Validation of American Society of Echocardiography Guideline-Recommended Parameters of Right Ventricular Dysfunction Using Artificial Intelligence Compared With Cardiac Magnetic Resonance Imaging

BACKGROUND

Right ventricular (RV) function is important in the evaluation of cardiac function, but its assessment using standard transthoracic echocardiography (TTE) remains challenging. Cardiac magnetic resonance imaging (CMR) is considered the gold standard. The American Society of Echocardiography recommends surrogate measures of RV function and RV ejection fraction (RVEF) by TTE, including fractional area change (FAC), free wall strain (FWS), and tricuspid annular planar systolic excursion (TAPSE), but they require technical expertise in acquisition and quantification.

METHODS

The aim of this study was to evaluate the sensitivity, specificity, and positive and negative predictive values of FAC, FWS, and TAPSE derived using a rapid, novel artificial intelligence (AI) software (LVivoRV) from a single-plane transthoracic echocardiographic apical four-chamber, RV-focused view without ultrasound-enhancing agents for detecting abnormal RV function compared with CMR-derived RVEF. RV dysfunction was defined as RVEF < 50% and RVEF < 40% on CMR.

RESULTS

TTE and CMR were performed within a median of 10 days (interquartile range, 2-32 days) of each other in 225 consecutive patients without interval procedural or pharmacologic intervention. The sensitivity and negative predictive value to detect CMR-defined RV dysfunction when all three AI-derived parameters (FAC, FWS, and TAPSE) were abnormal were 91% and 96%, while those of expert physician reads were 91% and 97%. Specificity and positive predictive value were lower (50% and 32%) compared with expert physician-read echocardiograms (82% and 56%).

CONCLUSIONS

AI-derived measurements of FAC, FWS, and TAPSE had excellent sensitivity and negative predictive value for ruling out significant RV dysfunction (CMR RVEF < 40%), comparable with that of expert physician readers, but lower specificity. Thus AI, using American Society of Echocardiography guidelines, may serve as a useful screening tool for rapid bedside assessment to exclude significant RV dysfunction.

Developing and evaluating ASTHMAXcel adventures: A novel gamified mobile application for pediatric patients with asthma

BACKGROUND

The ASTHMAXcel mobile application has been linked to favorable outcomes among adult patients with asthma.

OBJECTIVE

To assess the impact of ASTHMAXcel Adventures, a gamified, guideline-based, pediatric version on asthma control, knowledge, health care utilization, and patient satisfaction.

METHODS

Pediatric patients with asthma received the ASTHMAXcel Adventures mobile intervention on-site only at baseline (visit 1), 4 months (visit 2), and 6 months (visit 3). The asthma control test, asthma illness representation scale-self-administered, pediatric asthma impact survey, and Client Satisfaction Questionnaire-8 were used to assess asthma control, knowledge, and patient satisfaction. Patients reported the number of asthma-related emergency department (ED) visits, hospitalizations, and oral prednisone use.

RESULTS

A total of 39 patients completed the study. The proportion of controlled asthma increased from visit 1 to visits 2 and 3 (30.8% vs 53.9%, P = .04; 30.8% vs 59.0%, P = .02), and largely seen in boys. The mean asthma illness representation scale-self-administered scores increased from baseline pre- to postintervention, with sustained improvements at visits 2 and 3 (3.55 vs 3.76, P < .001; 3.55 vs 3.80, P = .001; 3.55 vs 3.99, P < .001). The pediatric asthma impact survey scores improved from baseline to visits 2 and 3 (43.33 vs 34.08, P < .001; 43.33 vs 31.74, P < .001). ED visits and prednisone use significantly decreased from baseline to visits 2 and 3 (ED: 0.46 vs 0.13, P = .03; 0.46 vs 0.02, P = .02; prednisone use, 0.49 vs 0.13, P = .02; 0.49 vs 0.03, P = .003. Satisfaction was high with mean client satisfaction questionnaire score of approximately 30 (out of 32) at all visits.

CONCLUSION

ASTHMAXcel Adventures improved asthma control, knowledge, and quality of life, and reduced ED visits and prednisone use with high satisfaction scores.

Determining the optimal duration for premature ventricular contraction monitoring

BACKGROUND

Premature ventricular contractions (VPC) have hour-to-hour and day-to-day variation. High VPC burden correlates with cardiomyopathy.

OBJECTIVE

To determine the optimal duration for ambulatory electrocardiogram monitoring for accurate assessment of VPC burden.

METHODS

Our group performed a retrospective analysis on patch monitors used for any indication with overall VPC burden ≥5.0% between February 1, 2016, and February 1, 2020. We generated cumulative daily VPC averages for each day of wear and performed linear regression analysis between each cumulative daily average and overall burden. Patients were divided into groups based on low or high VPC frequency, and the analysis was repeated. Split-sample validation was used to internally validate the overall prediction model.

RESULTS

A total of 116 patches representing 107 patients (mean age: 64.5; female: 48%) were analyzed. Mean overall VPC burden was 13.4% ± 7.5% (range: 5.0%-42.0%). Day 1 R² was 60%, P < .001, and continued to increase to R² 88%, P < .001 at day 14. Median percent and absolute error decreased from 22.70% (interquartile range [IQR]: 9.73-34.39) and 2.58% (IQR: 1.24-4.59) at day 1 to 5.62% (IQR: 2.82-8.39) and 0.55% (IQR: 0.28-1.05) at day 14. Patients with higher overall VPC frequencies achieved a more rapid rise in R² relative to those with lower frequencies. Split-sample validation supported the internal validity of our linear regression prediction model.

CONCLUSION

Mobile telemetry for a period of ∼7 days accurately reflects overall VPC burden. Measurement of VPC burden for only 24-48 hours may not accurately reflect total burden. Monitoring for 2 weeks or longer adds little additional VPC information.

QT prolongation in a diverse, urban population of COVID-19 patients treated with hydroxychloroquine, chloroquine, or azithromycin

Purpose

Hydroxychloroquine, chloroquine, and azithromycin have been used for treatment of COVID-19, but may cause QT prolongation. Minority populations are disproportionately impacted by COVID-19. This study evaluates the risk of QT prolongation and subsequent outcomes after administration of these medications in largely underrepresented minority COVID-19 patients.

Methods

We conducted an observational study on hospitalized COVID-19 patients in the Montefiore Health System (Bronx, NY). We examined electrocardiograms (ECG) pre/post-medication initiation to evaluate QTc, HR, QRS duration, and presence of other arrhythmias.

Results

One hundred five patients (mean age 67 years; 44.8% F) were analyzed. The median time from the first dose of any treatment to post-medication ECG was 2 days (IQR: 1–3). QTc in men increased from baseline (440 vs 455 ms, p < 0.001), as well as in women (438 vs 463 ms, p < 0.001). The proportion of patients with QT prolongation increased significantly (14.3% vs 34.3%, p < 0.001) even when adjusted for electrolyte abnormalities. The number of patients whose QTc > 500 ms was significantly increased after treatment (16.2% vs. 4.8%, p < 0.01). Patients with either QTc > 500 ms or an increase of 60 ms had a higher frequency of death (47.6% vs. 22.6%, p = 0.02) with an odds ratio of 3.1 (95% CI: 1.1–8.7). Adjusting for race/ethnicity yielded no significant associations.

Conclusions

Hydroxychloroquine, chloroquine, and/or azithromycin were associated with QTc prolongation but did not result in fatal arrhythmias. Our findings suggest that any harm is unlikely to outweigh potential benefits of treatment. Careful risk-benefit analyses for individual patients should guide the use of these medications. Randomized control trials are necessary to evaluate their efficacies.

Evaluating the ASTHMAXcel Mobile Application Regarding Asthma Knowledge and Clinical Outcomes

BACKGROUND

We sought to longitudinally assess the efficacy of the patient-facing ASTHMAXcel mobile application in improving asthma knowledge and outcomes in adults with asthma.

METHODS

ASTHMAXcel is a novel smartphone application consistent with the National Asthma Education and Prevention Program, Global Initiative for Asthma, and British Thoracic Society/Scottish Intercollegiate Guidelines Network guidelines. The intervention was provided for 1-time use at baseline only. The Asthma Knowledge Questionnaire (AKQ), the Asthma Control Test (ACT), and the mini-Asthma Quality of Life Questionnaire (mini-AQLQ) were administered at baseline and at 2, 4, and 6 months thereafter. Rates of asthma-related emergency department visits, hospitalizations, and prednisone use were also evaluated.

RESULTS

ACT scores increased significantly at 2, 4, and 6 months (mean scores: 15.1 vs 16.9, P = .038; 15.1 vs 17.2, P = .02; 15.1 vs 17.9, P = .003) after baseline. There were significant increases in AKQ scores at 4 and 6 months (11.7 vs 12.6, P = .02; 11.7 vs 13.1, P = .005) and in mini-AQLQ scores at 6 months (55.5 vs 64.2, P = .02). There were significant decreases in asthma-related emergency department visits at 6 months (0.6 vs 0, P < .001) and in hospitalizations at 4 and 6 months (0.3 vs 0.1, P = .02; 0.3 vs 0, P = .002). Prednisone use decreased at 4 and 6 months (1.2 vs 0.6, P = .01; 1.2 vs 0.3, P < .001).

CONCLUSIONS

ASTHMAXcel contributes to improved asthma knowledge and outcomes and to decreased health care utilization. ASTHMAXcel is an inexpensive, scalable aid for out-patient asthma management.