Epidemiology of arrhythmias and conduction disorders in older adults

Proteomic profile of human sinoatrial and atrioventricular nodes in comparison to working myocardium

The proteomic profile of the human cardiac conduction system: the sinoatrial node (SAN) and atrioventricular node (AVN), remains poorly understood. The aim of the current study is to identify proteomic characteristic of the human SAN and AVN in the comparison to working myocardium of the right atrium (RAM) and right ventricle (RVM). The proteomic analysis was performed on 10 autopsied human heart specimens collected from healthy adults. During the data-independent acquisition proteomics analysis 2752 different proteins were identified in all sample sets. In both nodal tissues (compared to working myocardium), the following pathways were upregulated: regulation of Insulin-like Growth Factor transport and uptake by Insulin-like Growth Factor Binding Proteins, post-translational protein phosphorylation, glutathione metabolism, metabolism of carbohydrates, glycolysis and gluconeogenesis. Other common for nodal tissue pathways were these related to immune system and related to extracellular matrix. The pathways related to cardiac muscle contraction were more abundant in RAM and RVM samples. The current study presents extensive comparative analysis of protein abundance in the human SAN and AVN. Few key differences may be found in the nodal proteome in comparison to working cardiomyocytes, including involvement of immune system and upregulated pathways related to extracellular matrix. The SAN exhibits enrichment in the PPAR signaling and pentose phosphate pathways, as well as prostaglandin synthesis and regulatory proteins, compared to the AVN.

Frequency of Electrocardiogram-Defined Cardiac Conduction Disorders in a Multi-Institutional Primary Care Cohort

Background

Disorders affecting cardiac conduction are associated with substantial morbidity. Understanding the epidemiology and risk factors for conduction disorders may enable earlier diagnosis and preventive efforts.

Objectives

The purpose of this study was to quantify contemporary frequency and risk factors for electrocardiogram (ECG)-defined cardiac conduction disorders in a large multi-institutional primary care sample.

Methods

We quantified prevalence and incidence of conduction disorders among adults receiving longitudinal primary care between 2001 and 2019, each with at least one 12-lead ECG performed prior to the start of follow-up and at least one ECG during follow-up. We defined conduction disorders using curated terms extracted from ECG diagnostic statements by cardiologists. We grouped conduction disorders by inferred anatomic location of abnormal conduction. We tested associations between clinical factors and incident conduction disease using multivariable proportional hazards regression.

Results

We analyzed 189,163 individuals (median age 55 years; 58% female). The overall prevalence of conduction disorders was 27% among men and 15% among women. Among 119,926 individuals (median age 55 years; 51% female), 6,802 developed an incident conduction system abnormality over a median of 10 years (Q1, Q3: 6, 15 years) of follow-up. Incident conduction disorders were more common in men (8.78 events/1,000 person-years) vs women (4.34 events/1,000 person-years, P < 0.05). In multivariable models, clinical factors including older age (HR: 1.25 per 5-year increase [95% CI: 1.24-1.26]) and myocardial infarction (HR: 1.39 [95% CI: 1.26-1.54]) were associated with incident conduction disorders.

Conclusions

Cardiac conduction disorders are common in a primary care population, especially among older individuals with cardiovascular risk factors.

Incidence and prognosis of cardiac conduction system diseases in hypertension: the STEP trial

Patients with cardiac conduction system diseases (CSD) may have increased incidence and mortality of cardiovascular events. Here we report a post hoc analysis of the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) randomized clinical trial (ClinicalTrials.gov number, NCT03015311) concerning the effect of intensive blood pressure (BP) control on the incidence of new-onset CSD and the prognostic implications of preexisting or new-onset CSD. The incidence of new-onset CSD was similar in the intensive (n = 205, 6.42%) and standard (n = 188, 5.94%) treatment arms. Participants with preexisting CSD had a higher risk for acute decompensated heart failure. Increased age, male sex and increased body mass index were independently associated with increased risk for new-onset CSD. Our results suggest that intensive BP control may not reduce the incidence of new-onset CSD compared with standard BP control.

Cardiovascular Mortality and Duration of Androgen Deprivation in Locally Advanced Prostate Cancer: Long-term Update of NRG/RTOG 9202

BACKGROUND

Androgen deprivation therapy (ADT) has been associated with coronary heart disease and myocardial infarction (MI) in prostate cancer patients, but controversy persists regarding its effects on cardiovascular mortality (CVM).

OBJECTIVE

We assessed the long-term relationship between ADT and CVM in a prostate cancer randomized trial (NRG Oncology/Radiation Therapy Oncology Group 9202).

DESIGN, SETTING, AND PARTICIPANTS

From 1992 to 1995, 1554 men with locally advanced prostate cancer (T2c-T4, prostate-specific antigen <150 ng/ml) received radiotherapy with 4 mo (short-term [STADT]) versus 28 mo (longer-term [LTADT]) of ADT.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Using the Fine-Gray and Cox regression models, the relationship between ADT and mortality was evaluated.

RESULTS AND LIMITATIONS

With a median follow-up of 19.6 yr, LTADT was associated with improved overall survival (OS) versus STADT (adjusted hazard ratio [HR] 0.88; p = 0.03) and prostate cancer survival (subdistribution HR [sHR] 0.70, p = 0.003). Comparing LTADT with STADT, prostate cancer mortality improved by 6.0% (15.6% [95% confidence interval 13.0-18.3%] vs 21.6% [18.6-24.7%]) at 15 yr, while CVM increased by 2.2% (14.9% [12.4-17.6%] vs 12.7% [10.4-15.3%]). In multivariable analyses, LTADT was not associated with increased CVM versus STADT (sHR 1.22 [0.93-1.59]; p = 0.15). An association between LTADT and MI death was detected (sHR 1.58 [1.00-2.50]; p = 0.05), particularly in patients with prevalent cardiovascular disease (CVD; sHR 2.54 [1.16-5.58]; p = 0.02).

CONCLUSIONS

With 19.6 yr of follow-up, LTADT was not significantly associated with increased CVM in men with locally advanced prostate cancer. Patients may have increased MI mortality with LTADT, particularly those with baseline CVD. Overall, there remained a prostate cancer mortality benefit and no OS detriment with LTADT.

PATIENT SUMMARY

In a long-term analysis of a large randomized prostate cancer trial, radiation with 28 mo of hormone therapy did not increase the risk of cardiovascular death significantly versus 4 mo of hormone therapy. Future studies are needed for patients with pre-existing heart disease, who may have an increased risk of myocardial infarction death with longer hormone use.

Arrhythmias among Older Adults Receiving Comprehensive Geriatric Care: Prevalence and Associated Factors

BACKGROUND

Cardiovascular diseases and arrhythmias are medical conditions that increase with age and are associated with significant morbidities and mortality. The aim of the present study was to investigate the prevalence of arrhythmias and clinical associations in the collective of older adults receiving comprehensive geriatric care (CGC).

METHODS

Holter ECG monitoring (HECG) of older patients hospitalized for CGC was analyzed. The prevalence of arrhythmias and the associations between the presence of arrhythmias, patients' characteristics and the functional status regarding basic activities of daily living (assessed by the Barthel index (BI)), walking ability (assessed by the timed up and go test (TUG)), and balance and gait (assessed by the Tinetti balance and gait test (TBGT)) were examined.

RESULTS

In the presented study, 626 patients were included (mean age: 83.9 ± 6.6 years, 67.7% were female). The most common arrhythmias detected in HECG were premature ventricular contractions (87.2%), premature atrial contractions (71.7%), and atrial fibrillation (22.7%). Atrial flutter was found in 1.0%, paroxysmal supraventricular tachycardia in 5.8%, non-sustained ventricular tachycardia in 12.5%, first-degree AV block in 0.8%, second-degree AV block type Mobitz I in 0.8%, second-degree AV block type Mobitz II in 0.3%, pause > 2.5 s any cause in 3.5%, and pause > 3 s any cause in 1.6% of the cases. Premature atrial contractions were associated with the female sex (74.8% vs. 65.3%, p = 0.018), whereas in male patients, the following arrhythmias were more common: premature ventricular contractions (91.6% vs. 85.1%, p = 0.029), ventricular bigeminus (8.4% vs. 3.8%, p = 0.021), and non-sustained ventricular tachycardia (17.3% vs. 10.1%, p = 0.014). Atrial fibrillation detected in HECG was more frequent in patients at high risk of falls, indicated by their TBGT score ≤ 18 (24.7% vs. 12.0%, p = 0.006), and premature ventricular contractions were more common in patients unable to walk (TUG score 5) compared to those with largely independent mobility (TUG score 1 or 2) (88.0% vs. 75.0%, p = 0.023). In a logistic regression analysis, atrial fibrillation detected in HECG was identified as a risk factor for a high risk of falls (odds ratio (OR): 2.35, 95% confidence interval (CI): 1.23-4.46).

CONCLUSION

In our study, investigation of HECG of older adults hospitalized for CGC revealed that premature atrial contractions, premature ventricular contractions, and atrial fibrillation were the most common arrhythmias. Premature atrial contractions were found to be more frequent in female patients, while male patients were more prone to premature ventricular contractions. In the investigated population, atrial fibrillation emerged as a risk factor associated with a high risk of falls.

Comparison of Machine Learning Algorithms Using Manual/Automated Features on 12-Lead Signal Electrocardiogram Classification: A Large Cohort Study on Students Aged Between 6 to 18 Years Old

PROPOSE

An electrocardiogram (ECG) has been extensively used to detect rhythm disturbances. We sought to determine the accuracy of different machine learning in distinguishing abnormal ECGs from normal ones in children who were examined using a resting 12-Lead ECG machine, and we also compared the manual and automated measurement using the modular ECG Analysis System (MEANS) algorithm of ECG features.

METHODS

Altogether, 10745 ECGs were recorded for students aged 6 to 18. Manual and automatic ECG features were extracted for each participant. Features were normalized using Z-score normalization and went through the student's t-test and chi-squared test to measure their relevance. We applied the Boruta algorithm for feature selection and then implemented eight classifier algorithms. The dataset was split into training (80%) and test (20%) partitions. The performance of the classifiers was evaluated on the test data (unseen data) by 1000 bootstrap, and sensitivity (SEN), specificity (SPE), AUC, and accuracy (ACC) were reported.

RESULTS

In univariate analysis, the highest performance was heart rate and RR interval in the manual dataset and heart rate in an automated dataset with AUC of 0.72 and 0.71, respectively. The best classifiers in the manual dataset were random forest (RF) and quadratic-discriminant-analysis (QDA) with AUC, ACC, SEN, and SPE equal to 0.93, 0.98, 0.69, 0.99, and 0.90, 0.95, 0.75, 0.96, respectively. In the automated dataset, QDA (AUC: 0.89, ACC:0.92, SEN:0.71, SPE:0.93) and stack learning (SL) (AUC:0.89, ACC:0.96, SEN:0.61, SPE:0.99) reached best performances.

CONCLUSION

This study demonstrated that the manual measurement of 12-Lead ECG features had better performance than the automated measurement (MEANS algorithm), but some classifiers had promising results in discriminating between normal and abnormal cases. Further studies can help us evaluate the applicability and efficacy of machine-learning approaches for distinguishing abnormal ECGs in community-based investigations in both adults and children.

Gut microbiome relationship with arrhythmias and conduction blocks: A two-sample Mendelian randomization study

INTRODUCTION

Past research based on observations has suggested that the gut microbiome (GM) could play a role in developing arrhythmias and conduction blocks. Nonetheless, the nature of this association remains uncertain due to the potential for reverse causation and confounding factors in observational research. The aim of this investigation is to elucidate the causal relationship between GM and the development of arrhythmias as well as conduction blocks.

METHODS

This study collected summary statistics regarding GM, arrhythmias, and conduction blocks. Two-sample Mendelian randomization (MR) analysis was carried out employing various methods, with inverse variance weighted being the primary approach, followed by weighted median, simple mode, MR-Egger, and MR-PRESSO. Moreover, the MR findings were corroborated through multiple sensitivity analyses.

RESULTS

Among them, for atrial fibrillation and flutter (AF), phylum_Actinobacteria and genus_RuminococcaceaeUCG004 demonstrated a negative correlation, while order_Pasteurellales, family_Pasteurellaceae, and genus_Turicibacter were associated with an increased risk. In the case of paroxysmal tachycardia (PT), genus_Holdemania and genus_Roseburia were found to reduce risk. For atrioventricular block (AVB), order_Bifidobacteriales, family_Bifidobacteriaceae, and genus_Alistipes exhibited a negative correlation, whereas genus_CandidatusSoleaferrea showed a positive correlation. Concerning the left bundle-branch block (LBBB), family_Peptococcaceae appeared to decrease the risk, while genus_Flavonifractor was linked to an increased risk. Lastly, no causative GM was identified in the right bundle-branch block (RBBB) context.

CONCLUSION

We have uncovered potential causal links between some GM, arrhythmias, and conduction blocks. This insight may aid in designing microbiome-based interventions for these conditions and their risk factors in future trials. Additionally, it could facilitate the discovery of novel biomarkers for targeted prevention strategies.

Prescribing patterns of fall risk-increasing drugs in older adults hospitalized for heart failure

BACKGROUND

Older adults hospitalized for heart failure (HF) are at risk for falls after discharge. One modifiable contributor to falls is fall risk-increasing drugs (FRIDs). However, the prevalence of FRIDs among older adults hospitalized for HF is unknown. We describe patterns of FRIDs use and examine predictors of a high FRID burden.

METHODS

We used the national biracial REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a prospective cohort recruited from 2003-2007. We included REGARDS participants aged ≥ 65 years discharged alive after a HF hospitalization from 2003-2017. We determined FRIDs -cardiovascular (CV) and non-cardiovascular (non-CV) medications - at admission and discharge from chart abstraction of HF hospitalizations. We examined the predictors of a high FRID burden at discharge via modified Poisson regression with robust standard errors.

RESULTS

Among 1147 participants (46.5% women, mean age 77.6 years) hospitalized at 676 hospitals, 94% were taking at least 1 FRID at admission and 99% were prescribed at least 1 FRID at discharge. The prevalence of CV FRIDs was 92% at admission and 98% at discharge, and the prevalence of non-CV FRIDs was 32% at admission and discharge. The most common CV FRID at admission (88%) and discharge (93%) were antihypertensives; the most common agents were beta blockers (61% at admission, 75% at discharge), angiotensin-converting enzyme inhibitors (36% vs. 42%), and calcium channel blockers (32% vs. 28%). Loop diuretics had the greatest change in prevalence (53% vs. 72%). More than half of the cohort (54%) had a high FRID burden (Agency for Healthcare Research and Quality (AHRQ) score ≥ 6), indicating high falls risk after discharge. In a multivariable Poisson regression analysis, the factors strongly associated with a high FRID burden at discharge included hypertension (PR: 1.41, 95% CI: 1.20, 1.65), mood disorder (PR: 1.24, 95% CI: 1.10, 1.38), and hyperpolypharmacy (PR: 1.88, 95% CI: 1.64, 2.14).

CONCLUSIONS

FRID use was nearly universal among older adults hospitalized for HF; more than half had a high FRID burden at discharge. Further work is needed to guide the management of a common clinical conundrum whereby guideline indications for treating HF may contribute to an increased risk for falls.

Feasibility of Permanent His Bundle Pacing in the Elderly vs the Very Elderly. A Single-Center Mid-Term Follow-Up Study

Purpose

Although feasibility studies have included older patients, specific data for His bundle pacing (HBP) in this population is scarce. The aim of this study was to evaluate the feasibility and mid-term performance of HBP in the elderly (70 to 79 years old) versus the very elderly (80 years old and above) patients with conventional indications for pacing.

Patients and Methods

About 105 patients older than 70 years of age with attempted HBP from the 1st of January 2019 to the 31st of December 2021 were reviewed. Clinical and procedural characteristics were recorded at baseline, and after a mid-term follow-up period.

Results

The procedural success rate was similar in both age groups (68.49% vs 65.62%). There was no significant difference in pacing or sensing thresholds, impedance, and fluoroscopy times. For both age intervals, patients with a baseline narrow QRS maintained a similar QRS duration after pacing, while in patients with a wide QRS, the paced QRS was significantly shorter. Baseline QRS duration, left bundle branch block morphology, and ejection fraction, were significantly associated with HBP procedural failure. The mean follow-up period was 830.34 days for the elderly and 722.76 days for the very elderly. After the follow-up period, both sensing and pacing thresholds were similar between the groups. Compared to the baseline values, there were no significant changes in both pacing and sensing parameters, irrespective of the age interval. During follow-up, no lead dislodgements were recorded. There were two cases of significant pacing threshold rise in the elderly (4%) and three cases in the very elderly group (14.2%) which were managed conservatively, without lead revision.

Conclusion

In elderly and very elderly patients, HBP is a feasible procedure associated with constant pacing and sensing parameters and with low complication rates over mid-term follow-up.

Cost-utility analysis of radiofrequency ablation versus optimal medical therapy in managing supraventricular tachycardia among Filipinos

Background

Radiofrequency ablation (RFA) is the standard of care in the management of supraventricular tachycardia (SVT). Its cost-effectiveness in an emerging Asian country has not been studied.

Objectives

A cost-utility analysis of RFA versus optimal medical therapy (OMT) among Filipinos with SVT was conducted using the public healthcare provider's perspective.

Methods

A simulation cohort using a lifetime Markov model was constructed using patient interviews, a review of literature, and expert consensus. Three basic health states were defined: stable, SVT recurrence, and death. The incremental cost per quality-adjusted life year (ICER) was determined for both arms. Utilities for the entry states were derived from patient interviews using the EQ5D-5L tool; utilities for other health states were taken from publications. Costs were assessed from the healthcare payer perspective. A sensitivity analysis was done.

Results

Base case analysis showed that RFA versus OMT is both highly cost-effective at 5 years and over a lifetime. RFA at 5 years costs about PhP276,913.58 (USD5,446) versus OMT of PhP151,550.95 (USD2,981) per patient. Discounted lifetime costs were PhP280,770.32 (USD5,522) for RFA, versus PhP259,549.74 (USD5,105) for OMT. There was improved quality of life with RFA (8.1 vs. 5.7 QALYs per patient). The 5-year and lifetime incremental cost-effectiveness ratios were PhP148,741.40 (USD2,926) and Php15,000 (USD295), respectively. Sensitivity analysis showed 56.7% of simulations for RFA fell below a GDP-benchmarked willingness-to-pay (WTP) threshold.

Conclusion

Despite the initial higher cost, RFA versus OMT for SVT is highly cost-effective from the Philippine public health payer's perspective.

Arrhythmia prevalence, predictors, and impact on hospital-associated outcomes among patients with diffuse large B-cell lymphoma

INTRODUCTION

Diffuse large B-cell lymphoma (DLBCL) patients have been reported to have cardiac manifestations, however, arrhythmias have not been characterized in this population. We examined the predictors of arrhythmias and assessed the impact of arrhythmias on inpatient outcomes among DLBCL patients.

METHODS

Retrospective cohort analysis was performed using the National Inpatient Sample data collected between 2016 and 2018. Multivariable logistic and linear regression models were used to examine the predictors of arrhythmias and inpatient outcomes among DLBCL patients.

RESULTS

11% of DLBCL patients had a diagnosis of arrhythmias. Patients aged 70 years or older had 2.6 times higher odds (95% CI: 2.37-2.78) of having arrhythmias compared to patients younger than 70 years. Females were 23% (AOR: 0.77; 95% CI: 0.71-0.83) less likely to have a diagnosis of arrhythmias relative to their male counterparts. Compared to non-Hispanic whites, patients who were non-Hispanic blacks (AOR: 0.69; 95% CI: 0.60-0.81), Hispanics (AOR: 0.60; 95% CI: 0.52-0.69) or in the non-Hispanic other category (AOR: 0.80; 95% CI: 0.70-0.91) were significantly less likely to be diagnosed with arrhythmias. Other factors that predicted arrhythmias were patient disposition and comorbidity index. Additionally, arrhythmias were associated with higher inpatient mortality, length of stay and hospital costs.

CONCLUSIONS

Older male patients were more likely to be diagnosed with arrhythmias while non-Hispanic blacks and Hispanics were less likely to have arrhythmias. These findings highlight the need for surveillance to enable early detection of arrhythmias in this population.

Competency in ECG Interpretation and Arrhythmias Management among Critical Care Nurses in Saudi Arabia: A Cross Sectional Study

Background: Electrographic interpretation skills are important for healthcare practitioners caring for patients in need of cardiac assessment. Competency in ECG interpretation skills is critical to determine any abnormalities and initiate the appropriate care required. The purpose of the study was to determine the level of competence in electrocardiographic interpretation and knowledge in arrhythmia management of nurses in critical care settings. Methods: A descriptive cross-sectional design was used. A convenience sample of 255 critical care nurses from 4 hospitals in the Al-Madinah Region in Saudi Arabia was used. A questionnaire was designed containing a participant’s characteristics and 10 questions with electrocardiographic strips. A pilot test was carried out to evaluate the validity and reliability of the questionnaire. Descriptive and bivariate analyses were conducted using an independent t-test, one-way ANOVA, or bi-variate correlation tests, as appropriate. A statistical significance of p < 0.05 was assumed. Results: Females comprised 87.5% of the sample, and the mean age of the sample was 32.1 (SD = 5.37) years. The majority of the participants (94.9%) had taken electrocardiographic interpretation training courses. The mean total score of correct answers of all 10 ECG strips was 6.45 (±2.54) for ECG interpretation and 4.76 (±2.52) for arrhythmia management. No significant differences were observed between ECG competency level and nursing experience or previous training. Nurses working in the ICU and CCU scored significantly higher than those working in ED. Conclusions: The electrocardiographic knowledge in ECG interpretation and arrhythmia management of critical care nurses is low. Therefore, improving critical care nurses’ knowledge of ECGs, identification, and management of cardiac arrhythmias is essential.

The Aging Heart: A Molecular and Clinical Challenge

Aging is associated with an increasing burden of morbidity, especially for cardiovascular diseases (CVDs). General cardiovascular risk factors, ischemic heart diseases, heart failure, arrhythmias, and cardiomyopathies present a significant prevalence in older people, and are characterized by peculiar clinical manifestations that have distinct features compared with the same conditions in a younger population. Remarkably, the aging heart phenotype in both healthy individuals and patients with CVD reflects modifications at the cellular level. An improvement in the knowledge of the physiological and pathological molecular mechanisms underlying cardiac aging could improve clinical management of older patients and offer new therapeutic targets.

Drug-related bradycardia precipitating hospital admission in older adults: an ongoing problem

BACKGROUND

Drug-related bradycardia (DRB) is a common clinical conundrum and can result in multiple hospital admissions as a result of the increased prescription of rate-limiting medications that can predispose to presyncopal or syncopal episodes.

AIM

To evaluate the incidence of DRB in elderly hospital inpatients.

METHODS

We conducted a retrospective analysis of all patients admitted to our acute medical unit between November 2018 and February 2019 and identified patients over the age of 70 with more than one diurnal bradycardic episode during their admission. We extracted patient demographics, presenting complaint, admission 12-lead ECG and medications from the hospital electronic database.

RESULTS

We screened 2312 adults and identified 100 patients over the age of 70 years with two or more episodes of diurnal bradycardia during their hospital admission. This constituted 4.32% of total admissions. Beta blockers were the most commonly prescribed rate-limiting medication (n=54, 87.1%), of which bisoprolol was the most frequently prescribed (n=41) and sinus bradycardia was the most commonly identified rhythm disturbance in our cohort of patients (n=41, 41%). Syncope was the most common presenting symptom and occurred in 23 patients, 14 (60.9%) of which were diagnosed with a DRB. Atrial fibrillation was more common in those with DRB compared with those with bradycardia not caused by medications (35.5% vs 10.5%, p=0.006), and atrial fibrillation was a significant predictor of DRB (OR=10.2, 95% CI 3.3 to 31.6, p<0.001).

CONCLUSION

Bradycardia is a significant cause of hospital admissions in older adults and can be avoided with pharmacovigilance. Caution should be exercised when initiating or changing the dose of rate-limiting agents in these patients; while those with atrial fibrillation should undergo regular review of their heart rate followed by appropriate medication dose adjustments.

Outcome of life-threatening arrhythmias among patients presenting in an emergency setting at a tertiary hospital in Accra-Ghana

Background

Management of life-threatening arrhythmia can be incredibly challenging in advanced health systems. In sub-Saharan Africa (SSA), this is likely more challenging because of weak pre-hospital and in-hospital critical care systems. Little is known about life-threatening arrhythmia and their outcomes in SSA. The aim of this study was to examine the types and outcomes of arrhythmias among haemodynamically unstable patients presenting at a tertiary hospital in Accra-Ghana.

Method

This was a retrospective case series study conducted at the Korle-Bu Teaching Hospital (KBTH), Accra-Ghana. Medical records of patients who presented with or developed haemodynamically unstable arrhythmias within 24h of admission from January 2018 to December 2020 were reviewed. The demographic characteristics and clinical data including outcomes of patients were collected. Descriptive statistics were used and results presented in frequency tables.

Results

A total of 42 patients with life-threatening arrhythmias were included. Haemodynamically unstable tachyarrhythmias were the most common arrhythmias found among the patients (66.7%). Approximately 52% of patients had structural heart diseases whereas 26.2% had no apparent underlying cause or predisposing factor. Cardioversion (52.4%), commonly electrical (63.6%), and transvenous pacemaker implantation (23.8%) were the common initial interventions. The majority of the patients (88.1%) survived and were discharged home.

Conclusion

Tachyarrhythmias are the most common haemodynamically unstable arrhythmias seen among patients presenting emergently in a leading tertiary hospital in Ghana. A high survival rate was observed and cannot be extrapolated to other healthcare settings in sub-Saharan Africa with limited resources to manage these clinical entities.

Trend in Age at the Initial Pacemaker Implantation in Patients With Bradyarrhythmia - A 50-Year Analysis (1970-2019) in Japan

BACKGROUND

This study investigated whether the age of patients undergoing pacemaker implantation is increasing.

METHODS AND RESULTS

This study retrospectively reviewed the consecutive cases of 3,582 patients who underwent an initial pacemaker implantation at our hospitals because of symptomatic bradyarrhythmias between 1970 and 2019. The exclusion criteria were: patients with AV block due to cardiac surgery or AV junction ablation, and patients aged <20 years. The patients were divided into 5×10-year groups: those treated in the 1970s (1970-1979), 1980s (1980-1989), 1990s (1990-1999), 2000s (2000-2009), and 2010s (2010-2019). A total of 3,395 patients satisfied the study criteria. The average age at which the patients underwent a first pacemaker implantation increased across the 10-year periods: 63.7±13.2 years in the 1970s, 66.2±12.6 years (1980s), 69.1±12.4 years (1990s), 72.0±11.1 years (2000s), and 75.8±10.0 years (2010s) and advanced significantly in the 1990s, 2000s, and 2010s compared to the 1970s (all P<0.001). The ratio of patients aged ≥80 and ≥90 years increased from 10.6% and 0% in the 1970 s to 38.2% (P<0.001) and 5.2% (P= 0.017) in the 2010s, respectively.

CONCLUSIONS

The average age at initial pacemaker implantation increased by 12.1 years over the last 50 years in Japan. In particular, the ratios of ≥80 and ≥90 years as the patients age increased significantly.

Cardiac arrhythmias six months following traumatic spinal cord injury

OBJECTIVE

To investigate the incidence of cardiac arrhythmias at six months following traumatic spinal cord injury (SCI) and to compare the prevalence of arrhythmias between participants with cervical and thoracic SCI.

DESIGN

A prospective observational study using continuous twenty-four-hour Holter monitoring.

SETTING

Inpatient rehabilitation unit of a university research hospital and patient home setting.

PARTICIPANTS

Fifty-five participants with acute traumatic SCI were prospectively included. For each participant, the SCI was characterized according to the International Standards for Neurological Classification of SCI by the neurological level and severity according to the American Spinal Injury Association Impairment Scale.

OUTCOME MEASURES

Comparisons between demographic characteristics and arrhythmogenic occurrences as early as possible after SCI (4 ± 2 days) followed by 1, 2, 3, 4 weeks and 6 month time points of Holter monitoring.

RESULTS

Bradycardia (heart rate [HR] <50 bpm) was present in 29% and 33% of the participants with cervical (C1-C8) and thoracic (T1-T12) SCI six months after SCI, respectively. The differences in episodes of bradycardia between the two groups were not significant (P < 0.54). The mean maximum HR increased significantly from 4 weeks to 6 months post-SCI (P < 0.001), however mean minimum and maximum HR were not significantly different between the groups at the six-month time point. There were no differences in many arrhythmias between recording periods or between groups at six months.

CONCLUSIONS

At the six-month timepoint following traumatic SCI, there were no significant differences in occurrences of arrhythmias between participants with cervical and thoracic SCI compared to the findings observed in the first month following SCI.

From 12 to 1 ECG lead: multiple cardiac condition detection mixing a hybrid machine learning approach with a one-vs-rest classification strategy

OBJECTIVE

Detecting different cardiac diseases using a single or reduced number of leads is still challenging. This work aims to provide and validate an automated method able to classify ECG recordings. Performance using complete 12-lead systems, reduced lead sets, and single-lead ECGs is evaluated and compared.

APPROACH

Seven different databases with 12-lead ECGs were provided during the PhysioNet/Computing in Cardiology Challenge 2021, where 88,253 annotated samples associated with none, one, or several cardiac conditions among 26 different classes were released for training, whereas 42,896 hidden samples were used for testing. After signal preprocessing, 81 features per ECG-lead were extracted, mainly based on heart rate variability, QRST patterns and spectral domain. Next, a One-vs-Rest classification approach made of independent binary classifiers for each cardiac condition was trained. This strategy allowed each ECG to be classified as belonging to none, one or several classes. For each class, a classification model among two binary Supervised Classifiers and one Hybrid Unsupervised-Supervised classification system was selected. Finally, we performed a 3-fold cross-validation to assess the system's performance.

MAIN RESULTS

Our classifiers received scores of 0.39, 0.38, 0.39, 0.38, and 0.37 for the 12, 6, 4, 3 and 2-lead versions of the hidden test set with the Challenge evaluation metric (CM). Also, we obtained a mean G-score of 0.80, 0.78, 0.79, 0.79, 0.77 and 0.74 for the 12, 6, 4, 3, 2 and 1-lead subsets with the public training set during our 3-fold cross-validation.

SIGNIFICANCE

We proposed and tested a machine learning approach focused on flexibility for identifying multiple cardiac conditions using one or more ECG leads. Our minimal-lead approach may be beneficial for novel portable or wearable ECG devices used as screening tools, as it can also detect multiple and concurrent cardiac conditions.

Naked mole-rats maintain cardiac function and body composition well into their fourth decade of life

The prevalence of cardiovascular disease increases exponentially with age, highlighting the contribution of aging mechanisms to cardiac diseases. Although model organisms which share human disease pathologies can elucidate mechanisms driving disease, they do not provide us with innate examples how cardiac aging might be slowed or attenuated. The identification of animal models that preserve cardiac function throughout most of life offers an alternative approach to study mechanisms which might slow cardiac aging. One such species may be the naked mole-rat (NMR), a mouse-sized (40 g) rodent with extraordinary longevity (> 37 years), and constant mortality hazard over its four decades of life. We used a cross-sectional study design to measure a range of physiological parameters in NMRs between 2 and 34 years of age and compared these findings with those of mice aged between 3 months and 2.5 years. We observed a rapid decline in body fat content and bone mineral density in old mice, but no changes in NMRs. Similarly, rhythm disorders (premature atrial and ventricular complexes) occurred in aged mice but not in NMRs. Magnetic resonance and ultrasound imaging showed age-dependent increases in cardiac hypertrophy and diastolic dysfunction in mice which were absent in NMRs. Finally, cardiac stress tests showed an age-dependent decline in normalized cardiac output in mice, which was absent in NMRs. Unlike mice, that manifest several aspects of human cardiac aging, NMRs maintain cardiac function and reserve capacity throughout their long lives and may offer insights on how to delay or prevent cardiac aging.

Conception and realization of an IoT-enabled deep CNN decision support system for automated arrhythmia classification

Arrhythmias are irregular heartbeats that may be life-threatening. Proper monitoring and the right care at the right time are necessary to keep the heart healthy. Monitoring electrocardiogram (ECG) patterns on continuous monitoring devices is time-consuming. An intense manual inspection by caregivers is not an option. In addition, such an inspection could result in errors and inter-variability. This article proposes an automated ECG beat classification method based on deep neural networks (DNN) to aid in the detection of cardiac arrhythmias. The data collected by an Internet of Things enabled ECG monitoring device are transferred to a server. They are analysed by a deep learning model, and the results are shared with the primary caregiver. The proposed model is trained using the MIT-BIH ECG arrhythmia database to classify into four classes: normal beat (N), left bundle branch block beat (L), right bundle branch block beat (R), and premature ventricular contraction (V). The received data are sampled with an overlapping sliding window and divided into an 80:20 ratio for training and testing, with tenfold cross-validation. The proposed method achieves higher accuracy with a simple model without any preprocessing when compared with previous works. For the train and test sets, we achieved accuracy rates of 99.09 and 99.03%, respectively. A precision, recall, and F1 scores of 0.99 is obtained. The proposed model achieves its goal of developing a simple and accurate ECG monitoring system with improved performance. This simple and efficient deep learning approach for heartbeat classification could be applied in real-time telehealth monitoring systems.

Cardiac conduction disturbances in rheumatologic disease: a cross-sectional study

BACKGROUND

Cardiovascular abnormalities are common in patients with rheumatologic disorders. Tachy-arrhythmias occur more frequently in these patients than the general population; however, the prevalence of bradyarrhythmias in this group is less clear. This investigation aimed to analyze the incidence and predictors of bradyarrhythmias and conduction disturbances, as well as the presence and influence of cardiologist management, in patients with rheumatologic disorders.

METHODS

We performed a retrospective chart review of 57 consecutive patients with rheumatologic conditions evaluated at a tertiary-care safety-net hospital. Conduction disturbances were defined by any electrocardiogram (ECG) finding indicating: bradycardia, sinoatrial block of any degree, atrioventricular nodal block of any degree, left anterior or posterior fascicular block, non-specific intraventricular conduction delay, complete or incomplete right bundle branch block, left bundle branch block, or paced rhythm. Univariate and multivariate analyses were used to assess the association of relative predictors of conduction disturbance, the primary outcome of this investigation, as well as the secondary outcome of cardiologist involvement in patient care. Statistical significance was defined as P<0.05. Variables found to be statistically significant in a univariate analysis were included in a multivariable logistic regression analysis.

RESULTS

The most common rheumatologic condition in our patient population was systemic lupus erythematous (21 patients, 36.8%) followed by gout (15 patients, 26.3%), rheumatoid arthritis (13 patients, 22.8%), sarcoidosis (6 patients, 10.5%), and two patients (3.5%) with other autoimmune diseases. A total of 31.6% of patients in this study were found to have conduction disturbances, higher than the prevalence of conduction disturbances in the general population. Multivariate logistic regression analysis showed significantly increased odds for conduction disturbances with increased age (odds ratio (OR): 1.05, 95% confidence interval (CI): 1.01-1.10, P<0.05). Similar analysis for the involvement of a cardiologist in the care of a patient with a rheumatologic disorder found increased odds for cardiologist involvement with advanced age (OR: 1.05, 95% CI: 1.002-1.09, P<0.05) and cardiovascular disease (OR: 5.0, 95% CI 1.24-21.90, P<0.05).

CONCLUSION

Prevalence of conduction abnormalities is greater in rheumatologic patients than the general population. Odds for conduction abnormalities increased with age; and the odds of cardiologist involvement increased with age and cardiovascular disease.

Cancer Chemotherapy-Induced Sinus Bradycardia: A Narrative Review of a Forgotten Adverse Effect of Cardiotoxicity

Cardiotoxicity is a common adverse effect of anticancer drugs (ACDs), including the so-called targeted drugs, and increases morbidity and mortality in patients with cancer. Attention has focused mainly on ACD-induced heart failure, myocardial ischemia, hypertension, thromboembolism, QT prolongation, and tachyarrhythmias. Yet, although an increasing number of ACDs can produce sinus bradycardia (SB), this proarrhythmic effect remains an underappreciated complication, probably because of its low incidence and severity since most patients are asymptomatic. However, SB merits our interest because its incidence increases with the aging of the population and cancer is an age-related disease and because SB represents a risk factor for QT prolongation. Indeed, several ACDs that produce SB also prolong the QT interval. We reviewed published reports on ACD-induced SB from January 1971 to November 2020 using the PubMed and EMBASE databases. Published reports from clinical trials, case reports, and recent reviews were considered. This review describes the associations between ACDs and SB, their clinical relevance, risk factors, and possible mechanisms of onset and treatment.

Bio-Conductive Polymers for Treating Myocardial Conductive Defects: Long-Term Efficacy Study

Following myocardial infarction (MI), the resulting fibrotic scar is nonconductive and leads to ventricular dysfunction via electrical uncoupling of the remaining viable cardiomyocytes. The uneven conductive properties between normal myocardium and scar tissue result in arrhythmia, yielding sudden cardiac death/heart failure. A conductive biopolymer, poly-3-amino-4-methoxybenzoic acid-gelatin (PAMB-G), is able to resynchronize myocardial contractions in vivo. Intravenous PAMB-G injections into mice show that it does not cause any acute toxicity, up to the maximum tolerated dose (1.6 mL kg^-1 ), which includes the determined therapeutic dose (0.4 mL kg^-1 ). There is also no short- or long-term toxicity when PAMB-G is injected into the myocardium of MI rats, with no significant changes in body weight, organ-brain ratio, hematologic, and histological parameters for up to 12 months post-injection. At the therapeutic dose, PAMB-G restores electrical conduction in infarcted rat hearts, resulting in lowered arrhythmia susceptibility and improved cardiac function. PAMB-G is also durable, as mass spectrometry detected the biopolymer for up to 12 months post-injection. PAMB-G did not impact reproductive organ function or offspring characteristics when given intravenously into healthy adult rats. Thus, PAMB-G is a nontoxic, durable, and conductive biomaterial that is able to improve cardiac function for up to 1 year post-implantation.

The utility of implantable loop recorders (ILR) in patient management: an age and indication stratified study in the outpatient-implant era

INTRODUCTION

Implantable loop recorders (ILR) are now routinely implanted for long-term cardiac monitoring in the clinic setting. This study examined the real-world performance of these devices, focusing on the management decision changes made in response to ILR-recorded data.

METHODS AND RESULTS

This was a single centre, prospective observational study of consecutive patients undergoing ILR implantation. All patients who underwent implantation of a Medtronic Reveal LINQ device from September 2017 to June 2019 at Barts Heart Centre were included.501 patients were included. 302 (60%) patients underwent ILR implantation for an indication of pre-syncope/syncope, 96 (19%) for palpitations, 72 (14%) for atrial fibrillation (AF) detection with a history of cryptogenic stroke and 31 (6%) for patients deemed to be high risk of serious cardiac arrhythmia.The primary outcome of this study was that an ILR-derived diagnosis altered management in 110 (22%) of patients. Secondary outcomes concerned sub-group analyses by indication: in patients who presented with syncope/presyncope, a change in management resulting from ILR data was positively associated with age (HR: 1.04 [95%CI 1.02-1.06]; p < 0.001) and negatively associated with a normal ECG at baseline (HR 0.54 [0.31-0.93]; p = 0.03). Few patients (1/57, 2%) aged < 40 years in this group underwent device implantation, compared to 19/62 patients (31%) aged 75 years and over (p = 0.0024). 22/183 (12%) of patients in the 40-74 age range had a device implanted.In patients who underwent ILR insertion following cryptogenic stroke, 13/72 patients (18%) had AF detected leading to a decision to commence anticoagulation.

CONCLUSION

These results inform the utility of ILR in the clinical setting. Diagnoses provided by ILR that lead to changes in management are rare in patients under age 40, particularly following syncope, presyncope or palpitations. In older patients new diagnoses are frequently made and trigger important changes in treatment.

Using increased trust in medical researchers to increase minority recruitment: The RECRUIT cluster randomized clinical trial

While extensive literature exists on barriers and strategies to increase minority participation in clinical trials, progress is limited. Few strategies were evaluated in randomized trials. We studied the impact of RECRUIT, a trust-based, cluster randomized minority recruitment trial layered on top of four traditional NIH-funded parent trials (BMT CTN, CABANA, PACES, STEADY-PD III; fifty specialty sites). RECRUIT was conducted from July 2013 through April 2017. Intervention sites implemented trust-based approaches customized to individual sites, promoting relationships between physician-investigators and minority-serving physicians and their minority patients. Control sites implemented only parent trials' recruitment procedures. Adjusting for within-site clustering, we detected no overall intervention effect, odds ratio 1.3 (95% confidence limits 0.7,2.4). Heterogeneity among parent trials may have obscured the effect. Of the four parent trials, three enrolled more minorities in intervention versus control sites. CABANA odds ratio = 4.2 (adjusted 95%CL 1.5,11.3). PACES intervention sites enrolled 63% (10/16) minorities; control sites enrolled one participant in total, a minority, yielding an incalculable odds ratio. STEADY-PD III odds ratio = 2.2 (adjusted 95%CL 0.6,8.5). BMT CTN odds ratio < 1, 0.8 (adjusted 95%CL 0.4,1.8). In conclusion, RECRUIT findings suggest the unique trust-based intervention increased minority recruitment to intervention trials in ¾ of studied trials. Physician-investigators' participation was critical to recruitment success. Lack of commitment to minority recruitment remained a barrier for some physician-investigators, especially in control sites. We recommend prospective physician investigators commit to minority recruitment activities prior to selection as site investigators and trial funding include some compensation for minority recruitment efforts. TRIAL REGISTRATION ClinicalTrials.govNCT01911208.

Automated Arrhythmia Detection Based on RR Intervals

Abnormal heart rhythms, also known as arrhythmias, can be life-threatening. AFIB and AFL are examples of arrhythmia that affect a growing number of patients. This paper describes a method that can support clinicians during arrhythmia diagnosis. We propose a deep learning algorithm to discriminate AFIB, AFL, and NSR RR interval signals. The algorithm was designed with data from 4051 subjects. With 10-fold cross-validation, the algorithm achieved the following results: ACC = 99.98%, SEN = 100.00%, and SPE = 99.94%. These results are significant because they show that it is possible to automate arrhythmia detection in RR interval signals. Such a detection method makes economic sense because RR interval signals are cost-effective to measure, communicate, and process. Having such a cost-effective solution might lead to widespread long-term monitoring, which can help detecting arrhythmia earlier. Detection can lead to treatment, which improves outcomes for patients.

Tai chi improves psychoemotional state, cognition, and motor learning in older adults during the COVID-19 pandemic

The aim of this study was to determine the effect of a 10-week tai chi intervention on psychoemotional state, cognition, and motor learning in older adults during the COVID-19 pandemic. Participants aged 60-78 years were randomized to either a control group (n = 15) or a tai chi group (n = 15) for a 10-week period. The tai chi group received two, 8-form tai chi classes of 60 min duration per week. Changes in psychoemotional state, cognition, and the learning of fast and accurate reaching movements were assessed. In addition, the potential roles of the autonomic nervous system and brain-derived neurotrophic factor (BDNF) were investigated. Tai chi practice decreased (P < 0.05) perceived stress, whereas no change in autonomic nervous system activity was observed. Improvements in mental switching correlated with decreased depressive symptoms and increased BDNF levels (P < 0.05), whereas improvements in inhibitory control tended to correlate with BDNF levels (P = 0.08). Improvements in visuospatial processing tended to correlate with decreased depressive symptoms (P = 0.07) while improved visuospatial processing correlated with improved motor planning during learning tasks (P < 0.05). This study suggests that tai chi is an effective intervention that can be delivered under pandemic conditions to improve mental and physical function in older adults.

Predictors of outcomes in hospitalized patients undergoing pacemaker insertion: Analysis from the national inpatient database (2016-2017)

BACKGROUND

Pacemaker implantation in the U.S. is rising due to an aging population. The aim of this analysis was to identify risk factors associated with increased mortality and complications in hospitalized patients requiring pacemaker implantation.

METHODS

We performed a retrospective analysis using the National Inpatient Sample database, identifying hospitalized patients who underwent pacemaker implantation using International Classification of Disease, Tenth Revision, Clinical Modification codes. Independent predictors of inpatient mortality were identified using multivariate logistic regression analysis.

RESULTS

There were 242,980 hospitalizations with pacemaker implantation during 2016 and 2017. The most frequently encountered indications for hospitalizations involving pacemaker insertion included sick sinus syndrome (SSS) (27.60%), complete atrioventricular (AV) block (21.57%), and second-degree AV block (7.83%). Chronic liver disease was associated with the highest adjusted odds of inpatient mortality (aOR = 5.76, 95% CI: 4.46 to 7.44, p < .001). Comorbid anemia had the highest statistically significant adjusted odds ratio (aOR) for predictors of post-procedural cardiac complications (aOR = 3.17, 95% CI: 2.81 to 3.58, p < .001). Mortality in hospitalized patients needing pacemaker implantation was 1.05%. About 3.36% of hospitalizations developed post procedural circulatory complications (PPCC), 2.45% developed sepsis, and 1.84% developed mechanical complications of cardiac electronic devices.

CONCLUSIONS

We identified several predictors of inpatient mortality in hospitalized patients undergoing pacemaker implantation, including chronic liver disease, protein-calorie malnutrition, chronic heart failure, anemia, and history of malignancy. Anemia, chronic liver disease, and congestive heart failure were independent predictors of adverse outcomes in such patients.

Clinically Significant High-Grade AV Block as a Reversible Cause for Acute Kidney Injury in Hospitalized Patients-A Propensity Score Matched Cohort

Background. High-grade AV block (HGAVB) is a life-threatening condition. Acute kidney injury (AKI) which is usually caused by renal hypo-perfusion is associated with adverse outcomes. We aimed to investigate the association between AKI and HGAVB. Methods. This is a retrospective cohort comparing the incidence of AKI among patients with HGAVB requiring pacemaker implantation compared with propensity score matched controls. Primary outcome was the incidence of AKI at admission. Secondary outcomes were change in creatinine levels, AKI during stay, recovery from AKI, mortality and major adverse kidney events (MAKE). Results. In total, 80 HGAVB patients were compared to 400 controls. HGAVB patients had a higher proportion of admission AKI compared to controls (36.2% versus 21.1%, RR = 1.71 [1.21–2.41], p = 0.004). Creatinine changes from baseline to admission and to maximum during hospitalization, were also higher in HGAVB (p = 0.042 and p = 0.033). Recovery from AKI was more frequent among HGAVB patients (55.2% vs. 25.9%, RR = 2.13 [1.31–3.47], p = 0.004) with hospitalization time, MAKE and crude mortality similar (p > 0.158). Conclusions. AKI occurs in about one third of patients admitted with HGAVB, more frequent compared to controls. Patients with AKI accompanying HGAVB were likelier to recover from AKI. Further studies to explore this relationship could aid in clinical decision making for HGAVB patients.

Age-Related Changes in Cardiac Autonomic Modulation and Heart Rate Variability in Mice

Objective

The aim of this study was to assess age-related changes in cardiac autonomic modulation and heart rate variability (HRV) and their association with spontaneous and pharmacologically induced vulnerability to cardiac arrhythmias, to verify the translational relevance of mouse models for further in-depth evaluation of the link between autonomic changes and increased arrhythmic risk with advancing age.

Methods

Heart rate (HR) and time- and frequency-domain indexes of HRV were calculated from Electrocardiogram (ECG) recordings in two groups of conscious mice of different ages (4 and 19 months old) (i) during daily undisturbed conditions, (ii) following peripheral β-adrenergic (atenolol), muscarinic (methylscopolamine), and β-adrenergic + muscarinic blockades, and (iii) following β-adrenergic (isoprenaline) stimulation. Vulnerability to arrhythmias was evaluated during daily undisturbed conditions and following β-adrenergic stimulation.

Results

HRV analysis and HR responses to autonomic blockades revealed that 19-month-old mice had a lower vagal modulation of cardiac function compared with 4-month-old mice. This age-related autonomic effect was not reflected in changes in HR, since intrinsic HR was lower in 19-month-old compared with 4-month-old mice. Both time- and frequency-domain HRV indexes were reduced following muscarinic, but not β-adrenergic blockade in younger mice, and to a lesser extent in older mice, suggesting that HRV is largely modulated by vagal tone in mice. Finally, 19-month-old mice showed a larger vulnerability to both spontaneous and isoprenaline-induced arrhythmias.

Conclusion

The present study combines HRV analysis and selective pharmacological autonomic blockades to document an age-related impairment in cardiac vagal modulation in mice which is consistent with the human condition. Given their short life span, mice could be further exploited as an aged model for studying the trajectory of vagal decline with advancing age using HRV measures, and the mechanisms underlying its association with proarrhythmic remodeling of the senescent heart.

Diagnostic value of electrocardiogram during routine electroencephalogram

INTRODUCTION

A single-lead electrocardiogram (EKG) is routinely recorded with electroencephalogram (EEG). This study investigates the frequency and types of EKG abnormalities during routine EEG.

METHODS

All routine EEGs (20-60 min) over one year were retrospectively analyzed. A blinded cardiologist interpreted EKG recordings. An epileptologist evaluated EEGs. Demographic data, underlying comorbidities, and indications for the EEG were extracted.

RESULTS

A total of 433 recordings for 365 patients were included. Mean (±SD) age was 46.8 (±21.3) years and 50.4% were females. EKG abnormalities were detected in 28.5% of patients; sinus tachycardia (11%), premature ventricular contractions (7.9%), atrial fibrillation (Afib) (6.3%), sinus bradycardia (2.2%) and premature atrial contractions (1.1%). Afib was more common in females than males (p = 0.020), confirmed in six out of seven patients and discovered in 17 patients. Age (OR: 1.67, 95%CI: 1.05-2.66, p = 0.031), prior diagnosis of epilepsy (OR: 2.25, 95% CI: 1.22 - 4.14, p = 0.009), history of seizure (OR: 1.97,  95%CI: 1.09-3.54, p = 0.024), abnormal EEG (OR: 2.14, 95%CI: 1.25 - 3.66, p = 0.005) and EEGs evaluating seizures/epilepsy (OR: 4.18, 95% CI: 1.32 - 13.21, p = 0.015) or syncope (OR: 3.21, 95% CI: 1.16 - 8.84, p = 0.024) were independently associated with abnormal EKG.

CONCLUSION

The frequency of EKG abnormalities captured during routine EEGs was high, with Afib being the most significant. Older age, history of epilepsy or seizure, abnormal EEGs, and EEGs evaluating seizures/epilepsy or syncope were significant predictors. These findings suggest neurologists to become more vigilant to EKG recorded during routine EEG as such findings might have diagnostic and therapeutic implications.

Trends in the use, complications, and costs of permanent pacemakers in Australia: A nationwide study from 2008 to 2017

OBJECTIVE

To characterize contemporary pacemaker procedure trends.

METHODS

Nationwide analysis of pacemaker procedures and costs between 2008 and 2017 in Australia. The main outcome measures were total, age- and gender-specific implant, replacement, and complication rates, and costs.

RESULTS

Pacemaker implants increased from 12,153 to 17,862. Implantation rates rose from 55.3 to 72.6 per 100,000, a 2.8% annual increase (incidence rate ratio [IRR] 1.028; 95% CI, 1.02-1.04; p < .001). Pacemaker implants in the 80+ age group were 17.37-times higher than the < 50 group (95% CI 16.24-18.59; p < .001), and in males were 1.48-times higher than in females (95% CI 1.42-1.55; p < .001). However, there were similar increases according to age (p = .10) and gender (p = .68) over the study period. Left ventricular lead rates were stable (IRR 0.995; 95% CI 0.98-1.01; p = .53). Generator replacements decreased from 20.5 to 18.3 per 100,000 (IRR 0.975; 95% CI 0.97-0.98; p < .001). Although procedures for generator-related complications were stable (IRR 0.995; 95% CI 0.98-1.01; p = .54), those for lead-related complications decreased (IRR 0.985; 95% CI 0.98-0.99; p < .001). Rates for all pacemaker procedures were consistently greater in males (p < .001). Although annual costs of all pacemaker procedures increased from $178 million to $329 million, inflation-adjusted costs were more stable, rising from $294 million to $329 million.

CONCLUSIONS

Increasing demand for pacemaker implants is driven by the ageing population and rising rates across all ages, while replacement and complication procedure rates appeared more stable. Males have consistently greater pacemaker procedure rates than females. Our findings have significant clinical and public health implications for healthcare resource planning.

From ECG signals to images: a transformation based approach for deep learning

Provocative heart disease is related to ventricular arrhythmias (VA). Ventricular tachyarrhythmia is an irregular and fast heart rhythm that emerges from inappropriate electrical impulses in the ventricles of the heart. Different types of arrhythmias are associated with different patterns, which can be identified. An electrocardiogram (ECG) is the major analytical tool used to interpret and record ECG signals. ECG signals are nonlinear and difficult to interpret and analyze. We propose a new deep learning approach for the detection of VA. Initially, the ECG signals are transformed into images that have not been done before. Later, these images are normalized and utilized to train the AlexNet, VGG-16 and Inception-v3 deep learning models. Transfer learning is performed to train a model and extract the deep features from different output layers. After that, the features are fused by a concatenation approach, and the best features are selected using a heuristic entropy calculation approach. Finally, supervised learning classifiers are utilized for final feature classification. The results are evaluated on the MIT-BIH dataset and achieved an accuracy of 97.6% (using Cubic Support Vector Machine as a final stage classifier).

Noninvasive Testing for Diagnosis of Stable Coronary Artery Disease in the Elderly

Efficient diagnostic approaches to detect coronary artery disease (CAD) in elderly patients are necessary to ensure optimal and timely treatment. The population of suspected CAD patients older than 70 years is especially vulnerable and constantly growing. Finding the optimal diagnostic approach is challenging due to certain features of this population, such as high prevalence of comorbidities, existing contraindications to exercise tests or cognitive decline, which hinders correct assessment of the patient's situation. Moreover, some symptoms of CAD can have variable significance in the elderly compared to younger adult groups. In this review, we present current recommendations of the United States (US) and European cardiologists' associations and discuss their applicability for diagnostics in the elderly population. Exercise electrocardiogram (ECG) and exercise stress echocardiography (SE) tests are not feasible for a substantial proportion of elderly patients. Coronary computed tomography angiography (CTA) appears to be an attractive alternative for such patients, but is not universally applicable; for instance, it is problematic in patients with significant calcification of the vessels. Moreover, more studies are needed to compare the results delivered by CTA to those of other diagnostic methods. Future efforts should be focused on comparative studies to better understand the limits and advantages of different diagnostic methods and their combinations. It is possible that some of the currently used diagnostic criteria could be improved to better accommodate the needs of the elderly population.

Intracavitary electrocardiography for tip location during central venous catheterization: A narrative review of 70 years of clinical studies

Intracavitary electrocardiography is an accurate and non-invasive method for central venous access tip location. Using the catheter as a traveling intracavitary electrode, intracavitary electrocardiography is based on the increase in the detected amplitude of the P wave while approaching the cavoatrial junction. Despite having been adopted diffusely in clinical practice only in the last years, this method is not novel. In fact, it has first been described in the late 40s, during electrophysiological studies. After a long period of quiescence, it is in the last two decades of the XX century that intracavitary electrocardiography became popular as an effective mean of central venous catheters tip location. But the golden age of this technique began with the new millennium, as documented by high-quality studies in this period. In fact, in those years, intracavitary electrocardiography has been studied broadly, and important achievements in terms of comprehension of the technique, accuracy, and feasibility of the method in different populations and conditions (i.e. pediatrics, renal patients, atrial fibrillation) have been gained. In this review, we describe the technique, its history, and its current perspectives.

A 10-week yoga practice has no effect on cognition, but improves balance and motor learning by attenuating brain-derived neurotrophic factor levels in older adults

Despite studies investigating the effect of yoga on cognitive and motor functioning in older adults, the effect on dual-task performance and motor learning and the specific mechanisms underlying the positive effect of yoga remain unclear. Thus, the aim of this study was to investigate the effects of yoga on cognition, balance under single- and dual-task conditions, and motor learning. The potential role of brain-derived neurotrophic factor (BDNF) in induced improvement was also explored. Participants aged 60-79 years were randomized to either a control group (n = 15) or a yoga group (n = 18) for a 10-week period. The yoga group received 90-min duration yoga classes two times per week. Changes in cognition, balance under single- and dual-task conditions, and learning fast and accurate reaching movements were assessed. Yoga practice decreased (P < 0.05) the velocity vector of the center of pressure under single- and dual-task conditions, whereas no changes in cognitive performance were observed. Although reaction and movement times during learning were decreased in both groups (P < 0.05), a faster reaction time (P < 0.05) and shorter movement time (P < 0.05) were observed in the yoga group than in the control group. Significant moderate relationships (P < 0.05) between changes in BDNF levels and functional improvements were observed. Thus, 10 weeks of yoga practice resulted in improved balance and learning in the speed-accuracy motor task that were mediated by increased BDNF levels, but had no impact on cognition in older adults.

An Industry Survey With Focus on Cardiovascular Safety Pharmacology Study Design and Data Interpretation

Introduction:

The Safety Pharmacology Society (SPS) conducted a membership survey to examine industry practices related mainly to cardiovascular (CV) safety pharmacology (SP).

Methods:

Questions addressed nonclinical study design, data analysis methods, drug-induced effects, and conventional and novel CV assays.

Results:

The most frequent therapeutic area targeted by drugs developed by the companies/institutions that employ survey responders was oncology. The most frequently observed drug-mediated effects included an increased heart rate, increased arterial blood pressure, hERG (IKr) block, decreased arterial blood pressure, decreased heart rate, QTc prolongation, and changes in body temperature. Broadly implemented study practices included Latin square crossover study design with n = 4 for nonrodent CV studies, statistical analysis of data (eg, analysis of variance), use of arrhythmia detection software, and the inclusion of data from all study animals when integrating SP studies into toxicology studies. Most responders frequently used individual animal housing conditions. Responders commonly evaluated drug effects on multiple ion channels, but in silico modeling methods were used much less frequently. Most responders rarely measured the J-Tpeak interval in CV studies. Uncertainties relative to Standard for Exchange of Nonclinical Data applications for data derived from CV SP studies were common. Although available, the use of human induced pluripotent stem cell cardiomyocytes remains rare. The respiratory SP study was rarely involved with identifying drug-induced functional issues. Responders indicated that the study-derived no observed effect level was more frequently determined than the no observed adverse effect level in CV SP studies; however, a large proportion of survey responders used neither.

Dietary and Lifestyle Patterns are Associated with Heart Rate Variability

Assessment of heart rate variability (HRV) and cardiac ectopic beats is a clinically relevant topic. The present exploratory observational study aimed to inspect the relationships of lifestyle, dietary patterns, and anthropometrics with HRV, premature ventricular complexes (PVCs), and supraventricular premature complexes (SVPCs). A cross-sectional study enrolling subjects undergoing Holter monitoring was performed. Sociodemographic and clinical characteristics, body composition (full-body bio-impedentiometry), dietary patterns (validated food frequency questionnaire and 24 h dietary recall), and quality of life were assessed. Generalized additive models were estimated to evaluate the relationships between outcomes of interest and variables collected. The study enrolled 121 consecutive patients undergoing 24 h Holter monitoring. Upon univariable analysis, HRV was found to have an inverse association with mass of body fat (MBF) (p-value 0.015), while doing physical activity was associated with a significantly higher HRV (p-value 0.036). Upon multivariable analysis, fruit consumption in the 24 h dietary recall was found to be directly associated with HRV (p-value 0.044). The present findings might be useful for improving the management of patients attending cardiac rhythm labs, and to tailor ad hoc prevention strategies (modification of lifestyle and eating habits) based on Holter parameters.

Suicide Attempt Following Pacemaker Implantation in an Eighty-Three-Year-Old Male: A Case Report

As the global population ages, cardiac pacing procedures are rising exponentially to keep pace with the increasing incidence of bradyarrhythmias. The efficacy of pacemakers is well established, but recipients may have poor psychosocial adaptation leading to development or exacerbation of mental disorders, that may manifest with anxiety, depressive symptoms or rarely suicidal tendencies. An 83-year-old male of African descent was referred to us for evaluation and expert management. He came with chief complaints of general body malaise, light-headedness, chest pain and fainting spells for about 6 months. He was diagnosed with hypertension 4 years prior, and there was no history of mental illness in the patient or his family. Echocardiography (ECHO) revealed features of hypertensive heart disease while electrocardiogram (ECG) showed features of third-degree heart block. He underwent successful pacing with a resultant ventricular paced rhythm. The patient was stable and symptom free post pacing, but on the fourth day he jumped off the window of the ward in the hospital’s second floor. Post suicide attempt examination revealed epistaxis, right periorbital hematoma with a temporal lacerated wound and deformed ankles bilaterally. ECG showed a ventricular paced rhythm and the chest radiograph showed an intact pacemaker. Ophthalmological review was evident for right sided blepharospasm with massive chemosis and bilateral constricted reactive pupils. Radiological investigations showed right orbital fracture, stable C5 and C6 fractures, and bilateral bimalleolar fractures with ankle dislocation. Neurosurgical review was unremarkable and psychiatric review could not be performed. The patient died 18 h after the suicide attempt incidence. Emotional disturbances post pacing impairs the quality of life and in the worst case scenario could lead to unanticipated cessation of life. In view of this, thorough evaluation and monitoring of the patient’s psychological well-being both pre and post pacing is paramount.

Life beyond 5 Years after TAVI: Patients' Perceived Health Status and Long-Term Outcome after Transcatheter Aortic Valve Implantation

Background

Transcatheter aortic valve implantation (TAVI) is currently recommended for patients with severe aortic stenosis at intermediate or high surgical risk. The decision process during TAVI evaluation includes a thorough benefit-risk assessment, and knowledge about long-term benefits and outcomes may improve patients' expectation management.

Objective

To evaluate patients' perceived health status and self-reported long-term outcome more than 5 years after TAVI.

Methods and Results

Demographic and procedure data were obtained from all patients treated with TAVI at our institution from 2006 to 2012. A cross-sectional survey was conducted on the patients alive, measuring health status, including the EQ-5D-5L questionnaire, and clinical outcomes. 103 patients (22.8%) were alive at a median follow-up period of 7 years (5.4–9.8). 99 (96%) of the 103 patients were included in the final analysis. The mean age at follow-up was 86.5 years ± 8.0 years, and 56.6% were female. Almost all patients (93.9%) described an improvement of their quality of life after receiving TAVI. At late follow-up, the mean utility index and EQ-VAS score were 0.80 ± 0.20 and 58.49 ± 11.49, respectively. Mobility was found to be the most frequently reported limitation (85.4%), while anxiety/depression was the least frequently reported limitation (19.8%). With respect to functional class, 64.7% were in New York Heart Association (NYHA) class III or IV, compared to 67.0% prior to TAVI (p=0.51). Self-reported long-term outcomes revealed mainly low long-term complication rates. 74 total hospitalizations were reported after TAVI, and among those 43% for cardiovascular reasons. Within cardiovascular rehospitalizations, new pacemaker implantations were the most frequently reported (18.9%), followed by cardiac decompensation and coronary heart disease (15.6%).

Conclusion

The majority of the patients described an improvement of health status after TAVI. More than five years after TAVI, the patients' perceived health status was satisfactory, and the incidence of clinical events and hospitalizations was very low.

Arrhythmias in Patients ≥80 Years of Age: Pathophysiology, Management, and Outcomes

Advances in medical care have led to an increase in the number of octogenarians and even older patients, forming an important and unique patient subgroup. It is clear that advancing age is an independent risk factor for the development of most arrhythmias, causing substantial morbidity and mortality. Patients ≥80 years of age have significant structural and electrical remodeling of cardiac tissue; accrue competing comorbidities; react differently to drug therapy; and may experience falls, frailty, and cognitive impairment, presenting significant therapeutic challenges. Unfortunately, very old patients are under-represented in clinical trials, leading to critical gaps in evidence to guide effective and safe treatment of arrhythmias. In this state-of-the-art review, we examine the pathophysiology of aging and arrhythmias and then present the available evidence on age-specific management of the most common arrhythmias, including drugs, catheter ablation, and cardiac implantable electronic devices.

Prevalence and Incidence of Atrial Fibrillation and Other Arrhythmias in the General Older Population: Findings From the Swedish National Study on Aging and Care

Aim: To study the prevalence and cumulative incidence of arrhythmias in the general population of adults aged 60 and older over a 6-year period. Study Design and Setting: Data were taken from the Swedish National Study on Aging and Care (SNAC), a national, longitudinal, multidisciplinary study of the general elderly population (defined as 60 years of age or older). A 12-lead resting electrocardiography (ECG) was performed at baseline and 6-year follow-up. Results: The baseline prevalence of atrial fibrillation (AF) was 4.9% (95% confidence interval [CI] = [4.5%, 5.5%]), and other arrhythmias including ventricular premature complexes (VPCs), supraventricular tachycardia (SVT), and supraventricular extrasystole (SVES) were seen in 8.4% (7.7%, 9.0%) of the population. A first- or second-degree atrioventricular (AV) block was found in 7.1% of the population (95% CI = [6.5%, 7.7%]), and there were no significant differences between men and women in baseline arrhythmia prevalence. The 6-year cumulative incidence of AF was 4.1% (95% CI = [3.5%, 4.9%]), or 6.9/1,000 person-years (py; 95% CI = [5.7, 8.0]). The incidence of AF, other arrhythmias, AV block, and pacemaker-induced rhythm was significantly higher in men in all cohorts except for the oldest. Conclusion: Our data highlight the prevalence and incidence of arrhythmias, which rapidly increase with advancing age in the general population.

External continuous ECG versus loop recording for atrial fibrillation detection in patients who had a stroke

BACKGROUND

Detection of atrial fibrillation (AF) in patients who had ischaemic stroke and transient ischaemic attack (IS/TIA) is recommended. We aimed to compare external loop recording (ELR) against simultaneous continuous ECG recording for AF detection in patients who had acute IS/TIA and determine sensitivity, specificity and positive predictive value of AF detection using ELR. We hypothesised ELR to detect 15% fewer patients with AF than continuous ECG recording.

METHODS

In this prospective cohort study, we included 1412 patients who had acute IS/TIA without prior AF. Monitoring was 48 hours. Primary outcome was AF >30 s. Cardiologist verified AF in continuous ECG was gold standard.

RESULTS

In continuous ECG, 38 (2.7%) patients had AF. ELR automatically categorised 219/1412 patients (15.5%) with AF, including 32/38 (85%) patients with AF in continuous ECG. After cardiologist adjudication of ELR recordings, AF was diagnosed in 57/219 patients, of which 32 (56%) had AF in continuous ECG. For adjudicated AF detection by ELR, sensitivity was 84%, 95% CI (69% to 94%), specificity was 98%, 95% CI (97% to 99%) and positive predictive value was 56%, 95% CI (42% to 69%).

CONCLUSION

Automatic AF detection with ELR results in an AF diagnosis in more than five patients without AF for each patient with AF as verified in continuous ECG. For adjudicated AF detection by ELR, sensitivity was confirmed to 84% and specificity 98%. Automatic ELR as investigated in this study may be considered to rule out AF, but it is not suitable as a single monitoring device for AF screening in patients early after stroke.

TRIAL REGISTRATION NUMBER

NCT02155907.