bluuebunny/crossref_metadata_2025_split huggingface dataset:
Performance of the 'International Criteria' for interpretation of athletes' ECGs in a Dutch cohort
Authors: Bultman L , Snoek J A , Jongman J K 
Published: June 2024

Abstract

Background/introduction
The prevalence of false-positive ECGs in cardiovascular pre-participation screening has historically been high. These false positives screening outcomes lead to additional health care costs. The most recent criteria for interpretation of athletes’ resting ECGs are the ‘International Criteria’ published in 2017. These criteria aim to reduce the amount of false positive ECGs, while preserving sensitivity. To assess the performance of these criteria in daily practice, evaluation across diverse cohorts is imperative.

Purpose
Our study aimed to assess the performance of the International Criteria within our Dutch cohort. The primary objective was to evaluate the impact of the International Criteria on the number of abnormal ECG’s, compared to the previous criteria (ESC 2010, Seattle, and Refined).

Methods
In this prospective observational cohort study all preparticipation screenings in a Dutch hospital between April 2016 and March 2023 were recorded in a database. Retrospectively, all ECGs were systematically re-evaluated. Statistical analysis was performed using McNemar's test for paired binary data.

Results
A total of 1862 ECGs were included. This cohort included both elite and amateur athletes aged 12-35 years. Application of the International Criteria classified 36 ECGs (1.9%) as abnormal, whereas use of the ESC 2010, Seattle, and Refined criteria resulted in 888 (47.6%), 70 (3.7%), and 73 (3.9%) abnormal ECGs, respectively. Applying the International Criteria significantly reduced the number of abnormal ECGs compared to the previous criteria (all p&lt;0.001). This reduction was mostly due to optimalisation of the definitions used in the borderline category. The sensitivity for known pathology within our cohort was 100% when using the International Criteria.
Notably, the newer definition for pathologic Q waves, as described in the Refined and International Criteria, did not decrease the prevalence of abnormal Q waves in our cohort. Abnormal Q waves were the most frequent observed abnormality, accounting for 70% of observed abnormalities in our female population. Another finding was the presence of an extreme axis in 18 athletes (0.97%). However, this is not considered an abnormal finding in the International Criteria.

Conclusions
Use of the International Criteria shows a significant and clinically relevant reduction of the number abnormal ECGs within this Dutch cohort, without an apparent reduction in sensitivity. One of the aspects with considerable potential for optimalization for future criteria appears to be the definition used for abnormal Q waves. Another potential improvement could be defining criteria for interpretation of ECGs with an extreme axis. Amount of abnormal ECGs and sensitivity. Prevalence of abnormalities using IC.
Interpretation of athlete's ECG in a pediatric population using the International Criteria
Authors: Graziano F , Manfrin L , Genta E O , Balla D , Vago H , Zorzi A , Corrado D , Brusamolin L , Giada F 
Published: June 2024

Abstract

Background
In Italy, the starting age for pre-participation screening (PPS) is defined by the single sports federations and sometimes includes individuals under the age of 12. Current International Criteria for ECG interpretation in athletes are recommended for subjects between 12 and 35 years of age.

Purpose
To define the prevalence of ECG alterations (normal, borderline, abnormal) in the ≤12 years population compared to older athletes, and to define which of these are training-related. To assess the applicability of the 2017 International Criteria to a population ≤12 year-old.

Methods
Athletes of both sexes, aged 7-18 years, undergoing PPS in the period 2019-2022, regardless of the sport discipline, were retrospectively enrolled. The screening protocol for competitive athletes is defined by Italian law. The ECG was interpreted according to the recommendations of the 2017 International Criteria.

Results
The final population was composed by 2140 athletes (mean age 12.5 ±2.61 years, 60% ≤12 years). No statistically significant differences were found in the percentage of normal (98% vs 97%, p=0.4), borderline (1.8% vs 1.5%, p=0.5) and abnormal (0.5% vs 1.2%, p=0.06) alterations in the group ≤12 years compared to &gt;12 years. The most frequently observed ECG abnormalities were incomplete right bundle branch block (iRBBB, 22.8%), early repolarisation (14.8%) and left ventricular hypertrophy (13.8%). When comparing the two age groups, a statistically significant difference was found in the prevalence of sinus bradycardia (SB, 0.6% vs 8.2%, p&lt;0.001), 1st degree atrio-ventricular block (AVB, 0.2% vs 1.6% p&lt;0.001) and T-wave inversion in V1-V3 (7.3% vs 2.3%, p&lt;0.001) (Figure 1). Furthermore, in the younger age group, there was no correlation between the prevalence of these ECG changes and the level of training.

Conclusions
SB and 1st degree AVB are extremely rare in athletes ≤12 year-old and do not appear to be training-related, and therefore should be considered as abnormal findings in this population. Furthermore, in both groups, complete RBBB, 2nd degree Mobitz 1 AVB and the presence of one premature ventricular beat on ECG should also be classified as abnormal. The results highlight the limitations of using International Criteria for the interpretation of the athlete's ECG in young people under 18 years, and particularly under 12. Figure 1
The role of depression in ischemic heart disease- An analysis of NHANES database 2017-2018
Authors: Truong N N K , Hayashi M , Vu V H 
Published: June 2024

Abstract

Background
Recent studies have shown frequent co-occurrence of depression and ischemic heart disease (IHD). However, the association between depression and IHD has not been elucidated. I conducted the study on National Health and Nutrition Examination Survey (NHANES) database 2017-2018 to investigate the potential correlation between the severity of depression, as assessed by the Patient Health Questionnaire-9 (PHQ-9), and IHD, while also accounting for possible confounders and mediators that may impact this relationship.

Methods
This is a cross-sectional study analyzing NHANES surveillance data for the period 2017 to 2018. NHANES is a cross-sectional survey that is conducted in a two-year cycle. Since 1999, continuous NHANES surveys have been done. We skipped over the older NHANES cycles from 1999-2000 to 2005-2006 due to the difference in how physical activity is measured. NHANES 2017-2018 is the most completed cycle because the following cycles were conducted during the COVID-19 pandemic. The study enrolled individuals aged 20 years or above, who were required to fill out questionnaires assessing their cardiac health and the severity of their depressive symptoms. Depression was classified into three categories based on the PHQ-9 score: none or minor (scored 0-4), moderate (scored 5-14), and severe (scored greater than 15). Multivariable logistic regression model was used to explore the relationship between depression severity and IHD. In addition, we also investigate the interaction of gender and depression severity in this model.

Results
A total of 1,557 participants were included in the study. Amongst those, 90.36% of study population reported no history of cardiovascular diseases. Male and female proportion was comparable, with female accounted for 56%. Depression severity measured by PHQ-9 scale was associated with IHD, with OR= 0.87, 95% CI 0.48- 1.53 for moderate depression and OR= 2.18, 95% CI 0.48- 5.03 for severe depression (p= 0.096). Female was significantly associated with a lower odds of IHD (OR= 0.46, 95%CI 0.26-0.79, p= 0.006). Interestingly, female with moderate depressive symptoms had higher odds of IHD compared to male. Meanwhile, individuals with severe depression were found to be at higher risk for IHD, independent of their gender.

Conclusion
In this cross-sectional study, the results imply that depression may be a risk factor for IHD in addition to other well-known traditional risk factors. Consequently, it is recommended that individuals at elevated risk for IHD, particularly women, undergo screening for depression.
Comparing protocol-led lipid management with daily practice in post-myocardial infarction patients
Authors: Van Trier T J , Omar Khader A , Liem A H , Groenemeijer B E , Schut A , Tijssen J G P , Martens F M A C , Alings M A 
Published: June 2024

Abstract

Introduction
The PENELOPE study demonstrated the effectiveness of a 3-step, guideline-based lipid management strategy in achieving low-density lipoprotein-cholesterol (LDL-C) goals in very high-risk atherosclerotic cardiovascular disease (ASCVD) patients. However, this was an uncontrolled observation. The PENELOPE-CTRL study therefore retrospectively compared these findings with real-world lipid management practices in the Netherlands.

Methods
Between 2019 and 2020, the PENELOPE study enrolled 663 patients &lt;70 years with acute coronary syndrome with a history of diabetes mellitus or ASCVD, to investigate a 3-step lipid lowering treatment (LLT) intensification (statins, +ezetimibe, +PCSK9 inhibitors) to achieve LDL-c ≤1.8 mmol/L. For the comparative analysis, the real-life PENELOPE-CTRL (N=827) comprised a comparable cohort of retrospectively included patients with similar inclusion criteria. The primary outcome was the proportion of patients reaching an LDL-C target of ≤1.8 mmol/L within six months and at one-year follow-up.

Results
Baseline lipid management was similar in both cohorts, with 33% in PENELOPE vs. 32% in PENELOPE-CTRL on target. The stepwise protocol outperformed real-life practice, with 86% (95% CI 83%-88%) vs. 55% (95% CI 51%-58%) reaching an LDL-c ≤1.8mmol/L within the study period (p&lt;0.001). After one year, this effect was attenuated but remained statistically significant in favour of the intervention (LDL on target 64% (95% CI 60%-68%) vs. 55% (95% CI 50%-60%), p=0.008).(Figure 1).

Conclusion
Using a stepwise lipid protocol significantly improves the proportion of patients reaching LDL-C target in very high-risk post-acute coronary syndrome patients compared to real-life controls. These effects were attenuated after one year follow-up, suggesting the need for long-term follow-up to lower lipid-driven residual risk. Protocol-led vs. daily LDL-C management.
Cholesterol paradox in atrial fibrillation: is it solved in lipid-lowering drugs users?
Authors: Bartos B , Cyganski P , Rynkiewicz A , Morze J 
Published: June 2024

Abstract

Background
In recent years, a growing number of prospective observational studies have consistently observed a paradoxical inverse association between atherogenic lipid fractions, particularly low-density lipoprotein cholesterol (LDL-C) and incident atrial fibrillation (AF), suggesting a protective role of hypercholesterolemia. However, elevated lipid levels at baseline study examinations increase likelihood of lipid-lowering therapy (LLT) initiation during follow-up, introducing substantial time-varying confounding. Consequently, patients under LLT may represent a more homogeneous clinical group for further exploration of the "cholesterol paradox" in AF.

Purpose
We aimed to investigate the association of baseline serum and genetically-predicted LDL-C levels with risk of AF development in patients receiving LLT.

Methods
We conducted a prospective cohort study of 90,114 UK Biobank participants aged 40–69 years, who did not have history of AF at baseline and who reported use of any kind of LLT during a nurse-led interview. Baseline LDL-C was measured in non-fasted serum samples using a direct assay. For genetically-predicted LDL-C, we used a previously published polygenic risk score (PRS). We used Cox proportional hazards regression to estimate AF risk associated with serum and genetically-predicted LDL-C levels. We considered two covariate adjustment sets: Model 1 - including age, sex and body mass index; and Model 2 further including ethnicity, deprivation index, smoking status, alcohol intake, systolic and diastolic blood pressure, glycated hemoglobin, anti-hypertensive and anti-diabetic medication use, prevalent coronary heart disease and valvular heart disease. Potential non-linearity was explored using restricted cubic splines.

Results
During a median of 13.1 years (1,199,436 person-years) of follow-up, 11,164 participants developed incident AF. The median baseline serum LDL-C was 2.9 mmol/L [interquartile range: 2.4-3.4 mmol/L]. In Model 1, a 1 mmol/L increase in LDL-C level was associated with lower risk of AF (hazard ratio [HR]: 0.75, 95% confidence interval [CI]: 0.73-0.77). Following further covariate adjustment (Model 2), the inverse association between LDL-C and risk of AF was attenuated (HR: 0.98, 95%CI: 0.96-1.01). There was no evidence for nonlinearity (Figure 1) of these associations (P-nonlinearity=0.74 and 0.63). PRS for LDL-C was neither associated with AF in Model 1 (HR per 1 standard deviation increase: 0.96, 95%CI: 0.92-1.00) nor Model 2 (HR: 0.97, 95%CI: 0.93-1.02).

Conclusions
In a cohort of patients receiving LLT, an inverse link between LDL-C and AF disappeared after adjustment for other clinical factors. Additionally, the absence of genetic evidence supporting a protective role of lipids further suggests that the "cholesterol paradox" in AF may be attributed to residual confounding rather than a causal relationship.
Direct oral anticoagulants compared to warfarin in morbidly obese patients on anticoagulation: a systematic review and meta-analysis
Authors: Sagris M , Ktenopoulos N K , Pamporis K P , Theofilis P T , Toutouzas K T , Tsioufis K T , Tousoulis D T 
Published: June 2024

Abstract

Introduction
Current guidelines and consensus statements advise against the use of direct oral anticoagulants (DOACs) for morbidly obese patients with body mass index (BMI) &gt; 40 kg/m2, indicating warfarin as the first-line treatment.

Methods
We systematically searched databases from their inception to October 3, 2023, to review and examine the effectiveness and safety of DOACs compared to warfarin in patients with BMI &gt; 40 kg/m2 and atrial fibrillation (AF) or venous thromboembolism (VTE). The outcomes of all-cause mortality, major and minor bleeding, stroke/systematic embolism (SE), and VTE their composite endpoint were analyzed using a random-effect model.

Results
This meta-analysis comprised 21 studies and 116,670 morbidly obese patients with AF or VTE on oral anticoagulation therapy -50,116 on DOACs (43%) vs. (57%) 66,554 on Warfarin-. The DOAC use was significantly associated with lower all-cause mortality and major bleeding risk compared to the warfarin group. Although the risk of composite endpoint, stroke/SE, and VTE were lower in the DOAC group, no statistically significant difference was observed, indicating no superiority of Warfarin compared to DOAC use. The risk of minor bleeding events, hemorrhagic stroke, and ischemic stroke were lower in the DOAC compared to the warfarin group. The same trend favoring DOACs over Warfarin in all assessed endpoints was observed in the subgroup analysis based on anticoagulation indication (AF or VTE).

Conclusion
Our findings are of paramount importance indicating, firstly, the non-superiority of Warfarin compared to DOAC use, and secondly, a significantly better profile of DOACs in terms of safety and effectiveness in morbidly obese patients with BMI &gt; 40 kg/m2 in all the assessed endpoints.
Comparison of changes on left atrial function obtained after two regimes of combined exercise in patients with coronary heart disease
Authors: Caminiti G , Marazzi G , D'antoni V , Morsella V , Catena M , Vadala S , Di Biasio D , Silvestrini M , Volterrani M 
Published: June 2024

Abstract

Introduction
Left atrial function is impaired in patients with coronary heart disease (CHD) and reflects a rising left ventricular diastolic pressure. The effects of exercise training on atrial function are poorly understood.

Aim
investigating the effects of two regimes of combined exercise training (CT) program on left atrial function in patients with CHD.

Methods
The study included 45 stable patients, who were randomly assigned to three groups: fifteen pts were assigned to a supervised CT with low frequency (two session/week) (CTLF); fifteen to supervised CT with high frequency (three session/week) (CTHF); a third group was asked to follow contemporary exercise preventive guidelines at home (control). The CT lasted 12-weeks. Before and after training, all patients performed a symptoms-limited exercise test and an echocardiography. The training included aerobic continuous at moderate intensity, and resistance exercise performed at 60% of 1 repetition maximum.

Results
At 12-weeks, exercise duration at ergometric test presented a significant greater increase in the CTLF and CTHF groups compared to control (p 0.002). Peak atrial longitudinal strain (PALS) and conduit phase presented a significant increase in the CTHF and were unchanged in CTLF and control (p 0.008). Peak atrial contraction strain (PACS) presented a greater increase in CTHF than control. Left ventricular global longitudinal strain, increased significantly in both CTHF and CTLF compared to control (p 0.004). No side effects were observed.

Conclusions
A regimen of CT at high frequency was more effective than low frequency in improving atrial function in CHD patients.
The impact of cardiac rehabilitation on muscle strength: a crucial element of functional capacity
Authors: Garcia A , Oliveira C , Martins A , Abrantes A , Alves Da Silva P , Roxo D , Ramalhinho M , Poupino J , Alves M , Cunha N , Aguiar Ricardo I , Pinto F , Abreu A 
Published: June 2024

Abstract

Introduction
Cardiac rehabilitation (CR) is defined as a multidisciplinary program encompassing exercise training, modification of cardiovascular risk factors, and psychosocial assessment. Physician-prescribed exercise is a crucial and safe component that can significantly enhance the quality of life and functional capacity.

Purpose
The purpose of this study is to assess whether improvements in muscular strength have an impact on functional capacity.

Methods
A prospective analysis of patients enrolled in a cardiac rehabilitation phase two program was conducted. Standardized forms were utilized to collect patient data, including baseline characteristics, muscle strength evaluation (upper and lower limb strength and Time Up and Go test), the six-minute walking test (6MWT), and cardiopulmonary exercise test. Descriptive and inferential statistics were performed.

Results
We enrolled 446 patients participating in the phase two CR program (81% male; mean age at the program's beginning was 61+/-11 years). The mean number of exercise sessions performed was 14+/-6. Among them, 85% had ischemic heart disease, 6% had valvular heart disease, and 3% had dilated cardiomyopathy. During the initial assessment, 73% of patients were in NYHA functional class II, 19% in NYHA I, and 8% in NYHA III. Forty-three percent of patients had a reduced left ventricular ejection fraction (LVEF &lt;50%). Throughout the CR program, there was an improvement in lower limb (mean value increased from 15 Kg to 20 Kg, p=0.001), upper limb strength (mean value increased from 19 to 23 Kg, p=0.001), and in the time taken for the Up and Go test (a decrease in mean time from 14 s to 9 s, p=0.001). Patients demonstrating improvement in at least one of these parameters also showed, at the end of the programme, enhanced 6MWT mean time (from 454 to 569 meters), peak VO2 (from 15 to 17 mL/Kg/min), and the duration of cardiopulmonary stress testing (from 7:50 to 8:39) (p=0.001). In patients with reduced LVEF, there was a tendency toward enhanced 6MWT time in those who showed improvement in all the three upper and lower limb strength and in the Time Up and Go test compared with those who do not improve in all these tests (620 to 553 meters), which did not reach significance.

Conclusion
Strength exercise is a vital component of CR programs and can significantly contribute to improvements in functional capacity. Therefore, its practice should be emphasized to enhance overall program effectiveness. Particularly in patients with reduced ejection fraction, a global strength improvement can have a positive impact on daily life functional capacity.
Outcome of early intervention in sudden cardiac arrest during exercise: case series
Authors: Baiazid D , Alhashimi H , Alassaf O , Musa A 
Published: June 2024

Abstract

Introduction
Exercise is frequently promoted in the realm of health and wellness as a cornerstone of vitality and longevity especially in young healthy individuals. However, for individuals with undiscovered coronary artery disease (CAD), an unexpected threat can emerge from sudden cardiac arrest (SCA).

Purpose
We are evaluating young patients presenting with cardiac arrest during strenuous exercise and found to have significant CAD.

Methodology
In this cross-sectional study all patients who were admitted as a case of post-exercise cardiac arrest between the years 2020 to 2023 and found to have CAD were evaluated. Their demographics, past medical history, laboratory workup findings, quality of CPR, coronary angiography (CAG) findings and outcomes were evaluated. Descriptive analyses were used to report results.

Results
7 cases fulfilled the inclusion criteria all of which were male with a mean age of 41 years old (range: 28-51). All patients had immediate high-quality cardiopulmonary resuscitation (CPR) starting at the time of collapse, the average CPR time till ROSC was 32.4 minutes (range: 10-47). Three patients (43%) were not known to have any comorbidities; 14% had diabetes mellitus, 29% had dyslipidemia, and 29% had previous ischemic heart disease. Furthermore, analysis of the laboratory workup of the three patients not known to have any comorbidities did not reveal any undiscovered comorbidity. Post-ROSC ECGs showed 3 anterior (43%), 3 inferior (43%) and 1 posterior (14%) territory changes and urgent CAG showed the Left Anterior Descending artery to be the culprit artery in four of the patients, Right Coronary artery in two and the Left Circumflex in the other two. 57% of patients were discharged alive, 29% of which had a neurological deficit, while 43% were deceased.
Discussion: Although cardiac arrest is not a common presentation of CAD, exercise can induce coronary stenosis and an adrenaline surge that can cause ventricular arrhythmias and/or cardiac arrest. While most patients in our study experienced positive outcomes, it's important to note that not all shared this favorable result. This variation emphasizes the importance of early intervention managing exercise-related cardiac events. Moreover, our study illustrates the importance of immediate high-quality CPR for better outcomes.

Conclusion
Strenuous exercise may precipitate cardiac arrest in individuals with undiscovered coronary artery disease; however, early life-saving interventions including high-quality CPR and percutaneous coronary intervention (PCI) have the potential to improve the overall prognosis.