bluuebunny/crossref_metadata_2025_split huggingface dataset:
Disease trajectories following myocardial infarction: insights from process mining of 145 million hospitalisation episodes
Authors: Hayward C , Batty J , Westhead D R , Johnson O , Gale C P , Wu J , Hall M 
Published: November 2023

Abstract
The number of survivors of MI has increased dramatically in recent decades, yet knowledge of post-myocardial infarction (MI) disease risk to date is limited. We investigated temporally ordered sequences of all conditions following MI in nationwide electronic health record data through the novel application of process mining. Here, we present, for the first time, the observed sequences of diseases that individuals accrue post MI.
We conducted a national retrospective cohort study of all hospitalisations (145,670,448 episodes, 34,083,204 individuals) admitted to NHS hospitals in England (1st January 2008-31st January 2017, final follow up 27th March 2017). Through process mining we identified trajectories of all major disease diagnoses following MI and compared their adjusted relative risk (RR) and all-cause mortality hazard ratios (HR) to a risk-set matched non-MI control cohort using flexible parametric survival models.
Among a total of 375,669 (1·1%) MI patients (872,450 episodes) and 1,878,345 (5·5%) matched non-MI patients (4,712,654 episodes), we identified 28,740 unique disease trajectories. The accrual of multiple circulatory diagnoses was more common amongst MI (RR 4·37, 95% CI 4·00-4·77) and conferred an increased risk of death (HR 1·32, 1·14-1·54) compared with matched controls.
Further, trajectories featuring neuro-psychiatric diagnoses (including anxiety and depression) in conjunction with circulatory disorders, were markedly more common and had increased mortality post MI (HR ranging from 1·12 to 1·74) compared with non-MI individuals.
Pathways involving both circulatory and digestive diseases appeared more frequently in the MI cohort versus matched controls (RR 4·03 [3·87-4·20] to 4·77 [4·28-5·32]). A number of trajectories including disorders of the eye/adnexa were also associated with an increased risk of death compared with matched controls (HR: 1·32, 1·11-1·57), with those eye/adnexa disorders consisting mainly of cataracts (77·6%).
This study quantifies the relative risk and mortality burden associated with disease trajectories following MI from a nationwide hospitalisation cohort for the first time. These data show the significant ongoing cardiovascular disease burden following MI, and crucially highlight the excess accrual of neuro-psychiatric diagnoses conferring increased mortality compared with non-MI individuals. These data provide a clear opportunity for early intervention targets, such as increased focus on the psychological and behavioural pathways for survivors of MI, to mitigate ongoing adverse disease trajectories, multimorbidity and premature mortality. Further understanding of the factors contributing to these trajectories is required to facilitate identification of patients in the early post-MI setting who would benefit most from closer follow-up and prompt intervention.Trajectories: primary diseasesTrajectories: primary+secondary diseases
Simulating atrial fibrillation patterns and screening strategies using virtual patient-level models
Authors: Cai M , Barrios-Espinosa C , Rienstra M , Crijns H , Schotten U , Heijman J 
Published: November 2023

Abstract

Introduction
Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased morbidity and mortality. However, early detection and treatment of AF are hampered by highly variable occurrence and duration of AF episodes, heterogenous patterns of AF progression, and poor symptom-rhythm correlation present in many patients.

Purpose
To develop a computational patient-level model for simulating individual AF episodes, AF progression, and associated clinical outcomes, and to compare the effectiveness of systematic or symptom-based 1-minute electrocardiography (ECG) or 14-day Holter screening using this model.

Methods
We developed a Markov model with 7 different rhythm and/or clinical states (sinus rhythm (SR), asymptomatic and symptomatic AF, each with or without previous stroke, and death) and age/sex-dependent transition probabilities estimated based on clinical data (Figure 1A). Additionally, transitions between SR and AF states were modulated by AF-related remodeling, which itself was controlled by the time in AF and age.

Results
The virtual patient-level model enabled the simulation of changes in rhythm status and clinical outcomes during an entire lifetime with minute-level resolution (Figure 1B). Age/sex-specific AF prevalence / incidence, the proportion of symptomatic episodes and mortality in 4000 virtual patients were in good agreement with clinical data (Figure 1C). We employed the perfect knowledge about rhythm status at any moment in time provided by the model to evaluate systematic and symptom-based 1-minute ECG and 14-day Holter screening for AF in this population. In total, 2372 virtual patients &gt;65 years developed AF. Systematic yearly 1-minute ECG recordings only identified 58 (2.4%) patients. In contrast, 14-day Holter-monitoring detected 18% of AF patients over 65 with a median of 532 days earlier than their clinical AF diagnosis, and identified 11.8% of AF patients who were either completely asymptomatic or only had symptomatic episodes &lt;3 hours. Short-term (2-week) screening after a first symptom had a very low yield, which increased with increasing screening frequency and duration of follow-up (Figure 2). The majority of the remaining AF patients could be diagnosed when their symptoms lasted ≥3 hours, providing time for a traditional clinical diagnosis.

Conclusion
Our novel patient-level AF model can simulate individual AF patterns and clinical outcomes such as stroke and death in large cohorts of virtual patients. The model highlights the variability of AF episodes that makes effective early detection of asymptomatic AF with short-term monitoring challenging, and provides a tool for future studies into AF progression, screening and prevention of AF-related stroke and mortality.Figure 1Figure 2
Relationship between pre-procedural non-ischemic ST-segment depression and the clinical outcomes after catheter ablation in persistent atrial fibrillation patients
Authors: Yano M , Egami Y , Kawanami S , Sugae H , Ukita K , Kawamura A , Nakamura H , Yasumoto K , Tsuda M , Okamoto N , Matsunaga-Lee Y , Nishino M , Tanouchi J 
Published: November 2023

Abstract

Background
ST-segment depression suggests the presence of coronary artery disease (CAD) during sinus rhythm, but the clinical significance, including the outcomes after catheter ablation (CA), in atrial fibrillation (AF) patients remains unknown.

Purpose
The aim of this study was to investigate the relationship between non-ischemic ST-segment depression during AF rhythm before CA and late arrhythmia recurrence in persistent AF (PerAF) patients.

Methods
The present study included PerAF patients from the Osaka Rosai Atrial Fibrillation ablation (ORAF) registry who underwent an initial ablation and had no history of CAD. We assigned the patients based on the presence of ST-segment depression before CA and evaluated the impact of relevant factors on ST-segment depression and the relationship between ST-segment depression, including leads locations (anterior leads, inferior leads, and lateral leads) or depression type (upsloping, horizontal and downsloping) or the degree of ST-segment depression and late recurrence of AF (LRAF).

Results
This study population included a total of 551 patients of which 189 had ST-segment depression. The median follow-up duration was 397 days and LRAF occurred in 195 patients. By multiple regression analysis, diabetes mellitus, hemoglobin, brain natriuretic peptide, left ventricular ejection fraction and left atrial diameter were significant determinants of ST-segment depression before CA. Kaplan-Meier analysis demonstrated that the patients with ST-segment depression had a significantly greater risk of LRAF than those without (p&lt;0.001). Multivariate Cox proportional hazards analysis showed ST-segment depression was independently and significantly associated with a higher risk of LRAF (p&lt;0.001). The patients with ST-segment depression≥0.15mV had a significantly higher risk of LRAF than those with ST-segment depression≥0.15mV (p&lt;0.001). No significant differences among the ST-segment depression leads locations and ST-segment depression type were observed.

Conclusion
Non-ischemic ST-segment depression during AF rhythm was significantly associated with LRAF post CA in PerAF patients.
Effect of telemedicine on health-related quality of life in patients with heart failure: insights from the iCOR randomised controlled trial
Authors: Pons Riverola A , Yun S , Jose N , Calero E , Ruiz M , Alcoberro L , Jimenez S , Moliner P , Ramos R , Ras M , Verdu J M , Garay A , Corbella M , Enjuanes C , Comin-Colet J 
Published: November 2023

Abstract

Background/introduction
Heart failure (HF) can negatively affect health-related quality of life (HRQoL) in HF patients by reducing their independence and limiting their daily activities. Patient-reported outcome measures (PROMs), such as HRQoL, are useful indicators to health status and have good correlation with prognosis. In the past years the addition of telemedicine (TM) to HF programmes has emerged as a promising strategy for the management of chronic HF patients. However, there is little information about the impact of TM on HRQoL.

Purpose
To determine the effect of a TM-based intervention on HRQoL of high-risk chronic HF patients compared to usual care (UC).

Methods
We performed a sub-analysis of the "Insuficiència Cardíaca Optimització Remota" (iCOR) study focusing on HRQoL. iCOR was a single centre, randomised, controlled trial, designed to evaluate a TM intervention added to an existing nurse-based, hospital/primary care multidisciplinary, integrated programme for high-risk chronic HF patients. Participants were randomised to TM or UC after hospital discharge ("vulnerable-phase") and were followed for 6 months. The primary study endpoint for the current analysis was the delta change of HRQoL after 6 months of follow-up, assessed using Minnesota Living with Heart failure Questionnaire (MLHFQ). Impaired HRQoL was considered when patient scored &gt; 55 points. To assess the change in HRQoL between the 2 groups, a repeated-measures ANOVA analysis was performed, adjusted for baseline HRQoL.

Results
178 patients with HF were analysed (81 TM vs 97 UC). The median age of the patients was 74±11 years, 41% were female and 57% had preserved ejection fraction.
As shown in figure 1, HRQoL was poor at baseline (median score of 55±20 points in TM vs 59±19 points in UC) and was not different between both groups (p-value &gt; 0.05). Although both groups showed an improvement in HRQoL after 6 months of follow-up (p-value 0.001 for time effect), HRQoL improved significantly more in the TM-based intervention group (from 55±20 to 14±15, mean Delta change= -37.9±26.4) than in UC group (from 59±19 to 23±21, mean delta change = -29.7±29.1, p-value 0.008) (Figure 1). We designed several multivariate linear regression models exploring the determinants of HRQoL at baseline and the determinants of change in HRQoL over time. As shown in Table 1, HRQoL at baseline, cognitive function (MMSE [mini-mental state examination] and Pfeiffer), affective status and randomisation arm were the only independent predictors of improvement of HRQoL over time.

Conclusions
The addition of TM to a standard HF programme is effective in improving HRQoL in high risk patients with chronic HF regardless cognitive function, affective status or frailty.HRQoL status changeDeterminants of HRQoL
Digital health in the EP lab: Initial experience using remote access and technical support for complex ablation procedures
Authors: Feher M , Heeger C , Kirstein B , Phan L , Hatahet S , Eitel C , Schmidtke C , Kuck K H , Vogler J , Tilz R 
Published: November 2023

Abstract

Aims/Objectives
Three-D electroanatomical mapping (EAM) systems are a prerequisite for treatment of complex arrhythmias. Until date, the EAM system is operated by qualified staff or a field technical engineer (FTE) from the control room.
Novel technology allows for remote access (RA) of the EAM from anywhere in the world. RA increases the flexibility of the EP lab, reduces travel time for the FTE and overcomes hospital access limitations e. g. during the COVID-19 pandemic.
We report on the safety and feasibility of remote operation of the EAM for complex ablation procedures.

Methods
RA mapping was achieved by combining the EAM software with an integrated audiovisual solution for remote support. Communication between the operator and the remote support was achieved using internet-based headphones in the RA group. The 3D EAM system was controlled exclusively from home office. In the conventional group (CG), EAM was exclusively controlled from the control room in the EP lab. Ablation procedures were performed as per institutional standard.

Results
We investigated 50 RA assisted consecutive electrophysiological procedures from 09/2022 to 02/2023 in our University Heart Center. We compared a group of patients undergoing ablation procedures with RA assistance (28/50 (56%) patients were male, median age: 66.5 yrs [IQR 56, 76], BMI: 25.2 kg/m2 [IQR 22, 30]) with a control group (31/50 (62%) male, median age: 66.5 yrs [IQR 54, 78], BMI 28.2 kg/m2 [IQR 24, 30], p &gt; 0.05 for all). Ablation procedures were matched in both groups: 20 pulmonary vein isolations (3 paroxysmal, 17 persistent atrial fibrillation ), 4 cavotricuspidal isthmus ablations, 13 ablations of atrial tachycardia, 1 premature ventricular complex ablation, 3 of ventricular tachycardia, 2 AV reentry tachycardia and 7 AV-node reentry tachycardia cases. In the RA group, the 3D EAM system was controlled exclusively from home office in all patients. In one patient, the internet based headphone connection was instable. Therefore, the communication was established via a conventional smartphone. No other technical issue was noted. No switch to in house support was required. There were no major complications observed.
Procedural data (total procedure time median 100 min [IQR 76, 120] vs. control group 86 min [IQR 60, 110], total fluoroscopy time (median 9.1 min [IQR 6, 13] vs. control group 8.7 min [IQR 5, 12], p &gt; 0.05) were comparable to previous procedures without RA.
Due to RA travel time could be reduced by 139 hr in total in comparison to the control group.

Conclusions
RA for EAM of any arrhythmia is feasible and safe in this single center study. Procedural data were comparable to previous procedures. In the future, this new solution might have a great impact on facilitating EP procedures.Table procedural data
Performance of a multisensor implantable defibrillator algorithm for HF monitoring in the presence of atrial fibrillation
Authors: Boriani G , Bertini M , Manzo M , Calo L , Santini L , Savarese G , Dello Russo A , Santobuono V E , Lavalle C , Viscusi M , Amellone C , Calvanese R , Santoro A , Imberti J , D'onofrio A 
Published: November 2023

Abstract

Background
Some implantable cardioverter defibrillators (ICD) are equipped with diagnostic algorithms that combine data from multiple sensors. The HeartLogic Index was shown to accurately stratify patients at risk of heart failure (HF) events. However, there are no data on its performance in the presence of atrial fibrillation (AF). We evaluated and compared the performance of the algorithm during sinus rhythm and during long-lasting AF episodes.

Methods
The feature was activated in 568 ICD patients from 26 centers. We analyzed stored data to identify periods of ≥30 consecutive days with atrial high-rate episode (AHRE) burden &lt;1hour/day, and periods with AHRE burden ≥20hours/day. Then, we identified patients who met both conditions during their follow-up (AHRE group, N=53), to allow pairwise comparison of periods. For control purposes, we identified patients with AHRE burden &lt;1h during the entire follow-up and we implemented a 2:1 propensity score matching versus the AHRE group (Matched non-AHRE group, N=106).

Results
In the AHRE group, the rate of HeartLogic alerts was 1.2 (95%CI:1.0-1.5) /patient-year during periods with AHRE burden &lt;1hour/day and 2.0 (95%CI:1.5-2.6) /patient-year during AHRE burden ≥20hours/day periods (p=0.004). Significantly higher values of the combined index were recorded during periods with AHRE burden ≥20 hours/day (in Figure the average combined index – Day 0: alert day). The rate of HF hospitalizations was 0.34 (95%CI:0.15-0.69) /patient-year during IN-alert periods and 0.06 (95%CI:0.02-0.14) /patient-year during OUT-of-alert periods (p&lt;0.001). The IN/OUT-of-alert state incidence rate ratio of HF hospitalizations was 8.59 (95%CI:1.67-55.31) during periods with AHRE burden &lt;1hour/day and 2.70 (95%CI:1.01-28.33) during AHRE burden ≥20hours/day periods. In the Matched non-AHRE group, the rate of HF hospitalizations was 0.29 (95%CI:0.12-0.60) /patient-year during IN-alert periods, and 0.04 (95%CI:0.02-0.08) /patient-year during OUT-of-alert periods (p&lt;0.001). The incidence rate ratio was 7.11 (95% CI: 2.19-22.44).

Conclusions
Patients seemed more exposed to alerts during periods of AF. The ability of the algorithm to identify increased risk of HF events was confirmed during AF, despite a lower IN/OUT-of-alert incidence rate ratio when compared to non-AF periods and non-AF patients.
Analisys of e-consults in a cardioly department. More than future
Authors: Sanchez Sanchez C , Fernandez Ruz L , Claros Ruiz J A , Delgado Prieto J L , Urbano Carrillo C 
Published: November 2023

Abstract

Background
Telemedicine is a new concept in the healthcare sector but due to the recent rapid technological advancements, it has been growing expeditiously, helped by the COVID-19 pandemic. In the field of cardiology, it has been gaining importance, and it can help to reduce waiting lists, which in countries like Spain can be months long. Mainly in certain procedures that do not require an anamnesis or a face-to-face physical examination by the cardiologist.

Purpose
Evaluate the main reasons for teleconsultation in our cardiology department (since its launch in 2021) from general practitioners, to develop training programs and how to optimize this type of consultation.

Methods
We conducted a retrospective study at our hospital, analyzing all teleconsultations since the cardiology program began in 2021. For each teleconsultation, we analyzed: the reason for the consultation, the response time of the cardiologist, if the patient was referred for a face-to-face consultation, and if changes were made in the treatment of the patients.

Results
We evaluated a total of 330 teleconsultations from 12 health centers whose patients corresponded to our service. The median age was 70 (±18,9) years and 55.7% were men. A growing trend in its use was observed from November 2021 to January 2023, going from 12 to 32 teleconsultations per month .The main reason for consultation was ECG doubts (47%), followed by the management of atrial fibrillation (20%) and the management of drugs in ischemic heart disease (10.6%). The rest were related to AHT control (4.5%), management of palpitations (3%) or congestion in heart failure (2%). Within the teleconsultations, 100% were resolved electronically, requiring face-to-face follow-up in only 22.4% of them. They were answered in an average of 2.1 (±2,6) days from their referral by the primary care physician and only 40% of the patients required changes in treatment. Regarding the doubts in the ECG, 73% were compatible variations from normality that did not require further follow-up. Among the questions in AF, 56% were based on doubts about anticoagulation, 13% about adverse effects in the medication, and 7% about heart rate control. 68% of teleconsultations about ischemic heart disease were about the duration of dual antiplatelet therapy.

Conclusion(s)
Teleconsultation in the field of cardiology is a very useful tool that allows contact between the cardiologist and the primary care physician in a short time without the need for the patient to attend emergency services (which are increasingly overloaded with non-urgent consultations) or wait for physical consultation for long periods of time. The field of teleconsultations should be restricted to assessments where the physical examination or patient history by the cardiologist is not essential, being limited to certain fields.
Digital follow-up program for patients undergoing atrial fibrillation ablation: a pilot single-center study
Authors: Brandao M , Teixeira R , Goncalves Almeida J , Fonseca P , Mosalina Manuel A , Ramires F , Ferreira P , Sousa M , Oliveira M , Goncalves H , Primo J , Fontes-Carvalho R 
Published: November 2023

Abstract

Introduction
Atrial fibrillation (AF) carries significant burden in health expenditure worldwide. Digital health technology may improve healthcare delivery, but its applicability in clinical practice and related outcomes remain a gap in evidence.

Aim
To report the implementation of a digital follow-up program (FUP) for patients submitted to AF ablation in an European center.

Methods
A digital FUP was implemented at a high-volume ablation center in 2020. The program featured a web platform for professionals, to record Clinician Reported Outcome Measurements (CROMs), during remote medical visits, and access Patient Reported Outcomes Measurements (PROMs). The program also included a mobile app for patients to report symptoms, vital signs, anthropometric and electrocardiographic data. Patients were invited to complete questionnaires at prespecified timepoints: Atrial Fibrillation Effect on qualiTy-of-life [AFEQT]; the Epworth and STOP-BANG for obstructive sleep apnea; nutritional questionnaire. Completeness rate was defined by the ratio of queries completed/queries sent at each timepoint.
The mHealth App Usability Questionnaire (MAUQ) questionnaire was sent to patients and doctors; patients also received a Patient Reported Experience Measure (PREMs) 15 days after the ablation, from which a Net Promotor Score (NPS, -100 to 100) was calculated to express user’s satisfaction. This retrospective analysis includes data collected from December 2020 to September 2022.

Results
From the 305 ablations performed in this period, 253 patients were enrolled in the digital FUP: age 60±11 years, 67% male, 78% paroxysmal AF, body mass index 27.4±4.2 kg/m2.
During a mean follow-up time of 11.9±5.8 months, 1120 CROMs were registered; 1449 PROMs were collected, including 5865 metrics reported by 90 different patients. App usage, measured by unique logins/month, was recorded in 54% of patients, of whom 13% submitted symptom checks weekly.
160 PREMs were registered; NPS scores for ablation and the app were 85.5 and 31.5, respectively [image].
Questionnaire overall completeness rate was: 54.5% for AFEQT; 14.4% for Epworth; 20.8% for STOP-BANG, that identified 55% of patients at high risk for sleep apnea. Nutritional assessment was completed by 18.7%; obese/pre-obese status was found in 21% and 48%, respectively; 18 patients were enrolled in a nutritional program.
All doctors "agreed"/"strongly agreed" to overall satisfaction with the app.

Conclusions
The digital FUP was feasible and aided comorbidities assessment. Strategies to improve patient’s engagement and digital literacy are warranted. Further studies are needed to evaluate the platform’s impact on clinical outcomes.