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Lauretti C, Antonio GL, Fernandes AE, Stocco FG, Girardi ACC, Verrier RL, Caramelli B. Empagliflozin's role in reducing ventricular repolarization heterogeneity: insights into cardiovascular mortality decline from the EMPATHY-HEART trial. Cardiovasc Diabetol 2024; 23:221. [PMID: 38926835 PMCID: PMC11210164 DOI: 10.1186/s12933-024-02311-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/16/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND The incidence of myocardial infarction (MI) and sudden cardiac death (SCD) is significantly higher in individuals with Type 2 Diabetes Mellitus (T2DM) than in the general population. Strategies for the prevention of fatal arrhythmias are often insufficient, highlighting the need for additional non-invasive diagnostic tools. The T-wave heterogeneity (TWH) index measures variations in ventricular repolarization and has emerged as a promising predictor for severe ventricular arrhythmias. Although the EMPA-REG trial reported reduced cardiovascular mortality with empagliflozin, the underlying mechanisms remain unclear. This study investigates the potential of empagliflozin in mitigating cardiac electrical instability in patients with T2DM and coronary heart disease (CHD) by examining changes in TWH. METHODS Participants were adult outpatients with T2DM and CHD who exhibited TWH > 80 µV at baseline. They received a 25 mg daily dose of empagliflozin and were evaluated clinically including electrocardiogram (ECG) measurements at baseline and after 4 weeks. TWH was computed from leads V4, V5, and V6 using a validated technique. The primary study outcome was a significant (p < 0.05) change in TWH following empagliflozin administration. RESULTS An initial review of 6,000 medical records pinpointed 800 patients for TWH evaluation. Of these, 412 exhibited TWH above 80 µV, with 97 completing clinical assessments and 90 meeting the criteria for high cardiovascular risk enrollment. Empagliflozin adherence exceeded 80%, resulting in notable reductions in blood pressure without affecting heart rate. Side effects were generally mild, with 13.3% experiencing Level 1 hypoglycemia, alongside infrequent urinary and genital infections. The treatment consistently reduced mean TWH from 116 to 103 µV (p = 0.01). CONCLUSIONS The EMPATHY-HEART trial preliminarily suggests that empagliflozin decreases heterogeneity in ventricular repolarization among patients with T2DM and CHD. This reduction in TWH may provide insight into the mechanism behind the decreased cardiovascular mortality observed in previous trials, potentially offering a therapeutic pathway to mitigate the risk of severe arrhythmias in this population. TRIAL REGISTRATION NCT: 04117763.
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Affiliation(s)
- Cristiane Lauretti
- Interdisciplinary Medicine Unit in Cardiology, Heart Institute of the Clinical Hospital of the Medical School of the University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44- Anexo II, Sao Paulo, 05403000, SP, Brazil
| | - Graziella L Antonio
- Interdisciplinary Medicine Unit in Cardiology, Heart Institute of the Clinical Hospital of the Medical School of the University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44- Anexo II, Sao Paulo, 05403000, SP, Brazil
| | - Ariana E Fernandes
- Interdisciplinary Medicine Unit in Cardiology, Heart Institute of the Clinical Hospital of the Medical School of the University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44- Anexo II, Sao Paulo, 05403000, SP, Brazil
| | - Fernando G Stocco
- Interdisciplinary Medicine Unit in Cardiology, Heart Institute of the Clinical Hospital of the Medical School of the University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44- Anexo II, Sao Paulo, 05403000, SP, Brazil
| | - Adriana C C Girardi
- Medical School Laboratory of Genetics and Molecular Cardiology , Heart Institute of the Clinical Hospital University of Sao Paulo , Sao Paulo, 05403000, Brazil, SP
| | - Richard L Verrier
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA, 02215, United States of America
| | - Bruno Caramelli
- Interdisciplinary Medicine Unit in Cardiology, Heart Institute of the Clinical Hospital of the Medical School of the University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44- Anexo II, Sao Paulo, 05403000, SP, Brazil.
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Dykiert I, Florek K, Kraik K, Gać P, Poręba R, Poręba M. Tpeak-Tend ECG Marker in Obesity and Cardiovascular Diseases: A Comprehensive Review. SCIENTIFICA 2024; 2024:4904508. [PMID: 38962529 PMCID: PMC11221957 DOI: 10.1155/2024/4904508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 05/13/2024] [Accepted: 06/13/2024] [Indexed: 07/05/2024]
Abstract
Globally, cardiovascular diseases are still the leading cause of death. Numerous methods are used to diagnose cardiovascular pathologies; there is still a place for straightforward and noninvasive techniques, such as electrocardiogram (ECG). Depolarization and repolarization parameters, including QT interval and its derivatives, are well studied. However, the Tpeak-Tend interval is a novel and promising ECG marker with growing evidence for its potential role in predicting malignant arrhythmias. In this review, we discuss the association between the Tpeak-Tend interval and several cardiovascular diseases, including long QT syndrome, cardiomyopathies, heart failure, myocardial infarction, and obesity, which constitutes one of the risk factors for cardiovascular diseases.
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Affiliation(s)
- Irena Dykiert
- Division of PathophysiologyDepartment of Physiology and PathophysiologyWroclaw Medical University, Wrocław, Poland
| | - Kamila Florek
- Students' Scientific Association of Cardiovascular Diseases PreventionDepartment of Internal and Occupational DiseasesHypertension and Clinical OncologyWroclaw Medical University, Wrocław, Poland
| | - Krzysztof Kraik
- Students' Scientific Association of Cardiovascular Diseases PreventionDepartment of Internal and Occupational DiseasesHypertension and Clinical OncologyWroclaw Medical University, Wrocław, Poland
| | - Paweł Gać
- Division of Environmental Health and Occupational MedicineDepartment of Population HealthWroclaw Medical University, Wrocław, Poland
| | - Rafał Poręba
- Department of Internal and Occupational DiseasesHypertension and Clinical OncologyWroclaw Medical University, Wrocław, Poland
| | - Małgorzata Poręba
- Department of Paralympic SportWroclaw University of Health and Sport Sciences, Wrocław, Poland
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Fialho GL, Pang TD, Kong WY, Tran AP, Yu CG, Rodriguez ID, Nearing BD, Waks JW, Maher TR, Clarke JR, Shepherd A, D'Avila A, Schachter SC, Verrier RL. Individuals with chronic epilepsy have elevated P-wave heterogeneity comparable to patients with atrial fibrillation. Epilepsia 2023; 64:2361-2372. [PMID: 37329175 DOI: 10.1111/epi.17686] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Identification of epilepsy patients with elevated risk for atrial fibrillation (AF) is critical given the heightened morbidity and premature mortality associated with this arrhythmia. Epilepsy is a worldwide health problem affecting nearly 3.4 million people in the United States alone. The potential for increased risk for AF in patients with epilepsy is not well appreciated, despite recent evidence from a national survey of 1.4 million hospitalizations indicating that AF is the most common arrhythmia in people with epilepsy. METHODS We analyzed inter-lead heterogeneity of P-wave morphology, a marker reflecting arrhythmogenic nonuniformities of activation/conduction in atrial tissue. The study groups consisted of 96 patients with epilepsy and 44 consecutive patients with AF in sinus rhythm before clinically indicated ablation. Individuals without cardiovascular or neurological conditions (n = 77) were also assessed. We calculated P-wave heterogeneity (PWH) by second central moment analysis of simultaneous beats from leads II, III, and aVR ("atrial dedicated leads") from standard 12-lead electrocardiography (ECG) recordings from admission day to the epilepsy monitoring unit (EMU). RESULTS Female patients composed 62.5%, 59.6%, and 57.1% of the epilepsy, AF, and control subjects, respectively. The AF cohort was older (66 ± 1.1 years) than the epilepsy group (44 ± 1.8 years, p < .001). The level of PWH was greater in the epilepsy group than in the control group (67 ± 2.6 vs. 57 ± 2.5 μV, p = .046) and reached levels observed in AF patients (67 ± 2.6 vs. 68 ± 4.9 μV, p = .99). In multiple linear regression analysis, PWH levels in individuals with epilepsy were mainly correlated with the PR interval and could be related to sympathetic tone. Epilepsy remained associated with PWH after adjustments for cardiac risk factors, age, and sex. SIGNIFICANCE Patients with chronic epilepsy have increased PWH comparable to levels observed in patients with AF, while being ~20 years younger, suggesting an acceleration in structural change and/or cardiac electrical instability. These observations are consistent with emerging evidence of an "epileptic heart" condition.
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Affiliation(s)
- Guilherme L Fialho
- Federal University of Santa Catarina, Florianopolis, Brazil
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Trudy D Pang
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Wan Yee Kong
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Anthony P Tran
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Calvin G Yu
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Ivo D Rodriguez
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Bruce D Nearing
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Jonathan W Waks
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Timothy R Maher
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - John-Ross Clarke
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Alyssa Shepherd
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Andre D'Avila
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Steven C Schachter
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Richard L Verrier
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
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Fialho GL, Nearing BD, Waks JW, Maher TR, Clarke JR, Shepherd A, D'Avila A, Verrier RL. Reduction in atrial and ventricular electrical heterogeneity following pulmonary vein isolation in patients with atrial fibrillation. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01543-7. [PMID: 37074510 DOI: 10.1007/s10840-023-01543-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/28/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) modulates the intrinsic cardiac autonomic nervous system and reduces atrial fibrillation (AF) recurrence. METHODS In this retrospective analysis, we investigated the impact of PVI on ECG interlead P-wave, R-wave, and T-wave heterogeneity (PWH, RWH, TWH) in 45 patients in sinus rhythm undergoing clinically indicated PVI for AF. We measured PWH as a marker of atrial electrical dispersion and AF susceptibility and RWH and TWH as markers of ventricular arrhythmia risk along with standard ECG measures. RESULTS PVI acutely (16 ± 8.9 h) reduced PWH by 20.7% (from 31 ± 1.9 to 25 ± 1.6 µV, p < 0.001) and TWH by 27% (from 111 ± 7.8 to 81 ± 6.5 µV, p < 0.001). RWH was unchanged after PVI (p = 0.068). In a subgroup of 20 patients with longer follow-up (mean = 47 ± 3.7 days after PVI), PWH remained low (25 ± 1.7 µV, p = 0.01), but TWH partially returned to the pre-ablation level (to 93 ± 10.2, p = 0.16). In three individuals with early recurrence of atrial arrhythmia in the first 3 months after ablation, PWH increased acutely by 8.5%, while in patients without early recurrence, PWH decreased acutely by 22.3% (p = 0.048). PWH was superior to other contemporary P-wave metrics including P-wave axis, dispersion, and duration in predicting early AF recurrence. CONCLUSION The rapid time course of decreased PWH and TWH after PVI suggests a beneficial influence likely mediated via ablation of the intrinsic cardiac nervous system. Acute responses of PWH and TWH to PVI suggest a favorable dual effect on atrial and ventricular electrical stability and could be used to track individual patients' electrical heterogeneity profile.
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Affiliation(s)
- Guilherme L Fialho
- Federal University of Santa Catarina, Florianopolis, Brazil
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Bruce D Nearing
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Jonathan W Waks
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Timothy R Maher
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - John-Ross Clarke
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Alyssa Shepherd
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Andre D'Avila
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Richard L Verrier
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
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Kumar HU, Nearing BD, Mittal S, Premchand RK, Libbus I, DiCarlo LA, Amurthur B, KenKnight BH, Anand IS, Verrier RL. Autonomic regulation therapy in chronic heart failure with preserved/mildly reduced ejection fraction: ANTHEM-HFpEF study results. Int J Cardiol 2023; 381:37-44. [PMID: 36934987 DOI: 10.1016/j.ijcard.2023.03.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/08/2023] [Accepted: 03/13/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Autonomic regulation therapy (ART) utilizing cervical vagus nerve stimulation (VNS) appeared to be safe and to improve autonomic tone, symptoms, and cardiac mechanical function in patients with symptomatic heart failure and reduced ejection fraction in the ANTHEM-HF Study. The ANTHEM-HFpEF Study is the first investigation to evaluate the safety and feasibility of ART in patients with symptomatic heart failure and preserved or mildly reduced ejection fraction (HFpEF, HFmrEF). METHODS This open-label interventional study enrolled 52 patients with HFpEF or HFmrEF, NYHA Class II-III, and LVEF ≥40%, who received stable guideline-directed medical therapy. All patients were successfully implanted with LivaNova VNS Therapy® system with an electrical lead surrounding the right cervical vagus nerve. RESULTS Adverse event incidence was low. At 12 months, NYHA class (p < 0.0001), 6-min walk distance (p < 0.05), and quality of life (p < 0.0001) were improved. Cardiac mechanical function measures were normal at baseline, except for left ventricular mass index in women and E/e' ratio in all patients, which were elevated at baseline, and were unchanged by ART. Autonomic tone and reflexes improved, indicated by 29% decrease in low-frequency/high-frequency heart rate variability to normal levels (p = 0.028) and by increased heart rate turbulence slope (p = 0.047). T-wave alternans (p = 0.001) and T-wave heterogeneity (p = 0.001) were reduced from abnormal to normal ranges. Nonsustained ventricular tachycardia incidence decreased (p = 0.027). CONCLUSIONS ART appeared well-tolerated and safe in patients with HFpEF or HFmrEF. Chronic ART did not alter mechanical function measures but was associated with improved heart failure symptoms, exercise tolerance, autonomic tone, and cardiac electrical stability. CLINICAL TRIAL REGISTRY Autonomic Neural Regulation Therapy to Enhance Myocardial Function in Heart Failure with Preserved Ejection Fraction [ClinicalTrials.gov #NCT03163030, registered 05/22/2017].
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Affiliation(s)
| | - Bruce D Nearing
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | | | - Richard L Verrier
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Fialho GL, Verrier RL, D'Avila A, Melo HM, Wolf P, Walz R, Lin K. Dual assessment of abnormal cardiac electrical dispersion and diastolic dysfunction for early detection of the epileptic heart condition. J Electrocardiol 2023; 78:69-75. [PMID: 36805647 DOI: 10.1016/j.jelectrocard.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/27/2023] [Accepted: 02/05/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND People with epilepsy (PWE) are at increased risk for premature death due to many factors. Sudden unexpected death in epilepsy (SUDEP) is among the most important causes of death in these individuals and possibly, sudden cardiac death (SCD) in epilepsy is also as important. The possibility of concurrent derangement in electrical and mechanical cardiac function, which could be a marker of early cardiac involvement in PWE, has not been investigated in that population. METHODS Electrical dispersion indices (T-wave peak to T-wave end, TpTe; QT dispersion, QTd; QT interval corrected for heart rate, QTc) were analyzed in patients with pharmacoresistant temporal lobe epilepsy and compared to a control group. The electromechanical relationship between those indices and echocardiographic parameters were further assessed in PWE. RESULTS In 19 PWE and 21 controls, we found greater TpTe and QTd in PWE (TpTe: 91.6 ± 16.4 ms vs. 65.2 ± 12.1 ms, p < 0.0001; and QTd: 45.3 ± 13.1 ms vs. 19 ± 6.2 ms, p < 0.0001, respectively). QTc was similar between PWE and controls (419.2 ± 31.4 ms vs. 435.1 ± 31.4 ms, p = 0.12). In multivariate linear regression, TpTe, QTc, and epilepsy duration were related to left ventricular mass; QTc was associated with left atrial volume; QTc, the number of seizures per month, epilepsy duration and antiseizure medication explained 81% of E/A mitral wave Doppler ratio. CONCLUSIONS This is the first report to demonstrate concurrent electrical dispersion and diastolic dysfunction in PWE. These noninvasive biomarkers could prove useful in early detection of the "Epileptic Heart" condition.
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Affiliation(s)
- Guilherme Loureiro Fialho
- Cardiology Division, Department of Internal Medicine, University Hospital (HU) Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil; Postgraduate Program in Medical Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil; Center for Applied Neuroscience, University Hospital (HU), Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Richard L Verrier
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Harvard Medical School, Boston, MA, USA.
| | - Andre D'Avila
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Harvard Medical School, Boston, MA, USA
| | - Hiago Murilo Melo
- Postgraduate Program in Medical Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil; Center for Applied Neuroscience, University Hospital (HU), Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Peter Wolf
- Postgraduate Program in Medical Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil; Danish Epilepsy Centre, Dianalund, Denmark; Neurology Division, Department of Internal Medicine, University Hospital, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Roger Walz
- Postgraduate Program in Medical Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil; Center for Applied Neuroscience, University Hospital (HU), Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil; Neurology Division, Department of Internal Medicine, University Hospital, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil; Center for Epilepsy Surgery of Santa Catarina (CEPESC), University Hospital (HU), Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Katia Lin
- Postgraduate Program in Medical Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil; Center for Applied Neuroscience, University Hospital (HU), Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil; Neurology Division, Department of Internal Medicine, University Hospital, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil; Center for Epilepsy Surgery of Santa Catarina (CEPESC), University Hospital (HU), Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil
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Verrier RL, Varma N, Nearing BD. Continuous multi-day tracking of post-myocardial infarction recovery of cardiac electrical stability and autonomic tone using electrocardiogram patch monitors. Ann Noninvasive Electrocardiol 2023; 28:e13035. [PMID: 36630149 PMCID: PMC9833356 DOI: 10.1111/anec.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/30/2022] [Accepted: 12/04/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Sudden cardiac death (SCD) risk is elevated following acute myocardial infarction (MI). The time course of SCD susceptibility post-MI requires further investigation. METHODS In this observational cohort study, we employed state-of-the-art noninvasive ECG techniques to track the daily time course of cardiac electrical instability and autonomic function following ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). Preventice BodyGuardian MINI-EL Holters continuously recorded ECGs for 7 days at hospital discharge and at 40 days for STEMI (N = 5) or at 90 days for NSTEMI patients (N = 5). Cardiac electrical instability was assessed by T-wave alternans (TWA) and T-wave heterogeneity (TWH); autonomic tone was determined by rMSSD-heart rate variability (HRV). RESULTS TWA was severely elevated (≥60 μV) in STEMI patients (80 ± 10.3 μV) at discharge and throughout the first recording period but declined by 50% to 40 ± 2.3 μV (p = .03) by Day 40 and remained in the normal range (<47 μV). TWH, a related phenomenon analyzed from 12-lead ECGs, was reduced by 63% in the five STEMI patients from discharge to normal (<80 μV) at follow-up (105 ± 27.3 to 39 ± 3.3 μV, p < .04) but increased by 65% in a STEMI case (89 to 147 μV), who received a wearable defibrillator vest and later implantable cardioverter defibrillator. In NSTEMI patients, TWA was borderline abnormal (47 ± 3.3 μV) at discharge and declined by 19% to normal (38 ± 1.2 μV) by Day 90 (p = .05). An overall reciprocal increase in rMSSD-HRV suggested recovery of vagal tone. CONCLUSIONS This study provides proof-of-principle for tracking post-MI SCD risk in individual patients with implications for personalized therapy.
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Affiliation(s)
- Richard L. Verrier
- Department of Medicine, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Bruce D. Nearing
- Department of Medicine, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusettsUSA
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Biomechanical Sensing Systems for Cardiac Activity Monitoring. Int J Biomater 2022; 2022:8312564. [PMID: 36438068 PMCID: PMC9699781 DOI: 10.1155/2022/8312564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/20/2022] Open
Abstract
Cardiovascular disease is consistently ranked high among the causes of death on a global scale. Monitoring of cardiovascular signs throughout the course of a long period of time and in real time is necessary in order to discover anomalies and begin early intervention at the appropriate time. To this purpose, a significant amount of interest among researchers has been directed toward the creation of flexible sensors that may be worn or implanted and are capable of constant, immediate observation of a variety of main physiological indicators. The real-time readings of the heart and arteries' pressure fluctuations can be reflected directly by mechanical sensors, which are one of the many types of sensors. Potential benefits of mechanical sensors include excellent accuracy and considerable versatility. Capacitive, piezoresistive, piezoelectric, and triboelectric principles are the foundations of the four types of mechanical sensors that are discussed in this article as recent developments for the purpose of monitoring the cardiovascular system. The biomechanical systems that are present in the cardiovascular system are then detailed, along with their monitoring, and this includes blood and endocardial pressure, pulse wave, and heart rhythm. In conclusion, we examine the usefulness of the use of continuous health monitoring for the treatment of vascular disease and highlight the difficulties associated with its translation into clinical practice.
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Siva Kumar S, Al-Kindi S, Tashtish N, Rajagopalan V, Fu P, Rajagopalan S, Madabhushi A. Machine learning derived ECG risk score improves cardiovascular risk assessment in conjunction with coronary artery calcium scoring. Front Cardiovasc Med 2022; 9:976769. [PMID: 36277775 PMCID: PMC9580025 DOI: 10.3389/fcvm.2022.976769] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background Precision estimation of cardiovascular risk remains the cornerstone of atherosclerotic cardiovascular disease (ASCVD) prevention. While coronary artery calcium (CAC) scoring is the best available non-invasive quantitative modality to evaluate risk of ASCVD, it excludes risk related to prior myocardial infarction, cardiomyopathy, and arrhythmia which are implicated in ASCVD. The high-dimensional and inter-correlated nature of ECG data makes it a good candidate for analysis using machine learning techniques and may provide additional prognostic information not captured by CAC. In this study, we aimed to develop a quantitative ECG risk score (eRiS) to predict major adverse cardiovascular events (MACE) alone, or when added to CAC. Further, we aimed to construct and validate a novel nomogram incorporating ECG, CAC and clinical factors for ASCVD. Methods We analyzed 5,864 patients with at least 1 cardiovascular risk factor who underwent CAC scoring and a standard ECG as part of the CLARIFY study (ClinicalTrials.gov Identifier: NCT04075162). Events were defined as myocardial infarction, coronary revascularization, stroke or death. A total of 649 ECG features, consisting of measurements such as amplitude and interval measurements from all deflections in the ECG waveform (53 per lead and 13 overall) were automatically extracted using a clinical software (GE Muse™ Cardiology Information System, GE Healthcare). The data was split into 4 training (Str) and internal validation (Sv) sets [Str (1): Sv (1): 50:50; Str (2): Sv (2): 60:40; Str (3): Sv (3): 70:30; Str (4): Sv (4): 80:20], and the results were compared across all the subsets. We used the ECG features derived from Str to develop eRiS. A least absolute shrinkage and selection operator-Cox (LASSO-Cox) regularization model was used for data dimension reduction, feature selection, and eRiS construction. A Cox-proportional hazards model was used to assess the benefit of using an eRiS alone (Mecg), CAC alone (Mcac) and a combination of eRiS and CAC (Mecg+cac) for MACE prediction. A nomogram (Mnom) was further constructed by integrating eRiS with CAC and demographics (age and sex). The primary endpoint of the study was the assessment of the performance of Mecg, Mcac, Mecg+cac and Mnom in predicting CV disease-free survival in ASCVD. Findings Over a median follow-up of 14 months, 494 patients had MACE. The feature selection strategy preserved only about 18% of the features that were consistent across the various strata (Str). The Mecg model, comprising of eRiS alone was found to be significantly associated with MACE and had good discrimination of MACE (C-Index: 0.7, p = <2e-16). eRiS could predict time-to MACE (C-Index: 0.6, p = <2e-16 across all Sv). The Mecg+cac model was associated with MACE (C-index: 0.71). Model comparison showed that Mecg+cac was superior to Mecg (p = 1.8e-10) or Mcac (p < 2.2e-16) alone. The Mnom, comprising of eRiS, CAC, age and sex was associated with MACE (C-index 0.71). eRiS had the most significant contribution, followed by CAC score and other clinical variables. Further, Mnom was able to identify unique patient risk-groups based on eRiS, CAC and clinical variables. Conclusion The use of ECG features in conjunction with CAC may allow for improved prognostication and identification of populations at risk. Future directions will involve prospective validation of the risk score and the nomogram across diverse populations with a heterogeneity of treatment effects.
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Affiliation(s)
- Shruti Siva Kumar
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States,*Correspondence: Shruti Siva Kumar
| | - Sadeer Al-Kindi
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, United States,School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Nour Tashtish
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, United States,School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Varun Rajagopalan
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, United States,School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Pingfu Fu
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, United States
| | - Sanjay Rajagopalan
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, United States,School of Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Anant Madabhushi
- Wallace H. Coulter Department of Biomedical Engineering, Radiology and Imaging Sciences, Biomedical Informatics (BMI) and Pathology, Georgia Institute of Technology and Emory University, Research Health Scientist, Atlanta Veterans Administration Medical Center, Atlanta, GA, United States
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L Fialho G, Lin K. T-wave heterogeneity in epilepsy: Could we kill two (or three) birds with one stone? Epilepsy Behav 2022; 134:108747. [PMID: 35637101 DOI: 10.1016/j.yebeh.2022.108747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Guilherme L Fialho
- Cardiology Division, Federal University of Santa Catarina, (UFSC), Florianópolis, SC, Brazil; Medical Sciences Post-graduate Program, Federal University of Santa Catarina, (UFSC), Florianópolis, SC, Brazil.
| | - Katia Lin
- Medical Sciences Post-graduate Program, Federal University of Santa Catarina, (UFSC), Florianópolis, SC, Brazil; Center for Applied Neurosciences (CeNAp), Federal University of Santa Catarina, (UFSC), Florianópolis, SC, Brazil; Neurology Division, Federal University of Santa Catarina, (UFSC), Florianópolis, SC, Brazil.
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11
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Verrier RL, Pang TD, Nearing BD, Schachter SC. The Epileptic Heart and the Case for Routine Use of the Electrocardiogram in Patients with Chronic Epilepsy. Neurol Clin 2022; 40:699-716. [DOI: 10.1016/j.ncl.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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12
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Pang TD, Nearing BD, Verrier RL, Schachter SC. T-wave heterogeneity crescendo in the surface EKG is superior to heart rate acceleration for seizure prediction. Epilepsy Behav 2022; 130:108670. [PMID: 35367725 DOI: 10.1016/j.yebeh.2022.108670] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/12/2022] [Accepted: 03/14/2022] [Indexed: 11/19/2022]
Abstract
We examined whether T-wave heterogeneity (TWH) on the surface electrocardiographic (EKG) could predict epileptic seizure onset. Patients with electroencephalography-confirmed generalized tonic-clonic seizures (GTCS) (n = 6) exhibited abnormal elevations in TWH (>80 µV) at baseline (105 ± 20.4 µV), which increased from 30 min prior to seizure without heart rate increases > 2 beats/min until 10 min pre-seizure. Specifically, TWH on 3-lead surface EKG patch recordings increased from 1-hour baseline to 30 min (<0.05), 20 min (p < 0.002), 10 min (p = 0.01), and 1 min (p = 0.01) before seizure onset. At 10 min following GTCS, TWH returned to 110 ± 20.3 µV, similar to baseline (p = 0.54). This pre-ictal TWH warning pattern was not present in patients with psychogenic nonepileptic seizures (PNES) (n = 3), as TWH did not increase until PNES and returned to baseline within 10 min after PNES. Acute elevations in TWH may predict impending GTCS and may discriminate patients with GTCS from those with behaviorally similar PNES.
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Affiliation(s)
- Trudy D Pang
- Department of Neurology, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States; Harvard Medical School, 99 Brookline Avenue, RN-301, Boston, MA 02215, United States.
| | - Bruce D Nearing
- Harvard Medical School, 99 Brookline Avenue, RN-301, Boston, MA 02215, United States; Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States.
| | - Richard L Verrier
- Harvard Medical School, 99 Brookline Avenue, RN-301, Boston, MA 02215, United States; Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States.
| | - Steven C Schachter
- Department of Neurology, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States; Harvard Medical School, 99 Brookline Avenue, RN-301, Boston, MA 02215, United States; Massachusetts General Hospital, Boston, MA, United States; Consortia for Improving Medicine with Innovation & Technology (CIMIT), 125 Nashua St., Suite 324, Boston, MA 02114, United States.
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13
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Verrier RL, Nearing BD, D'Avila A. Spectrum of clinical applications of interlead ECG heterogeneity assessment: From myocardial ischemia detection to sudden cardiac death risk stratification. Ann Noninvasive Electrocardiol 2021; 26:e12894. [PMID: 34592018 PMCID: PMC8588374 DOI: 10.1111/anec.12894] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/23/2021] [Accepted: 09/03/2021] [Indexed: 12/11/2022] Open
Abstract
Heterogeneity in depolarization and repolarization among regions of cardiac cells has long been recognized as a major factor in cardiac arrhythmogenesis. This fundamental principle has motivated development of noninvasive techniques for quantification of heterogeneity using the surface electrocardiogram (ECG). The initial approaches focused on interval analysis such as interlead QT dispersion and Tpeak -Tend difference. However, because of inherent difficulties in measuring the termination point of the T wave and commonly encountered irregularities in the apex of the T wave, additional techniques have been pursued. The newer methods incorporate assessment of the entire morphology of the T wave and in some cases of the R wave as well. This goal has been accomplished using a number of promising vectorial approaches with the resting 12-lead ECG. An important limitation of vectorcardiographic analyses is that they require exquisite stability of the recordings and are not inherently suitable for use in exercise tolerance testing (ETT) and/or ambulatory ECG monitoring for provocative stress testing or evaluation of the influence of daily activities on cardiac electrical instability. The objectives of the present review are to describe a technique that has been under clinical evaluation for nearly a decade, termed "interlead ECG heterogeneity." Preclinical testing data will be briefly reviewed. We will discuss the main clinical findings with regard to sudden cardiac death risk stratification, heart failure evaluation, and myocardial ischemia detection using standard recording platforms including resting 12-lead ECG, ambulatory ECG monitoring, ETT, and pharmacologic stress testing in conjunction with single-photon emission computed tomography myocardial perfusion imaging.
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Affiliation(s)
- Richard L Verrier
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce D Nearing
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andre D'Avila
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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