Energy Drinks and Their Acute Effects on Heart Rhythm and Electrocardiographic Time Intervals in Healthy Children and Teenagers: A Randomized Trial

Beyond their effect on blood pressure, the effect of energy drinks on heart rate in children and teenagers has not been evaluated until now. Thus, this study aimed to investigate the acute cardiovascular effects of energy drinks in healthy children and teenagers. Twenty-six children and adolescents (mean age 14.49 years) received a commercially available energy drink (ED) and placebo on two consecutive days based on the maximum caffeine dosage as proposed by the European Food Safety Authority. Heart rhythm and electrocardiographic time intervals were assessed in a prospective, randomized, double-blind, placebo-controlled, crossover clinical study design. ED consumption resulted in a significantly increased number of supraventricular extrasystoles (SVES) compared to the placebo, whereas supraventricular tachycardia or malignant ventricular arrhythmias were not observed. The mean heart rate (HR) was significantly lower following consumption of EDs. In contrast, QTc intervals were not affected by EDs. Being the first of its kind, this trial demonstrates the cardiovascular and rhythmological effects of EDs in minors. Interestingly, EDs were associated with adverse effects on heart rhythm. Whether higher dosages or consumption in children with preexisting conditions may cause potentially harmful disorders was beyond the scope of this pilot study and remains to be determined in future trials. Trial Registration Number (DRKS-ID): DRKS00027580.

Mobile Health for Arrhythmia Diagnosis and Management

Palpitations are a common symptom managed by general practitioners and cardiologists; atrial fibrillation (AF) is the most common arrhythmia in adults. The recent commercial availability of smartphone-based devices and wearable technologies with arrhythmia detection capabilities has revolutionized the diagnosis and management of these common medical issues, as it has placed the power of arrhythmia detection into the hands of the patient. Numerous mobile health (mHealth) devices that can detect, record, and automatically interpret irregularities in heart rhythm and abrupt changes in heart rate using photoplethysmography (PPG)- and electrocardiogram-based technologies are now commercially available. As opposed to prescription-based external rhythm monitoring approaches, these devices are more inexpensive and allow for longer-term monitoring, thus increasing sensitivity for arrhythmia detection, particularly for patients with infrequent symptoms possibly due to cardiac arrhythmias. These devices can be used to correlate symptoms with cardiac arrhythmias, assess efficacy and toxicities of arrhythmia therapies, and screen the population for serious rhythm disturbances such as AF. Although several devices have received clearance for AF detection from the United States Food & Drug Administration, limitations include the need for ECG confirmation for arrhythmias detected by PPG alone, false positives, false negatives, charging requirements for the battery, and financial cost. In summary, the growth of commercially available devices for remote, patient-facing rhythm monitoring represents an exciting new opportunity in the care of patients with palpitations and known or suspected dysrhythmias. Physicians should be familiar with the evidence that underlies their added value to patient care and, importantly, their current limitations.

Subcutaneouscardiac Rhythm Monitors: A Comprehensive Review

Subcutaneous loop recorders (SCRMs) are subcutaneous electronic devices which have revolutionized the field of arrhythmia detection. They have become increasingly appealing due to advances such as miniaturization of device, longer battery life, bluetooth capabilities and relatively simple implantation technique without the need for complex surgical suites. They can be implanted in the office, patient bedside without the need to go to the operating room. One of the most common indications for their implantation is detection of atrial fibrillation (AF) after a cryptogenic stroke. They have also been utilized for assessing the success of rhythm control strategies such post pulmonary venous isolation. More recently studies have assessed the utility of SCRMs for detecting silent AF in at risk populations such as patients with sleep apnea or those on hemodialysis. In this paper, we review the evolution of SCRMs, the clinical studies assessing their value for different indications, their role incurrent clinical practice and future avenues in the era of smart wearable devices like apple watch etc.

Caffeine increases performance and leads to a cardioprotective effect during intense exercise in cyclists

The present study was designed to investigate the effects of different caffeine dietary strategies to compare the impact on athletic performance and cardiac autonomic response. The order of the supplementation was randomly assigned: placebo(4-day)-placebo(acute)/PP, placebo(4-day)-caffeine(acute)/PC and caffeine(4-day)-caffeine(acute)/CC. Fourteen male recreationally-trained cyclists ingested capsules containing either placebo or caffeine (6 mg kg-1) for 4 days. On day 5 (acute), capsules containing placebo or caffeine (6 mg kg-1) were ingested 60 min before completing a 16 km time-trial (simulated cycling). CC and PC showed improvements in time (CC vs PP, Δ - 39.3 s and PC vs PP, Δ - 43.4 s; P = 0.00; ƞ2 = 0.33) and in output power (CC vs PP, Δ 5.55 w and PC vs PP, Δ 6.17 w; P = 0.00; ƞ2 = 0.30). At the final of the time-trial, CC and PC exhibited greater parasympathetic modulation (vagal tone) when compared to the PP condition (P < 0.00; ƞ2 = 0.92). Our study provided evidence that acute caffeine intake (6 mg∙kg-1) increased performance (time-trial) and demonstrated a relevant cardioprotective effect, through increased vagal tone.

Cardiac monitoring for patients with palpitations

Palpitations are one of the most common reasons for medical consultation. They tend to worry patients and can affect their quality of life. They are often a symptom associated with cardiac rhythm disorders, although there are other etiologies. For diagnosis, it is essential to be able to reliably correlate the symptoms with an electrocardiographic record allowing the identification or ruling out of a possible rhythm disorder. However, reaching a diagnosis is not always simple, given that they tend to be transitory symptoms and the patient is frequently asymptomatic at the time of assessment. In recent years, electrocardiographic monitoring systems have incorporated many technical improvements that solve several of the 24-h Holter monitor limitations. The objective of this review is to provide an update on the different monitoring methods currently available, remarking their indications and limitations, to help healthcare professionals to appropriately select and use them in the work-up of patients with palpitations.

Reversible, regional ST-segment elevation due to chylothorax

Chylothorax is an uncommon complication of thoracic surgery and, to our knowledge, has never been documented as a cause of dynamic ST-segment elevation (STE). A 63-year-old woman with history of right pneumonectomy presented with chest pain and regional STE on 12-lead electrocardiogram (ECG). Normal troponin-I and a computed tomography (CT) scan showing a large right hemithoracic fluid collection indicated the unique cause of STE, which resolved after thoracentesis, was pericardial inflammation and cardiac compression from chylothorax. This case emphasizes nuances of ECG interpretation in the context of regional STE and explores the pathophysiology that links chylothorax with acute pericarditis.

Interaction of Energy Drinks with Prescription Medication and Drugs of Abuse

In recent years, the consumption of energy drinks (EDs) has become increasingly popular, especially among adolescents. Caffeine, a psychostimulant, is the main compound of EDs which also contain other substances with pharmacological effects. This review aims to compile current evidence concerning the potential interactions between EDs, medicines, and drugs of abuse as they are frequently consumed in combination. The substances involved are mainly substrates, inductors or inhibitors of CYP1A2, psychostimulants, alcohol and other depressant drugs. Furthermore, intoxications reported with EDs and other substances have also been screened to describe acute toxicity. The results of our review show that the consumption of both EDs alone and in combination is not as safe as previously thought. Health professionals and consumers need to be aware of the potential interactions of these drinks as well as the absence of long-term safety data.

Low physical activity is associated with impaired endothelial function in patients with type 2 diabetes and controls after 5 years of follow-up

BACKGROUND

The long-term association between physical activity and endothelial function has not previously been investigated in patients with type 2 diabetes. Therefore, we aimed to evaluate the relationship between physical activity and endothelial function, assessed by peripheral arterial tonometry, in patients with type 2 diabetes and non-diabetic controls after 5 years of follow-up.

METHODS

We included 51 patients with newly diagnosed type 2 diabetes and 53 sex- and age matched controls. Participants underwent baseline clinical characterization including objective measurement of physical activity level using accelerometery. After 5 years of follow-up, participants were re-examined, and endothelial function was assessed as natural logarithm of reactive hyperemia index (lnRHI).

RESULTS

Physical activity at baseline was associated with lnRHI after 5 years of follow-up in both patients with type 2 diabetes and controls. An increase of 1 standard deviation (SD) in daytime physical activity corresponded to a 6.7 % increase in RHI (95 % confidence interval: 1.1;12.5 %, p = 0.02). We found no difference in lnRHI between patients with diabetes and controls (0.67 ± 0.29 vs. 0.73 ± 0.31, p = 0.28).

CONCLUSIONS

Daytime physical activity is associated with endothelial function after 5 years of follow-up in patients with type 2 diabetes and controls.

Managing athletes with palpitations of unknown origin with an external loop recorder: a cohort study

BACKGROUND

Palpitations in athletes are usually benign, but the presence of major cardiac arrhythmias should be ruled out despite the infrequent appraisal of symptoms. External loop recorders (ELR) are promising to identify arrhythmias in these circumstances, but experiences in athletes are lacking. We aimed to investigate the feasibility and diagnostic yield of an ELR in athletes with unexplained palpitations in a cohort study.

METHODS

122 consecutive subjects (61 athletes and 61 sedentary controls) with sporadic palpitations and inconclusive diagnosis were enrolled and equipped with an ELR. Findings were categorized as major and minor arrhythmic findings, non-arrhythmic findings or negative monitoring.

RESULTS

Long-term ELR monitoring was feasible in all subjects, with median duration of 12 (11; 15) days. Major arrhythmic events during palpitations were found in 9 (14.8%) athletes: 7 experienced sustained paroxysmal supraventricular tachycardia, and 2 had non sustained ventricular tachycardia. Minor arrhythmic events (premature supraventricular or ventricular beats) were observed in 13 athletes (21.3%). Non-arrhythmic findings (i.e., sinus rhythm or sinus tachycardia) were recorded in 28 athletes (45.9%), whereas 11 (18%) had negative monitoring. In the sedentary group, arrhythmic events were similar for types and frequency to athletes. The diagnostic yield of loop monitoring was 82.8% in the overall population and 82.0% in the athlete's group.

CONCLUSIONS

In the management of an athlete symptomatic with unexplained palpitations after 24-hour ECG monitoring and stress test, ELR is an efficient tool to identify major arrhythmic events, which can be present in up to 10% of symptomatic athletes during practice and competition.

Heinzel F, Davos CH, Kudaiberdieva G, Frederix I, Svendsen JH, Hansen D. Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

Human Body-Electrode Interfaces for Wide-Frequency Sensing and Communication: A Review

Several on-body sensing and communication applications use electrodes in contact with the human body. Body-electrode interfaces in these cases act as a transducer, converting ionic current in the body to electronic current in the sensing and communication circuits and vice versa. An ideal body-electrode interface should have the characteristics of an electrical short, i.e., the transfer of ionic currents and electronic currents across the interface should happen without any hindrance. However, practical body-electrode interfaces often have definite impedances and potentials that hinder the free flow of currents, affecting the application's performance. Minimizing the impact of body-electrode interfaces on the application's performance requires one to understand the physics of such interfaces, how it distorts the signals passing through it, and how the interface-induced signal degradations affect the applications. Our work deals with reviewing these elements in the context of biopotential sensing and human body communication.

The 2020 ESC Guidelines on the Diagnosis and Management of Atrial Fibrillation

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The Clinical Significance of Drug-Food Interactions of Direct Oral Anticoagulants

Cardiovascular diseases are the most common cause of death in the world. For almost 60 years, vitamin K antagonists (VKAs) were the mainstay of anticoagulation therapy, but in recent years direct oral anticoagulants (DOACs) have become the anticoagulant treatment of choice. DOACs were initially considered drugs with no significant food interactions; however, clinical observations from daily practice have proved otherwise as interactions with food ingredients have been reported. Food, dietary supplements or herbs may contain substances that, when administered concomitantly with DOACs, can potentially affect the plasma concentration of the drugs. The aim of this paper was to evaluate the clinical significance of drug-food interactions of DOACs, such as dabigatran, rivaroxaban, apixaban, edoxaban and betrixaban. Patients treated with anticoagulants should avoid products containing St. John's wort and take special care with other food ingredients. As the interest in dietary supplements is on the rise, healthcare providers can contribute to the development of well-designed clinical trials on interactions between DOACs and food, and distribute sufficient knowledge about the proper use of these supplements among patients.

Implantable loop recorders in patients with heart disease: comparison between patients with and without syncope

OBJECTIVE

Patients with heart disease are at increased risk for sudden cardiac death. Guidelines recommend an implantable loop recorder (ILR) for symptomatic patients when symptoms are sporadic and possibly arrhythmia-related. In clinical practice, an ILR is mainly used in patients with unexplained syncope. We aimed to compare the clinical value of an ILR in patients with heart disease and a history of syncope versus those with non-syncopal symptoms.

METHODS

In this observational single-centre study, we included symptomatic patients with heart disease who received an ILR. The primary endpoint was an actionable event which was defined as an arrhythmic event leading to a change in clinical management. The secondary endpoint was an event leading to device implantation.

RESULTS

One hundred and twenty patients (mean age 47±17 years, 49% men) were included. The underlying disease substrate was inherited cardiomyopathy (31%), congenital heart disease (28%), channelopathy (23%) and other (18%). Group A consisted of 43 patients with prior syncope and group B consisted of 77 patients with palpitations and/or near-syncope. The median follow-up duration was 19 months (IQR 8-36). The 3-year cumulative event rate was similar between groups with regard to the primary endpoint (38% vs 39% for group A and B, respectively, logrank p=0.54). There was also no difference in the 3-year cumulative rate of device implantation (21% vs 13% for group A and B, respectively, logrank p=0.65).

CONCLUSION

In symptomatic patients with heart disease, there is no difference in the yield of an ILR in patients presenting with or without syncope.

The Cardiovascular Benefits of Caffeinated Beverages: Real or Surreal? /"Metron Ariston - All in Moderation"

Caffeinated beverages are the most widely consumed beverages globally with coffee and tea as the two most prominent sources of caffeine. Caffeine content varies across different types of beverages. In addition to caffeine, coffee and tea have other biologically active compounds, and all may affect general and cardiovascular (CV) health. Moderate caffeine consumption (<300-400 mg/day), regardless of the source, is considered safe by both European and US Health Authorities, as it is not associated with adverse health and CV effects, while it may confer certain health benefits. There is a nonlinear association between coffee ingestion and CV risk; moderate coffee drinking is inversely significantly associated with CV risk, with the highest benefit at 2-4 cups per day, while heavy coffee drinking might confer increased risk. With regards to tea, due to a lower caffeine content per serving, its consumption is only limited by the total caffeine daily intake. Both these caffeinated beverages, coffee and tea, have additional phenolic compounds, with anti-oxidant and anti-inflammatory activities, which confer cardioprotective benefits. Of the several coffee compounds, chloroacetic acids and melanoidins offer such beneficial effects, while diterpenes may have unfavorable effects on lipids. Most of the tea ingredients (polyphenols) are cardioprotective. A major concern relates to energy drinks with their much higher caffeine content which puts individuals, especially adolescents and young adults, at high health and CV risk. All these issues are herein discussed, including pertinent studies and meta-analyses, pathogenetic mechanisms involved and relevant recommendations from health authorities.

Energy Drink-Associated Electrophysiological and Ischemic Abnormalities: A Narrative Review

An increasing number of cardiovascular adverse effects, emergency room visits, and deaths have been linked to energy drinks. In this review, we summarized available published literature assessing electrophysiological and ischemic adverse effects associated with energy drink consumption. Overall, 32 case reports and 19 clinical trials are included in this review. Ventricular arrhythmia, supraventricular arrhythmia, and myocardial ischemia were amongst the most commonly reported in case reports with 3 having a fatal outcome. Although serious ischemic changes, arrhythmias, or death were not observed in clinical trials, significant electrophysiological changes, such as PR/PQ interval shortening/prolongation, QT/QTc shortening/prolongation, and ST-T changes, were noted. QT/QTc interval prolongation appears to be the most significant finding in clinical trials, and there appears to be a dose-response relationship between energy drink consumption and QTc prolongation. The exact mechanisms and the particular combination of ingredients behind energy drink-induced cardiac abnormalities require further evaluation. Until more information is available, energy drink use should be considered as part of the differential diagnosis in appropriate patients presenting with electrocardiographic changes. Further, certain patient populations should exercise caution and limit their energy drink consumption.

Subcutaneous cardiac rhythm monitors: state of the art review

Introduction: Subcutaneous cardiac rhythm monitors (SCRMs) provide continuous ambulatory electrocardiographic monitoring for surveillance of known and identification of infrequent arrhythmias. SCRMs have proven to be helpful for the evaluation of unexplained symptoms and correlation with intermittent cardiac arrhythmias. Successful functioning of SCRM is dependent on accurate detection and successful transmission of the data to the device clinic. As the use of SCRM is steadily increasing, the amount of data that requires timely adjudication requires substantial resources. Newer algorithms for accurate detection and modified workflow systems have been proposed by physicians and the manufacturers to circumvent the issue of data deluge.Areas covered: This paper provides an overview of the various aspects of ambulatory rhythm monitoring with SCRMs including indications, implantation techniques, programming strategies, troubleshooting for issue of false positive and intermittent connectivity and strategies to circumvent data deluge.Expert opinion: SCRM is an invaluable technology for prolonged rhythm monitoring. The clinical benefits from SCRM hinge on accurate arrhythmia detection, reliable transmission of the data and timely adjudication for possible intervention. Further improvement in SCRM technology is needed to minimize false-positive detection, improve connectivity to the central web-based server, and devise strategies to minimize data deluge.

Diagnostic value of implantable loop recorders in patients with unexplained syncope or palpitations

Background

The implantable loop recorder (ILR) is a small cardiac rhythm‐monitoring device. Our aim was to determine ILR diagnostic value in patients with unexplained syncope, presyncope, or palpitations suggesting cardiac arrhythmias.

Methods

This has been a retrospective, observational, single‐center study. We included 181 patients in whom ILR was implanted at the Clinical Center of Serbia between January 2006 and July 2019. An event was marked as diagnostic if it led to a diagnosis and ILR was considered diagnostic if it verified or excluded an arrhythmia as the cause of syncope or palpitations.

Results

The mean age was 51.8 ± 17.8 years and 94 (51.9%) were male. The mean follow‐up period was 20.2 ± 15.8 months. ILR was diagnostic in 98 patients (54.1%). There was no significant difference in diagnostic value of ILR in regard to the baseline patients’ characteristics. The mean time to occurrence of the diagnostic event was 11.1 ± 9.6 months. The time to occurrence of a diagnostic event did not differ significantly between patients who underwent basic as compared to extended diagnostics before ILR implantation.

Conclusions

ILR was able to achieve an etiological diagnosis in 54.1% of patients with unexplained syncope, presyncope, or palpitations suggesting cardiac arrhythmias. In a subgroup of patients with recurrent palpitations, ILR was significantly less diagnostic than in patients with syncope or presyncope. ILR should be implanted beforehand in syncope evaluation process.

Sex differences in echocardiographic predictors of bradycardia detected by implantable loop recorder in patients with syncope and palpitations

OBJECTIVE

Our aim was to investigate whether echocardiography may aid in identifying patients, specifically men, at risk of bradycardia as detected by implantable loop recorders (ILR) in patients evaluated for syncope and palpitations.

METHODS

We included ambulatory patients undergoing ILR implantation for syncope (84%), presyncope (9%), and palpitations (8%). Echocardiographic examination was performed prior to implantation (2.9 months [IQR 1.0-6.0 months]). Echocardiograms were analyzed for conventional and speckle tracking parameters. We examined time to first event of bradycardia, defined as (a) heart rate <30 beats/min and (b) ≥4 beats, including sinus arrest, asystole, sinoatrial block, and second- and third-degree atrioventricular nodal block. We applied Cox proportional hazards models.

RESULTS

A total of 285 patients we enrolled, and during a median time of 2.7 years [IQR 1.0, 3.3 years] of continuous heart rhythm monitoring, 84 (29%) had bradycardia detected by ILR. Patients with bradycardia were older (61 ± 19 years vs 55 ± 18 years, P = .01) and more frequently men (62% vs 44%, P = .01). Sex modified the association between echocardiographic parameters and bradycardia (P interaction <0.05 for all), such that left ventricular LV mass index (HR: 1.02 per 1g/m² increase [1.01-1.04], P < .001), LV ejection fraction (HR: 1.04 per 1% decrease [1.01-1.08], P = .02), and global longitudinal strain (HR: 1.09 per 1% decrease [1.01-1.19], P = .03) were associated with bradycardia in men but not women (P > .05 for all in female). After adjusting for baseline clinical characteristics, medical therapy, and loop indication, the abovementioned parameters remained significantly associated with incident bradycardia in men.

CONCLUSION

Echocardiographic parameters of LV structure and function may potentially be more useful for predicting bradycardia in men than women, among patients undergoing ILR implantation for syncope, presyncope, and palpations.

Driving following defibrillator implantation: a nationwide register-linked survey study

AIMS

Patients are restricted from driving following implantable cardioverter defibrillator (ICD) implantation or shock. We sought to investigate how many patients are aware of, and adhere to, the driving restrictions, and what proportion experience an ICD shock or other cardiac symptoms while driving.

METHODS AND RESULTS

We performed a nationwide survey of all living Danish residents 18 years or older who received a first-time ICD between 2013 and 2016 (n = 3913) and linked their responses with nationwide registers. Of 2741 respondents (47% primary prevention, 83% male, median age 67 years), 2513 (92%) held a valid driver's license at ICD implantation, 175 (7%) of whom had a license for professional driving. Many drivers were unaware of driving restrictions: primary prevention 58%; secondary prevention 36%; post-appropriate shock 28%; professional drivers 55%. Almost all (94%) resumed non-professional driving after ICD implantation, more than one-third during the restricted period; 35% resumed professional driving. During a median follow-up of 2.3 years, 5 (0.2%) reported receiving an ICD shock while driving, one of which resulted in a traffic accident. The estimated risk of harm was 0.0002% per person-year.

CONCLUSION

In this nationwide study, many ICD patients were unaware of driving restrictions, and more than one third resumed driving during a driving restriction period. However, the rate of reported ICD shocks while driving was very low.

Clinical outcomes following rhythm control for atrial fibrillation: is early better?

Introduction: An integral aspect of atrial fibrillation (AF) management involves better symptom control, incorporating a rate control, rhythm control, or a combination strategy. The 2020 ESC Guidelines suggest that rhythm control strategy should be recommended for symptomatic patients, to mitigate their symptoms and improve the quality of life. However, adequately powered randomized control trials and prospective 'real-world' registries are needed to fully assess the impact of early rhythm control strategies on clinical outcomes in patients with AF.Objective: In this narrative review, we discuss clinical outcomes following rhythm management approach among patients with AF, considering the effectiveness of an early intervention strategy.Expert opinion: Patients involvement and shared decision-making are crucial when deciding the optimal management strategy among patients with AF. For those with newly diagnosed symptomatic AF, an early invasive approach such as catheter ablation may have a role in preventing AF progression and subsequent pathophysiological changes.

Kounis Syndrome Following Hypnale zara (Hump-Nosed Pit Viper) Bite in Sri Lanka

A 47-y-old man was bitten by a hump-nosed viper (Hypnale zara) and gradually developed retrosternal chest pain associated with ST segment elevation on electrocardiogram. He had normal troponin I levels and no evidence of coagulopathy. Initially, he was managed as having anterior ST elevation myocardial infarction with thrombolysis. Later, because troponin levels were normal, he was suggested to have the type I variant of Kounis syndrome (allergic coronary artery spasm). This was supported by high eosinophil counts in peripheral blood. He was successfully managed with supportive treatment and discharged 6 d after the snakebite. Cardiac complications are rarely reported after hump-nosed viper bites, and clinical reports of coronary vasospasm after snakebites are extremely rare in the literature. This is the first known report of Kounis syndrome after a hump-nosed viper bite.

Report of ventricular fibrillation in a 44-year-old man using kratom

Kratom is an unregulated kappa-opioid receptor agonist available for order on the internet that is used as a remedy for chronic pain. We present a case of a middle-aged man who suffered a cardiac arrest in the setting of kratom ingestion.

Gastric perforation mimicking ST-segment elevation myocardial infarction

ST-elevation myocardial infarction (STEMI) is one of the medical emergencies in cardiology with high morbidity and mortality rate which requires rapid response. In elderly patients, its presenting symptoms may be atypical which may cause the diagnosis of MI to be delayed or missed. Therefore, ST-segment elevation on ECG has become the main instrument for initial diagnosis. However, there are a variety of conditions mimicking the ECG changes of STEMI. We report a case of 70-year-old patient with acute peritonitis and pneumoperitoneum secondary to gastric perforation with dynamic ECG changes mimicking anteroseptal STEMI. After the surgery, the ECG dynamically reverted to normal. He was then discharged after 4 days without any remaining symptoms. Misinterpretation of ECG findings may lead to unnecessary aggressive intervention, costly management strategies and delay in appropriate treatment.

Association between lipid profile and endothelial dysfunction as assessed by the reactive hyperemia index

INTRODUCTION

We investigated the associations between endothelial dysfunction (ED) as evaluated by the reactive hyperemia index (RHI) obtained using Endo-PAT2000® and atherosclerotic risk factors in patients who underwent coronary artery angiography (CAG).

METHODS

The subjects consisted of 191 patients who were clinically suspected to have CAD and underwent CAG, and in whom we could perform Endo-PAT2000®. We divided the patients into ED (RHI<1.67, n = 71) and non-ED (RHI≥1.67, n = 120) groups.

RESULTS

The ED group was significantly older and showed a higher ratio of low-density lipoprotein cholesterol (LDL-C) to high-density lipoprotein cholesterol (HDL-C) (L/H) than the non-ED group. A multivariate logistic regression analysis was performed to examine the associations between the presence of ED and age, gender, and BMI in addition to L/H. Age [odds ratio (OR) = 1.03, p = .02] and L/H (OR = 1.64, p = .01) were identified as significant independent markers of the presence of ED. Next, we divided 122 patients with statin treatment into ED (n = 40) and non-ED (n = 82) groups. The ED group tended to have higher L/H and lower HDL-C than the non-ED group. HDL-C (OR = 0.95, p = .01) and age (OR = 1.05, p = .04) were identified as independent markers of the presence of ED.

CONCLUSIONS

L/H was an independent marker of the presence of ED in patients without dyslipidemia. In addition, among patients with statin treatment, HDL-C was an independent marker of the presence of ED.

Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

The mammographic appearance of the BioMonitor implantable loop recorder

The imaging appearance of implantable loop recorders (ILR's) have been described in literature (Steinberger and Margolies, 2017; Mayo and Leung, 2017; Tsau and Berger, 2004)^1-3; however, the mammographic appearance of the BioMonitor ILR produced by BIOTRONIK has not been described. It is important for radiologists interpreting breast imaging to become familiar with the appearance of different implantable cardiac devices on mammograms in order to create accurate reports and adjust imaging protocols to improve imaging quality and lessen patient discomfort as needed.

Factors associated with bleeding events in patients on rivaroxaban for non-valvular atrial fibrillation: A real-world experience

BACKGROUND

Rivaroxaban is a direct oral anticoagulant (DOAC) approved for the treatment of non-valvular atrial fibrillation (NVAF). Data related to the risk factors associated with rivaroxaban-induced bleeding in patients with NVAF remain scarce in the community setting. We sought to investigate these bleeding risk factors in a racially diverse patient population.

METHODS

We conducted a single-center, retrospective study based on a chart review of patients who received rivaroxaban from our outpatient pharmacy from January 2015 to April 2018 for NVAF. Any reported bleeding event (BE) was recorded as either major or minor bleeding event. Demographic and clinical data were collected and analyzed.

RESULTS

Of the 327 patients included in our analysis, 105 (32%) were female, and the mean age was 62 ± 12 years. Among the included patients, 176 (54%) patients were black, 71 (22%) were white, 51 (15.6%) were Hispanic, 13 (4%) were Asian, and 15 (4.6%) belonged to other races. 89 (27.2%) of the patients had co-prescription of aspirin. A total of 24 (7.3%) patients developed BE, out of which 9 (2.7%) patients had a major BE, and 15 (4.5%) patients had minor BE. Non-fatal gastrointestinal bleeding and epistaxis were the most common type of BE. On multivariable analysis, concurrent aspirin use (81 to 325 mg) (P = 0.03; odds ratio (OR) 2.60 [1.08-6.28]) and increasing age (P = 0.00; OR 1.06 [1.01-1.11]) were independent predictors of BE.

CONCLUSION

In community practice, aspirin co-prescription is common among NVAF patients prescribed rivaroxaban. Increasing age and concurrent aspirin use are independent predictors of BE.

LC-MS/MS method for rapid and accurate detection of caffeine in a suspected overdose case

Excessive intake of caffeine, otherwise known to be a safe and mild central nervous system stimulant, causes nausea, vomiting, convulsions, tachycardia, and eventually fatal arrhythmias and death. Caffeine intoxication, a global problem, has been increasing in Japan since 2013. Thus, there is a need for rapid and accurate diagnosis of caffeine poisoning in forensic and clinical toxicology investigations. Herein, we demonstrate rapid and accurate caffeine quantitation by liquid chromatography tandem mass spectrometry using the standard addition method in a fatal case. Biological samples were diluted 500-100,000-fold and subjected to a simple pretreatment (adding caffeine standard and internal standard and passing through a lipid removal cartridge). The multiple reaction monitoring transitions were 195 → 138 for quantitation, 195 → 110 for the qualifier ion, and 204 → 144 for the internal standard (caffeine-d9). The standard plots were linear over 0-900 ng/mL (r² = 0.9994-0.9999) for biological samples, and the reproducibility (%RSD) of the method was 1.53-6.97% (intraday) and 1.59-10.4% (interday). Fatal levels of caffeine (332 μg/mL) and toxic to fatal levels of olanzapine (625 ng/mL), along with other pharmaceuticals were detected in the external iliac venous blood. The cause of death was determined to be multi-drug poisoning, predominantly caused by caffeine. Our method is useful for not only forensic cases but also the rapid diagnosis of caffeine overdose in emergency clinical settings.

Remote Monitoring Alert Burden: An Analysis of Transmission in >26,000 Patients

OBJECTIVES

This study sought to determine the remote monitoring (RM) alert burden in a multicenter cohort of patients with a cardiac implantable electronic device (CIED).

BACKGROUND

RM of CIEDs allows timely recognition of patient and device events requiring intervention. Most RM involves burdensome manual workflow occurring exclusively on weekdays during office hours. Automated software may reduce such a burden, streamlining real-time alert responses.

METHODS

We retrospectively analyzed 26,713 consecutive patients with a CIED undergoing managed RM utilizing PaceMate software between November 2018 and November 2019. Alerts were analyzed according to type, acuity (red indicates urgent, and yellow indicates nonurgent) and CIED category.

RESULTS

In total, 12,473 (46.7%) patients had a permanent pacemaker (PPM), 9,208 (34.5%) had an implantable cardioverter-defibrillator (ICD), and 5,032 (18.8%) had an implantable loop recorder (ILR). Overall, 82,797 of the 205,804 RM transmissions were alerts, with the remainder being scheduled transmissions. A total of 14,638 (54.8%) patients transmitted at least 1 alert. Permanent pacemakers were responsible for 25,700 (31.0%) alerts, ICDs for 15,643 (18.9%) alerts, and ILRs for 41,454 (50.1%) alerts, with 3,935 (4.8%) red alerts and 78,862 (95.2%) yellow alerts. ICDs transmitted 2,073 (52.7%) red alerts; 5,024 (32.1%) ICD alerts were for ventricular tachyarrhythmias and antitachycardia pacing/shock delivery.

CONCLUSIONS

In an RM cohort of 26,713 patients with CIEDs, 54.8% of patients transmitted at least 1 alert during a 12-month period, totaling over 82,000 alerts. ILRs were overrepresented, and ICDs were underrepresented, in these alerts. The enormity of the number of transmissions and the growing ILR alert burden highlight the need for new management pathways for RM.

A New Scoring System Detecting the Supraventricular Tachycardia Inducibility and Radiofrequency Ablation With High Specificity in Electrophysiological Study

Aim

The relationship between arrhythmia induction and ablation with palpitation characteristics has been demonstrated in electrophysiological study (EPS) patients. However, there is insufficient data on palpitation characteristics and their sensitivity and specificity. We aimed to identify the relationship between scoring composed of palpitation characteristics with the supraventricular tachycardia (SVT) induction and the success rate of the procedure.

Method

A total of 119 patients, diagnosed as paroxysmal supraventricular tachycardia (PSVT) by electrocardiography, rhythm Holter or symptoms, and underwent EPS, were enrolled in the study. A psychiatrist administered the Hospital Anxiety and Depression Score (HADS) questionnaire.

Results

In SVT induced group, palpitation duration (p = 0.048), palpitation spread to neck (p 0.004), responsiveness to medication (p = 0.008), induction with stress (p = 0.007), admission to emergency (p = 0.021) and documented PSVT (p = 0.017) were more common. Atropine administration (p = 0.001) was higher, and the Wenckebach cycle length (p < 0.001) was longer in the non-induced arrhythmia group. The presence of dual AV pathways was higher in SVT induced group (p = 0.002). There were no differences between groups in terms of anxiety score (p = 0.192), depression score (p = 0.730), and total psychiatric results (p = 0.280) in the HADS questionnaire. In scoring designed by the palpitation characteristics, the score of four and over predicted SVT induction with 63.6% sensitivity and 92.5% specificity. Radio-frequency ablation (RFA) was performed succesfully in 82.1% of patients with a score of ≥4.

Conclusion

Supraventricular tachycardia induction score obtained from the palpitations characteristics and arrhythmia documentation can be useful in predicting the induction of SVT and the success of RFA.

The metabolic syndrome in heart failure: insights to specific mechanisms

The presence of comorbidities significantly influences long-term morbidity and mortality of symptomatic and asymptomatic heart failure (HF) patients. Metabolic syndrome and diabetic cardiomyopathy are two clinical conditions that share multiple pathophysiological mechanisms and that might be both responsible for cardiac dysfunction. However, it is argued whether metabolic syndrome (MS) independently increases HF risk or the association between MS and HF merely reflects the impact of individual risk factors included in its definition on HF development. Similarly, in the context of diabetic cardiomyopathy, many aspects are still challenging starting from the definition up to the therapeutic management. In this clinical review, we focused the attention on molecular pathways, myocyte alterations, and specific patterns of metabolic syndrome and diabetic cardiomyopathy in order to better define the potential diagnostic and therapeutic approaches of these two pathological conditions.

Associations between consumption of coffee and caffeinated soft drinks and late stillbirth-Findings from the Midland and North of England stillbirth case-control study

OBJECTIVE

The consumption of caffeinated drinks and soft drinks is widespread in society, including by pregnant women. Data regarding the association of caffeine intake and stillbirth are varied. We aimed to investigate the degree of consumption of caffeinated drinks or soft drinks in the last four weeks of pregnancy in women who experienced a late stillbirth compared to women with ongoing live pregnancies at similar gestation. Influences on maternal caffeine intake and soft drink consumption during pregnancy were also investigated.

STUDY DESIGN

A case-control study undertaken in 41 maternity units in the United Kingdom. Cases were women who had a singleton non-anomalous stillbirth ≥28 weeks' gestation (n = 290) and controls were women with an ongoing pregnancy at the time of interview (n = 729). Data were collected using an interviewer-administered questionnaire which included questions regarding consumption of a variety of caffeinated drinks and soft drinks in the last four weeks of pregnancy as well as other behaviours (e.g. cigarette smoking).

RESULTS

Multivariable analysis adjusting for co-existing demographic and behavioural factors found the consumption of instant coffee, energy drinks and cola were associated with increased risk of stillbirth. There was an independent association between caffeine intake and late stillbirth (adjusted Odds Ratio 1.27, 95 % Confidence Interval (95 %CI) 1.14, 1.43 for each 100 mg increment/day). 15 % of cases and 8% of controls consumed more than the World Health Organisation (WHO) recommendation (>300 mg of caffeine/day; aOR 2.30, 95 % CI 1.40, 4.24). The population attributable risk for stillbirth associated with >300 mg of caffeine/day was 7.4 %. The majority of respondents reduced caffeine consumption in pregnancy. Midwives and internet resources were the most frequently used sources of information which influenced maternal behaviour with regard to soft drinks and caffeine, and this did not differ between cases and controls.

CONCLUSIONS

Women should be informed that consumption of caffeine during pregnancy is associated with increased risk of stillbirth, particularly at levels greater than recommended by the WHO (>300 mg/day). Recommendations from midwives and internet-based resources are likely to be the most effective means to influence maternal behaviour.

Cardiac Electronic Devices: Future Directions and Challenges

Cardiovascular implantable electronic devices (CIEDs) are essential management options for patients with brady- and tachyarrhythmias or heart failure with concomitant optimal pharmacotherapy. Despite increasing technological advances, there are still gaps in the management of CIED patients, eg, the growing number of lead- and pocket-related long-term complications, including cardiac device–related infective endocarditis, requires the greatest care. Likewise, patients with CIEDs should be monitored remotely as a part of a comprehensive, holistic management approach. In addition, novel technologies used in smartwatches may be a convenient tool for long-term atrial fibrillation (AF) screening, especially in high-risk populations. Early detection of AF may reduce the risk of stroke and other AF-related complications. The objective of this review article was to provide an overview of novel technologies in cardiac rhythm–management devices and future challenges related to CIEDs.

Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) Study

BACKGROUND

Current guidelines recommend 4 weeks of private driving restriction after implantation of a primary-prevention implantable cardioverter-defibrillator (ICD). These driving restrictions result in significant inconvenience and social implications. Advances in medical treatment and ICD programming have lowered the overall rate of device therapies. The objective of this study was to assess the incidence of ICD therapies at 30, 60, and 180 days after implantation.

METHODS

Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) was a retrospective cohort study conducted at 2 Canadian university centres enrolling patients with new implantation of a primary-prevention ICD. Device programming was standardised according to current guidelines. A total of 803 patients were enrolled.

RESULTS

The cumulative rates of appropriate ICD therapies at 30, 60, and 180 days were 0.12%, 0.50%, and 0.75%, respectively. There was no syncope during the first 6 months. The median duration to the first appropriate ICD therapy was 208 (range 23-1109) days after implantation. The rate of inappropriate ICD therapies at 30 days was only 0.2%. Overall, < 13.6% of all appropriate ICD therapies occurred within the first 6 months after implantation.

CONCLUSIONS

The rate of appropriate ICD therapies within the first 30 days after device insertion is extremely low in contemporary primary prevention cohorts with guideline-concordant device programming. There was no increased risk for ventricular arrhythmia early after ICD insertion. The results of DREAM-ICD suggest the need for a revision of the existing driving restrictions for primary-prevention ICD recipients.

Improving Door-to-Balloon Time for Patients With Acute ST-Elevation Myocardial Infarction: A Controlled Clinical Trial

According to the latest guidelines, the best intervention to restore blood flow through occluded coronary arteries is angioplasty at a time less than 90 minutes. Thereby, the present study was conducted to determine the impact of implementing ST-elevation myocardial infarction (STEMI) code on door-to-balloon time in patients with ST-segment elevation myocardial infarction. This clinical trial was conducted in 2019 at Booali Sina heart center hospital in Qazvin, Iran, in 2019. Fifty-eight patients with STEMI were purposively and consecutively enrolled in the study. Patients were then divided into control and intervention groups, based on their referral period. In both groups, patients were observed since their Arrived by emergency medical services to emergency department until inflating the balloon in the occluded coronary artery, and the intended times were recorded by the researchers. For Participants in the intervention group the "STEMI code" was designed and activated by an emergency physician once there is a patient experiencing a chest pain and early confirmed as a myocardial infarction. The SPSS program (v. 16) was used for data analysis at a significance level of less than 0.05. The difference in the door-to-balloon mean time in both control (113.5 ± 43.6 minutes) and intervention (79.3 ± 27.4 minutes) groups, was statistically significant (P = 0.001). Regarding other parameters, the reduction in the mean between Cath lab time (26.2 ± 18.2 minutes) and balloon time (15.5 ± 7.8 minutes) was also statistically significant (P = 0.008). In this study, implementation of the "STEMI code" could greatly prevent parallel work and squandering time while treating patients with acute myocardial infarction. As the door-to-balloon time gets shorter, the bed occupancy rate in the emergency department had reduced which in turn allowed more patients to be admitted.

Fitness to Drive After Syncope and/or in Cardiovascular Disease - An Overview and Practical Advice

The risk of syncope occurring while driving has implications for personal and public safety. Little is thought about the medical considerations related to the driving of motor vehicles. Physicians treating patients with cardiovascular disease need to acquire basic competences to be able to advise them about their fitness to drive. Current knowledge, governmental regulations, and recommendations concerning fitness to drive in patients with syncope and/or cardiovascular disease are presented. Narrative review with educational and clinical advice. Cardiovascular disease can make a driver lose control of a vehicle without warning and thereby lead to an accident. The main pathophysiological mechanisms of sudden loss of control are disturbances of brain perfusion (eg, syncope with or without cardiac arrhythmia, sudden cardiac death due to ventricular fibrillation or asystole, stroke, etc.) and marked general weakness (eg, after major surgery or in heart failure). Patients with syncope and/or cardiovascular disease should be properly advised by their physicians about their fitness to drive, and restrictions should be documented.

Electrocardiography in euthyroid individuals: a Danish general population study

BACKGROUND

Thyroid hormones within the euthyroid range have been linked to mortality and differences in heart rate. However, some relations between thyroid hormone concentration and various electrocardiographic measurements remain unassessed. We aimed to investigate the association between thyroid hormone concentrations within the euthyroid range and different electrocardiographic markers in people free of thyroid disease.

METHODS

We obtained electrocardiograms (ECG) and blood samples of free T4, total T3, and thyrotropin (TSH) in 20,852 subjects from the general population (the GESUS study). Relations between concentrations of TSH, free T4, and total T3 and heart rate, QTc, QRS duration, PR interval, P-wave duration and T-wave morphology were assessed in a multivariate adjusted linear model stratified by sex.

RESULTS

Roughly half of the 18,046 included participants with thyroid hormone measurements within euthyroid range were men, and the average age was 56 years. Heart rate increased with concentrations of T3 (6.4 bpm/nM, P<0.001 in women and 5.3 bpm/nM, P<0.001 in men) and T4 (3.7 bpm/10pM, P<0.001 in women and 3.1 bpm/10pM, P<0.001 in men). We found no relation between TSH and heart rate. PR interval and QRS duration decreased with higher concentrations of T3 (all P<0.01). QTc increased with higher concentrations of T4 in men (5 ms/10pM), and T waves were flatter, more asymmetric, and more often had notches with higher concentrations of T4 (all P≤0.01).

CONCLUSIONS

Thyroid hormone concentrations within the euthyroid range in people free of thyroid disease were associated with changes in the electrocardiogram in a general population.

The diagnostic yield of implantable loop recorders stratified by indication: "real-world" use in a large academic hospital

PURPOSE

To report on the clinical utility of implantable loop recorders (ILRs) in a large academic hospital setting over a 4-year period.

METHODS

Retrospective study (2013-2016) of patients receiving ILRs for any indication including syncope, cryptogenic stroke (CrS), atrial fibrillation (AF) burden, palpitations, ventricular arrhythmias (VA), and other. Remote checks, symptomatic transmissions, and in-person checks were reviewed. Time to diagnosis was documented.

RESULTS

A total of 263 patients (54% male, mean age 63 ± 15 years, mean follow-up 601 (range 9-1714) days) received ILRs for 324 indications; multiple indications were noted in 53/263 (20.2%) patients. ILR indications were 126 (39%) syncope, 81 (25%) CrS, 46 (14%) AF, 37 (11%) palpitations, 10 (3%) VA, and 24 (7%) other. Diagnostic yield for each indication was compared to the overall yield for all other indications. Three indications showed a significantly higher yield: AF (65% vs. 22%, p < 0.002), palpitations (60% vs. 24%, p < 0.001), and VA (70% vs. 28%, p < 0.004). For all other indications, there were no significant differences. Syncope had nearly half the diagnostic yield of previously published trials (28% vs. 43-56%). We observed a fourfold increase in ILR implant rate over the study duration.

CONCLUSIONS

In a "real-world" academic hospital setting, the diagnostic rate of ILRs was highest for AF, palpitations, and VA; however, these high yield indications comprised only 29% of all indications. The diagnostic yield for the commonest indication (syncope) was approximately half that reported in the previously published trials. With increasing implantation rates, additional studies are required to refine guideline-based indications for ILR implantation to improve diagnostic yield.

Peripheral arterial endothelial dysfunction predicts future cardiovascular events in diabetic patients with albuminuria: a prospective cohort study

Background

Reactive hyperemia-peripheral arterial tonometry (RH-PAT) is a noninvasive and simple test for evaluating the endothelial function. There has been sparse evidence on the usefulness of the RH-PAT index (RHI) in predicting future cardiovascular diseases among diabetic patients.

Methods

Asymptomatic diabetic patients with albuminuria were selected; their medical history and laboratory findings were evaluated every 3 to 4 months, respectively. The primary outcome was a composite of three-point major adverse cardiovascular events (3-point MACE): death from cardiovascular causes, acute coronary events, or nonfatal stroke. On the contrary, secondary outcomes included a composite of 3-point MACE, hospitalization for heart failure, or chronic kidney disease (CKD) progression. RHI was measured using the Endo-PAT2000 at the baseline. RHI < 1.67 was considered to indicate peripheral endothelial dysfunction (PED).

Results

In total, 149 subjects were included (mean age, 61.8 ± 9.2 years; duration of diabetes was 12 years). During the follow-up period (median, 49.7 months), of the 149 subjects, primary outcomes were detected in 12 (1 [2.3%] and 11 [10.5%] of those without and with PED, respectively). The presence of PED in baseline measurements significantly increased both primary and secondary outcomes, following adjustment for age, sex, hypertension, glycated hemoglobin, low-density lipoprotein cholesterol, triglyceride, systolic blood pressure, baseline estimated glomerular filtration rate, overt proteinuria, duration of diabetes, premedical history of ischemic events, anti-platelet agents, and smoking history (hazard ratio [HR]: 10.95; 95% confidence interval CI 1.00–119.91 for the primary outcome; HR, 4.12; 95% CI 1.37–12.41 for secondary outcome). In addition, PED could predict secondary outcomes independent of the risk score according to the American College of Cardiology/American Heart Association (HR: 3.24; 95% CI 1.14–9.17).

Conclusions

PED can independently predict future cardiovascular events among diabetic patients with albuminuria.

Myocardial infarction evaluation from stopping time decision toward interoperable algorithmic states in reinforcement learning

BACKGROUND

The Elliot wave principle commonly characterizes the impulsive and corrective wave trends for both financial market trends and electrocardiograms. The impulsive wave trends of electrocardiograms can annotate several wave components of heart-beats including pathological heartbeat waveforms. The stopping time inquires which ordinal element satisfies the assumed mathematical condition within a numerical set. The proposed work constitutes several algorithmic states in reinforcement learning from the stopping time decision, which determines the impulsive wave trends. Each proposed algorithmic state is applicable to any relevant algorithmic state in reinforcement learning with fully numerical explanations. Because commercial electrocardiographs still misinterpret myocardial infarctions from extraordinary electrocardiograms, a novel algorithm needs to be developed to evaluate myocardial infarctions. Moreover, differential diagnosis for right ventricle infarction is required to contraindicate a medication such as nitroglycerin.

METHODS

The proposed work implements the stopping time theory to impulsive wave trend distribution. The searching process of the stopping time theory is equivalent to the actions toward algorithmic states in reinforcement learning. The state value from each algorithmic state represents the numerically deterministic annotated results from the impulsive wave trend distribution. The shape of the impulsive waveform is evaluated from the interoperable algorithmic states via least-first-power approximation and approximate entropy. The annotated electrocardiograms from the impulsive wave trend distribution utilize a structure of neural networks to approximate the isoelectric baseline amplitude value of the electrocardiograms, and detect the conditions of myocardial infarction. The annotated results from the impulsive wave trend distribution consist of another reinforcement learning environment for the evaluation of impulsive waveform direction.

RESULTS

The accuracy to discern myocardial infarction was found to be 99.2754% for the data from the comma-separated value format files, and 99.3579% for those containing representative beats. The clinical dataset included 276 electrocardiograms from the comma-separated value files and 623 representative beats.

CONCLUSIONS

Our study aims to support clinical interpretation on 12-channel electrocardiograms. The proposed work is suitable for a differential diagnosis under infarction in the right ventricle to avoid contraindicated medication during emergency. An impulsive waveform that is affected by myocardial infarction or the electrical direction of electrocardiography is represented as an inverse waveform.