualized based on risk of ischemia and bleeding. Although multiple strategies exist to risk stratify patients, including application of the PRECISE-DAPT and DAPT scores, there is currently no standardized risk assessment protocol.

Purpose

To determine if the PRECISE-DAPT and DAPT scores can identify patients at increased risk of ischemia or bleeding in a cohort prescribed 12 months of DAPT following PCI.

Methods

We calculated the PRECISE-DAPT and DAPT scores for 469 consecutive patients at baseline after PCI. Patients were grouped based on score treatment recommendation; PRECISE-DAPT prolonged or shortened (PRECISE DAPT <25 vs. ≥25) and DAPT prolonged or shortened (DAPT ≥2 vs <2). End points included 1-year rates of major adverse cardiovascular events (MACE) and TIMI major or minor bleeding.

Results

Among 469 patients, mean age was 64.4 (SD 12.2); 102 (21.7%) were women. Index presentation consisted of a STEMI in 207 (44.1%), NSTEMI in 99 (21.1%), and UA in 60 (12.8%). At presentation, 174 (37.1%) were current smokers, 115 (24.5%) had a prior MI, 118 (25.2%) had diabetes, 249 (53.1%) had dyslipidemia and 281 (60.0%) were previously diagnosed as hypertensive. Overall, there was an increase in bleeding and no difference in MACE for patients with a PRECISE-DAPT score ≥25 (13.3% vs. 4.1% P<0.001). No difference in bleeding or MACE was present in patients stratified by the DAPT score.

Conclusion

A PRECISE-DAPT score ≥25 was associated with an increased rate of bleeding and no difference in MACE in patients prescribed 12 months of DAPT. This supports the use of the PRECISE-DAPT as a prospective tool in clinical practice.

Funding Acknowledgement

Type of funding source: None
Modifiable risk factors, limiting symptoms, anxiety and high expectations regarding therapy are common in patients with paroxysmal/persistent atrial fibrillation
Authors: Lachonius M , Widell C , Bergfeldt L , Odell A
Published: November 2020

Background

Atrial fibrillation (AF) is the most common heart rhythm disorder, increases the risk for stroke and heart failure, and commonly impairs health related quality of life. Increasing evidence shows the causative role of several risk-factors and that aggressive lifestyle interventions might reduce AF and its impact. The size of the problem and how to provide optimal multi-disciplinary management is less well known.

Purpose

To screen for potentially amenable risk factors and describe how patients rate their symptom burden, well-being and expectations of future treatment.

Methods

The risk profile, symptom burden, well-being and expectations of future treatment were identified in 352 consecutive patients referred for possible cardioversion and visiting a specialist nurse at an AF outpatient clinic. Various questionnaires and instruments were used in addition to medical history, ECG recording, and height, weight, BMI calculation and blood pressure (BP) measurement.

Results

Altogether 69% had 1–5 possibly modifiable risk factors, 50% were overweight or obese, 39% had a BP >140/90 mmHg, 28% symptoms suggesting obstructive sleep apnoea and 25% reporterd no physical exercise. Respiratory distress during exertion was the most common symptom. Most patients had high expectations for their upcoming AF treatment, but men expected a full recovery more often than women (p=0.01). About 28% worried about their future health and reduced survival due to their AF.

Conclusion

Most of the patients with paroxysmal/persistent AF have risk factors suitable for life styles interventions. Many patients experience limitations in daily life, anxiety about their AF and worry about their future health and survival. Women and men also have different expectations of future care and treatment for recurrent AF.

Funding Acknowledgement

Type of funding source: None
Sex difference in the impact of smoking on Clinical outcomes following LVAD implantation
Authors: Imamura T , Combs P , Siddiqi U , Mirzai S , Stonebraker C , Bullard H , Simone P , Jeevanandam V
Published: November 2020

Background

Smoking would have a negative impact on clinical outcomes following left ventricular assist device (LVAD) implantation. However, its impact on male and female cohorts separately remains uninvestigated.

Purpose

We aimed to investigate the association between smoking and post-LVAD outcomes among male and female cohorts separately.

Methods

Data of consecutive patients who received LVAD implantation at our institute between Jan 2013 and Sep 2018 were retrospectively reviewed. Clinical outcomes were compared between the never smokers and the current smokers among male and female cohorts separately. Those with former smoking were excluded.

Results

Of all, 85 male patients (median 56 years old) and 45 female patients (median 56 years old) were included. Among the male cohort, total readmission rate was higher in the current smokers than never smokers (incidence rate ratio 1.51, p=0.09). Rates of gastrointestinal bleeding, stroke, and hemolysis trended to be higher in current smokers (Figure 1A). Among the female cohort, these rates were not different irrespective of the smoking status (Figure 1B). Survival was not different irrespective of smoking status among both male and female cohorts.

Conclusion

The impact of smoking on post-LVAD outcomes seems to be different between males and females. Different therapeutic strategy might be required for the LVAD candidates with active smoking between male and female cohort.

Figure 1

Funding Acknowledgement

Type of funding source: None
Predicted survival and self-reported physical activity in ambulatory patients with stage c/d heart failure
Authors: Boonbumrung N.B , Krailak L.K , Nakviroj P.N , Puwanant S
Published: November 2020

Background

There is a paucity of evidence with regard to the correlation of physical activity (PA) and survival estimated by the Seattle Heart Failure Model.

Objectives

To evaluate the association between 1- and 5-year survival estimated by the Seattle Heart Failure Model and self-reported PA in ambulatory heart failure (HF) patients in a HF clinic.

Methods

We prospectively enrolled 115 consecutive outpatients with HF in multidisciplinary HF clinic. All patients had complete baseline self-reported physical activity data, using a modified version of the international Physical Activity Questionnaire-Short Form questionnaire. PA was categorized as poor, intermediate, or ideal activity according to American Heart Association (AHA) criteria. Predicted survival was computed by the Seattle Heart Failure Model (SHFM). The relationships between these measures were examined.

Results

Among the 115 patients enrolled, the mean age was 57 years, 72% were male, 64% had reduced ejection fraction, and 21% had stage-D HF with AHA criteria. Few patients met the criteria for ideal physical activity (5% ideal, 56% intermediate, 39% poor). Predicted 1- and 5-year survival rates of the cohort were 94±8% and 75±20%, respectively. A daily physical activity was significantly associated with 1-year and 5-year survival estimated by SHFM.

Conclusions

In ambulatory patients with HF, physical inactivity was significantly associated with predicted short-term and long-term mortality in not only stage C HF patients but also stage D patients. The survival benefit of physical activity was sustainably more pronounced at 5 years. Poor physical activity was associated with the largest risk of predicted mortality.

Funding Acknowledgement

Type of funding source: None
Accurate prediction of left ventricular diastolic dysfunction in 2D echocardiography using ensemble of deep convolutional neural networks
Authors: Karuzas A , Sablauskas K , Verikas D , Skrodenis L , Teleisyte E , Matuliauskas D , Balciunas J , Kiziela A , Rumbinaite E , Lapinskas T , Ereminiene E , Mizariene V , Vaskelyte J.J , Jurkevicius R , Plisiene J
Published: November 2020

Introduction

Deep convolutional neural networks (CNNs) have been shown to be reliable in evaluating geometrically assessed systolic heart function, however, studies evaluating diastolic heart function, which reflects hemodynamic status, are scarce. This study presents a novel CNNs approach for recognition and evaluation of different diastolic left ventricular (LV) function measurements.

Purpose

To create a new CNNs approach in the assessment of LV diastolic function and compare the results with clinicians' measurements.

Methods

A total of 4586 2D echocardiographic images were extracted from the studies of 330 patients referred with varying indications. The ensemble of four CNNs was trained (80/20% training/validation patient split) for the assessment of transmitral inflow (E and A wave peak velocities), mitral septal and lateral annular velocities (e'), tricuspid regurgitation systolic velocity (Vmax) and detection the left atrial endocardium in apical four-chamber views. Additionally, E/A ratio, average E/e' ratio and left atrial volume index (LAVi) values were calculated for the evaluation of diastolic dysfunction according to the 2016 ASE/EACVI recommendations. CNNs performance in detecting diastolic dysfunction was compared to expert cardiologists on a set of 20 separate cases.

Results

Study results on the validation data showed that CNNs accurately predicted peak E/A ratio, average E/e' ratio (R2=0.88 and R2=0.89, respectively) and tricuspid regurgitation Vmax (R2=0.82). Figure 1 illustrates different functional LV measurements among the obtained echocardiographic images. Regarding the geometrical assessment of diastolic function, the segmentation model traced the left atrial endocardial border (intersection over union = 0.94) and subsequently was used in predicting the LAVi (R2=0.92). The ensemble of four CNNs had the area under the ROC curve of 0.93 for the detection of diastolic dysfunction when compared to expert cardiologists.

Conclusion

Deep CNNs demonstrate the capacity to detect peak velocities across different Doppler imaging modes and delineate left atrial endocardium border while using a relatively small dataset. Combining multiple CNNs has the potential of performing an accurate assessment of the diastolic LV function.

Funding Acknowledgement

Type of funding source: None
The artificial intelligence system in prediction of the prevalence of acute coronary syndromes based on weather conditions
Authors: Molek P , Wlodarczyk A , Bochenek B , Wypych A , Nessler J , Zalewski J
Published: November 2020

Background

It was shown that different individual weather conditions are associated with the incidence of acute coronary syndromes (ACS). Despite this, the prediction of the number of ACS depending on the weather conditions in the given place and time is not effective to date.

Purpose

We sought to investigate whether the artificial intelligence system might be useful in prediction of the prevalence of ACS based on weather conditions.

Methods

In this study, data of 159307 consecutive patients obtained from National Health Service registry, hospitalized due to ACS in Lesser Poland Province (province area of 15008 km2, population of 3.4 M in 2014) between 2008 and 2018 have been compared with meteorological conditions collected in the Institute of Meteorology and Water Management from five weather stations scattered across Lesser Poland Province. Because of small sample size in three of them, only data from two stations (Krakow-Balice, n=75565, Tarnow, n=30079) were used for further analysis. In four separate seasons, the number of ACS events in each day was compared with meteorological conditions on a given day and six days before. We analysed weather conditions such as: wind 10 metres above ground (W_10), temperature (T), dew point temperature (T_dp), relative humidity 2 metres above the ground (Hum_2), atmospheric pressure reduced to mean sea level (Pres), atmospheric precipitation (Prec), and 3 hours atmospheric pressure changes (Pres_3h). For all parameters extreme (maximum – max, minimum – min) values and ranges of these parameters in each day were analysed. All data were used in a system based on machine learning (Random Forest), which allowed to create a model that predicted the incidence of ACS and to determine importance of each inputted weather parameter in this prediction.

Results

All weather parameters were divided into machine learning data (70%) and test data (30%) to verify functioning of the model. The correlation between real number of ACS and predicted number of ACS for two meteorological stations for spring ranges from 0.69 to 0.71 with confidence intervals (CI) of 0.63–0.77, for summer the correlation was 0.66–0.75 with CI of 0.59–79, for autumn 0.69–0.74 with CI of 0.63–0.79 and for winter 0.69–0.72 with CI 0.63–0.77 (P<0.0001 for each prediction, example of prediction in the Figure 1A). Among all analysed meteorological parameters the most important in the machine learning were range of relative humidity, range of dew point temperature and maximal relative humidity (Figure 1B).

Conclusions

Artificial intelligence system seems to be useful in predicting the prevalence of ACS with model based on weather conditions.

Figure 1. ACS prediction for summer in Krakow

Funding Acknowledgement

Type of funding source: None
Ventricular transmural decremental conduction explains short t-peak-t-end interval in “in silico” ECG reconstruction model
Authors: Benchimol Barbosa P.R , Barbosa E.C , Barbosa E.C
Published: November 2020

Introduction

In chronic hepatic cirrhosis (CHC), T-wave peak to T-wave end interval (TPTE) has shown prognostic value for survival and liver transplantation. Altered cellular ionic regulatory systems may produce decremental conduction in ventricular endocardial to epicardial activation wavefront propagation and ECG waveforms, particularly the T-wave. It was investigated whether ventricular transmural activation wavefront conduction may affect T-wave shape and impact TPTE duration, using “in silico” ECG reconstruction.

Methods

Mammalian-derived ventricular endocardial to epicardial AP waveforms (APW) were simulated and deployed in 10 discrete layers in homogeneous impedance ventricular wedge-like model. A uniform conduction model was employed to mimic normal heart, in which the speed of propagation of the activation wavefront was nonzero and constant in all layers. In CHC heart, a decremental conduction model was employed, in which the speed of propagation of the activation wavefront was maximal at the endocardial layer and exponentially decayed to greater than zero speed at the epicardial layer. ECG was computed as the sum of dipoles weighted by the inverse of the squared distance to an observation electrode arbitrarily located outside the wedge. One dipole was one layer thick, and its charge was assumed as the time-integral of the current generated by the difference of potential between adjacent APW, from endocardial to epicardial layers. ECG was reconstructed in one axis.

Results

Two-dimensional transmural APW distribution and respective reconstructed ECGs are presented in Figures 1 and 2. In uniform endocardial to epicardial transmural conduction model, QRS complex was taller and shorter as well as TPTE was larger (Fig. 1) than respective counterparts in decremental conduction model (Fig. 2). Additionally, peak-amplitude of the T-wave as well as the maximal slope of the TPTE were lower in decremental as compared to uniform conduction model.

Conclusion

Using “in silico” ECG reconstruction, decrementally conducted model of epicardial to endocardial ventricular transmural activation wavefront propagation yields wider and lower amplitude QRS complex as well as shorter TPTE, as compared to respective counterparts in uniformly conducted activation wavefront model. Ventricular transmural decremental conduction model offers an insight into electrophysiological background of ECG findings in CHC. (NCT01433848)

Transmural APW distribution vs ECG

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Universidade do Estado do Rio de Janeiro; Rio de Janeiro, RJ - Brazil
Cost-effectiveness analysis of a telemonitoring program on patients with heart failure in Normandy: an 8-year retrospective analysis (2009–2017)
Authors: Sabatier R , Legallois D , Jodar M , Donio V , Courouve L , Hauchard K , Boudevin F , De Chalus T , Belin A , Milliez P
Published: November 2020

Background

SCAD is a 3-month telemonitoring program for HF patients, associated with therapeutic education, proposed after an acute HF episode. SCAD is based on an interactive algorithm allowing to generate educative messages and alarms based on patients' responses registered on a digital tablet. It is funded by the French Health Insurance through a pilot program: ETAPES (470€/patient).

Purpose

To describe the profile of patients using SCAD & assess the medico-economic impact of the SCAD system.

Methods

Multicenter retrospective cohort study using SCAD data matched with French Health Insurance data. All patients telemonitored by SCAD in 7 centers have been included, since 01/01/2010 to 12/31/2016. Only direct costs were considered, estimated from a societal perspective limited to reimbursements. Analyses were performed to assess the difference in healthcare consumptions and costs between the year before and the year after inclusion in the SCAD program. Patients who died in the 12 months after SCAD initiation were excluded.

Results

627 patients benefited from SCAD program between 01/01/2010 and 12/31/2016 and were retrieved in French Health Insurance data through probabilistic matching. Out of the 627 patients, 99 died in the 12 months after SCAD initiation. Analyses were performed on 528 patients.72.2% were male, mean age was 66.0 years old and mean BMI 28.2. HFrEF represented 51.9% of patients, HFmrEF 25.9% and HFpEF 22.2%. 58.0% were in NYHA class 2 at baseline, 29.2% in class 3, 8.5% in class 1 and 4.3% in class 4. Mean Charlson Comorbidity Index score was 2.6 at baseline. Patients reported their level of fatigue (10 representing significant fatigue) and morale (10 = good morale) at baseline: mean fatigue=4.0/10 & mean morale=7.4/10. Medico economic results are presented in table 1 and show an important & significant decrease of hospitalizations costs and some transfer of cost toward ambulatory care.

Conclusion

On the year following remote monitoring, total health expenditure has been reduced by 18% on average (mean=3 210€/patient) and 42% in median (5 500€/patient) vs 12 months before.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This analysis has been funded through an institutional grant from Amgen
The risk of sudden cardiac death or ventricular arrhythmias on Immune checkpoint Inhibitors
Authors: Mirabel M , Karapetiantz P , Marijon E , Le Beller C , Reda Al-Sayed Z , Hulot J.S , Lillo-Lelouet A
Published: November 2020

Background

Immune checkpoint inhibitors (ICI) have significantly improved the prognosis of many advanced cancers, and may be given in non-metastatic cancer in the near future. ICI have recently been reported to induce fulminant cardiotoxic effects such as myocarditis, responsible for ∼50% mortality rates.

Objective

To estimate the risk of sudden death (SD) and ventricular arrhythmias in patients receiving ICI using the World Health Organization individual case safety report (ICSR) database, Vigibase (WHO international pharmacovigilance database).

Methods

The system organ class MEDRA was used to identify cases as ICSR with the terms sudden death, sudden cardiac death, cardiac arrest, ventricular fibrillation, ventricular tachycardia, ventricular arrhythmia and torsades de pointes (named as SD events) from Nov 1967 to Nov 2019. We used the ATC code L01 which regroups 219 antineoplastic agents including ICI avelumab (anti-PDL1), ipilimumab (anti CTLA4), nivolumab (anti-PD1) and pembrolizumab (anti-PD1). A disproportionality analysis was performed to estimate of relative Odds Ratio (ROR). Signals were considered significant when the lower boundary of the 99.97% confidence interval (ROR0.25) was ≥1.

Results

We found that avelumab was significantly associated with SD events (ROR0.25=1.7). This overreporting was not observed for other ICIs. Avelumab was associated with 12 cases of cardiac arrest (n=11) or sudden death (n=1), which were reported since 2017 as the drug became available. There were however no signals regarding other terms including ventricular arrhythmias.

Conclusions

In spite of the potential severity of ICI-myocarditis, ICI do not appear as associated with the occurrence of sudden death or life-threatening arrhythmias, with the exception of avelumab (anti-PDL1), one of the latest developed ICI, indicated in metastatic Merkel cell carcinoma and advanced renal cell carcinoma. Further attention is warranted to confirm this signal that may vary among ICI therapies.

Funding Acknowledgement

Type of funding source: None
Reconfiguring traditional EKG interpretation with artificial intelligence – a reliable, time-saving alternative?
Authors: Mehta S , Gibson M , Avila J , Villagran C , Fernandez F , Niklitschek S , Vera F , Rocuant R , Cardenas G , Frauenfelder A , Vieira D , Merchant S , Vijayan Y , Tamayo C.J , Pinos D
Published: November 2020

Background

Time and accuracy are key factors that may make or break an efficient triage and management in most medical premises, particularly so when expedited diagnosis saves lives - a not so uncommon scenario in the field of cardiology. By studying the different variables involved in cardiologist-EKG interactions that lead to the identification and management of different cardiovascular entities, we delved into the applications of Artificial Intelligence (AI) algorithms in order to improve upon the classic, but dated, EKG methodology. With this study, we pit our algorithm against cardiologists to perform a thorough analysis of the time invested to diagnose an EKG as Normal, as well as an assessment of the accuracy of said label.

Purpose

To present a faster and reliable AI-guided EKG interpretation methodology that outperforms cardiologists' capabilities in identifying Normal EKG records.

Methods

The International Telemedical System (ITMS) developed and tested an EKG assessing AI algorithm and incorporated it into the workflow of their Telemedicine Integrated Platform, a digital EKG reading program where cardiologists continuously report their findings remotely in real time. During the month of April 2019; 35 ITMS cardiologists reported a grand total of 61,441 EKG records, later subjecting them to the AI algorithm, implemented through the “One Click Report” process. Through this simple 2-step approach, the algorithm provides a suggestion of “Normal” or “Abnormal” to the cardiologist based on the patterns of the fiducial points included in said EKG reports. A comparison of the time of normal EKG diagnosis is made and the correlation between AI and cardiologists is assessed.

Results

On average, our AI algorithm discerned a normal EKG within 30.63s (95% CI 26.51s to 34.75s), in solid contrast with cardiologists' interpretations alone, which amounted to 83.54s (95% CI from 69.43s to 97.65s). This accounts for an overall saving of 52.91s (95% CI 42.45s to 63.83s) by implementing this innovative methodology in a cardiologist practice. In addition, this method correctly reported 23,213 Normal EKG records out of the total 25,013 AI output, reaching a 92.8% correlation between man and machine. The total average time saved in normal EKG readings with AI (23,213) would accrue an approximate of 20,470 minutes (ie, 42 8-hours work shifts worth of time dedicated to diagnosing a normal EKG).

Conclusions

The implementation of automated AI-driven technologies into daily EKG interpretation tasks poses an attractive time-saving alternative for faster and accurate results in a modern cardiology practice. By further expanding on the concept of an intelligent EKG characterization device, a more efficient and patient-centered clinical exercise will ensue.

Funding Acknowledgement

Type of funding source: None
Prognostic value of a normal Artificial Intelligence applicative response in subjects with stable chest pain. From the ARTICA co-operative registry
Authors: Mazzanti M , Shirka E , Marini M , Pottle A , Goda A , Pugliese F
Published: November 2020

Background

An innovative artificial intelligence (AI) Decision Support System (DSS) ESC guidelines based has already been used at point of care with efficacy for evaluating subjects with stable chest pain (SCP) and it has been proved to correctly identify absence of significant coronary artery disease (CAD) versus standard care approach (SD) without known prognostic implication yet.

Purpose

The aim is to determine the prognostic value of “no testing/Follow up” AI DSS response in a referral population evaluated for SCP.

Methods

From 2016 to 2019, an AI DSS ESC guidelines based applicative was used on 1.291 subjects with SCP to determine testing appropriateness compared with human specialist standard evaluation. 590 of them, 332 males, mean age 62±11 years deemed to be completely negative – by “no testing/follow up” response - were evaluated. The negative response was defined and confirmed by a normal Coronary Tomography Angiography scan executed in all these subjects. Mean follow-up was 3.46±1.76 years. Two groups based on pre-test likelihood of having CAD were analyzed – low and intermediate. No subjects with high pre-test likelihood were present. The primary endpoint was cumulative incidence of cardiovascular death, hospitalizations for acute coronary syndrome and coronary revascularizations.

Results

The primary endpoints classification is displayed in the Table. The unadjusted hazard ratio for primary endpoint was 3.84 (95% CI 0.32–8.68, p=0.009) in patients with intermediate compared to those with low pre-test likelihood of CAD. Moreover, the “no testing and Follow up” response showed an incremental prognostic value over conventional risk factors (χ2=7, P=0.022) and over a combination of conventional factors and ST-T changes (χ2=9, P=0.014).

Conclusions

In an outpatient population without known CAD evaluated for chest pain, after the administration of AI DSS, a “No tests/Follow up” confers an excellent prognosis regardless of the ESC SCORE Charts and rest ECG abnormalities. These preliminary data confirms the safety of ARTICA AI DSS use in subjects with stable chest pain.

Funding Acknowledgement

Type of funding source: None
The assessment of the accuracy and credibility of cardiovascular health information on social media platforms
Authors: Ragab A.A , Arinze J.T , Akbulut F , Orji R
Published: November 2020

Background

Cardiovascular diseases (CVD) is a major cause of death worldwide. Effective and accurate dissemination of scientific information is key to addressing this public health problem. Social media platforms play major roles in public health promotion considering that a significant percent of the world population use social media. About 40% of the adults in the US use social media for health information. There is little knowledge about the accuracy and credibility of CVD related information posted on social media platforms.

Purpose

The study aimed to assess the scientific credibility and accuracy of cardiovascular health information of highly shared social media posts.

Methods

Cardiovascular related posts on social media platforms (Facebook and Twitter) were mined using the content analyzer platform (BuzzSumo). All articles published between June 2018 and June 2019, with over 10,000 shares, were selected and ranked by two physicians based on the accuracy and credibility of the titles, reported statistics, interpretation of results, sample size, and external validity. A point was scored for each of the five assessment criteria and articles with scores of less than five were considered to be misleading.

Results

A total of 50 articles, with 3,397,918 shares (median: 44350, IQR:25100–78000), were selected and scored. Misleading articles were 32/50 (64%) with 2,528,800 shares (median: 44350, IQR: 39575–80250). Twenty-six percent of the articles had misleading titles, 16% had misleading reported statistics, 30% had wrong interpretation of results, 36% reported small sample size studies, and 54% of them lacked external validity. Overall, articles on diet (41%) had more misleading titles than articles on other topics (14%), p=0.03.

Conclusion

More than half of the articles on widely used social media platforms contain misleading information on cardiovascular health. A concerted effort is needed to ensure the accuracy and credibility of public health information shared on these platforms to avoid misleading users.

Figure 1

Funding Acknowledgement

Type of funding source: None