Mandibular Advancement vs CPAP for Blood Pressure Reduction in Patients With Obstructive Sleep Apnea

BACKGROUND

Hypertension guidelines recommend diagnosis and treatment of obstructive sleep apnea (OSA) in patients with hypertension. The mandibular advancement device (MAD) is an oral appliance therapy for patients who decline or cannot tolerate continuous positive airway pressure (CPAP).

OBJECTIVES

We compared the relative effectiveness of MAD vs CPAP in reducing 24-hour ambulatory blood pressure (BP).

METHODS

In an investigator-initiated, randomized, noninferiority trial (prespecified margin 1.5 mm Hg), 321 participants aged ≥40 years with hypertension and increased cardiovascular risk were recruited at 3 public hospitals for polysomnography. Of these, 220 participants with moderate-to-severe OSA (apnea-hypopnea index ≥15 events per hour) were randomized to either MAD or CPAP (1:1). The primary outcome was the difference between the 24-hour mean arterial BP at baseline and 6 months.

RESULTS

Compared with baseline, the 24-hour mean arterial BP decreased by 2.5 mm Hg (P = 0.003) at 6 months in the MAD group, whereas no change was observed in the CPAP group (P = 0.374). The between-group difference was -1.6 mm Hg (95% CI: -3.51 to 0.24, noninferiority P < 0.001). The MAD group demonstrated a larger between-group reduction in all secondary ambulatory BP parameters compared with the CPAP group, with the most pronounced effects observed in the asleep BP parameters. Both the MAD and CPAP improved daytime sleepiness, with the between-group difference similar (P = 0.384). There were no between-group differences in cardiovascular biomarkers.

CONCLUSIONS

MAD is noninferior to CPAP for reducing 24-hour mean arterial BP in participants with hypertension and increased cardiovascular risk. (Cardiosleep Research Program on Obstructive Sleep Apnea, Blood Pressure Control and Maladaptive Myocardial Remodeling-Non-inferiority Trial [CRESCENT]; NCT04119999).

Prognostic benefits of His-Purkinje capture in physiological pacemakers for bradycardia

INTRODUCTION

Clinical outcomes of long-term ventricular septal pacing (VSP) without His-Purkinje capture remain unknown. This study evaluated the differences in clinical outcomes between conduction system pacing (CSP), VSP, and right ventricular pacing (RVP).

METHODS

Consecutive patients with bradycardia indicated for pacing from 2016 to 2022 were prospectively followed for the clinical endpoints of heart failure (HF)-hospitalizations and all-cause mortality at 2 years. VSP was defined as septal pacing due to unsuccessful CSP implant or successful CSP followed by loss of His-Purkinje capture within 90 days.

RESULTS

Among 1016 patients (age 73.9 ± 11.2 years, 47% female, 48% atrioventricular block), 612 received RVP, 335 received CSP and 69 received VSP. Paced QRS duration was similar between VSP and RVP, but both significantly longer than CSP (p < .05). HF-hospitalizations occurred in 130 (13%) patients (CSP 7% vs. RVP 16% vs. VSP 13%, p = .001), and all-cause mortality in 143 (14%) patients (CSP 7% vs. RVP 19% vs. VSP 9%, p < .001). The association of pacing modality with clinical events was limited to those with ventricular pacing (Vp) > 20% (pinteraction < .05). Adjusting for clinical risk factors among patients with Vp > 20%, VSP (adjusted hazard ratio [AHR]: 4.74, 95% confidence interval [CI]: 1.57-14.36) and RVP (AHR: 3.08, 95% CI: 1.44-6.60) were associated with increased hazard of HF-hospitalizations, and RVP (2.52, 95% CI: 1.19-5.35) with increased mortality, compared to CSP. Clinical endpoints did not differ between VSP and RVP with Vp > 20%, or amongst groups with Vp < 20%.

CONCLUSION

Conduction system capture is associated with improved clinical outcomes. CSP should be preferred over VSP or RVP during pacing for bradycardia.

Role of electroanatomical mapping-guided superior vena cava isolation in paroxysmal atrial fibrillation patients without provoked superior vena cava triggers: a randomized controlled study

AIMS

Data about whether empirical superior vena cava (SVC) isolation (SVCI) improves the success rate of paroxysmal atrial fibrillation (PAF) are conflicting. This study sought to first investigate the characteristics of SVC-triggered atrial fibrillation and secondly investigate the impact of electroanatomical mapping-guided SVCI, in addition to circumferential pulmonary vein isolation (CPVI), on the outcome of PAF ablation in the absence of provoked SVC triggers.

METHODS AND RESULTS

A total of 130 patients undergoing PAF ablation underwent electrophysiological studies before ablation. In patients for whom SVC triggers were identified, SVCI was performed in addition to CPVI. Patients without provoked SVC triggers were randomized in a 1:1 ratio to CPVI plus SVCI or CPVI only. The primary endpoint was freedom from any documented atrial tachyarrhythmias lasting over 30 s after a 3-month blanking period without anti-arrhythmic drugs at 12 months after ablation. Superior vena cava triggers were identified in 30 (23.1%) patients with PAF. At 12 months, 93.3% of those with provoked SVC triggers who underwent CPVI plus SVCI were free from atrial tachyarrhythmias. In patients without provoked SVC triggers, SVCI, in addition to CPVI, did not increase freedom from atrial tachyarrhythmias (87.9 vs. 79.6%, log-rank P = 0.28).

CONCLUSION

Electroanatomical mapping-guided SVCI, in addition to CPVI, did not increase the success rate of PAF ablation in patients who had no identifiable SVC triggers.

REGISTRATION

ChineseClinicalTrials.gov: ChiCTR2000034532.

A Simple Score to Predict New-onset Atrial Fibrillation After Ablation of Typical Atrial Flutter

BACKGROUND

New-onset atrial fibrillation (NeAF) is common after cavotricuspid isthmus-dependent counterclockwise atrial flutter (CCW-AFL) ablation. This study aimed to investigate a simple predictive model of NeAF after CCW-AFL ablation.

METHODS

From January 2013 to December 2017, consecutive patients receiving CCW-AFL ablation were enrolled from three centers. Clinical, echocardiographic, and electrocardiographic data were collected and followed. Patients from two centers and another center were assigned into the derivation and validation cohorts, respectively. In the derivation cohort, logistic regression was performed to evaluate the ability of parameters to discriminate those with and without NeAF. A score system was developed and then validated.

RESULTS

Two hundred seventy-one patients (mean 59.7±13.6 age; 205 male) were analyzed. During follow-up (73.0±6.5 months), 107 patients (39.5%) had NeAF. 190 and 81 patients were detected in the derivation and validation cohorts, respectively. Hypertension, age ≥70 years, left atrial diameter ≥42 mm, P wave duration ≥120 ms and the negative component of flutter wave in lead II ≥120 ms were selected as the final parameters. A weighted score was used to develop the HAD-AF score ranging from 0 to 9. In the derivation cohort, area under the receiver operating characteristic curve (AUC) was 0.938 (95% CI 0.902-0.974), superior to those of currently used CHA2DS2-VASC (0.679, 95% CI 0.600-0.757) and HATCH scores (0.651, 95% CI 0.571-0.730) (P<0.001). Performance maintained in the validation cohort.

CONCLUSIONS

39.5% of patients developed NeAF in 6 years after CCW-AFL ablation. HAD-AF score can reliably identify patients likely to develop NeAF after CCW-AFL ablation.

A machine learning approach to differentiate wide QRS tachycardia: distinguishing ventricular tachycardia from supraventricular tachycardia

BACKGROUND

Differential diagnosis of wide QRS tachycardia (WQCT) has been a challenging issue. Published algorithms to distinguish ventricular tachycardia (VT) and supraventricular tachycardia (SVT) have limited diagnostic capabilities.

METHODS

A total of 278 patients with WQCT from January 2010 to March 2022 were enrolled. The electrophysiological study confirmed SVT in 154 patients and VT in 65 ones. Two hundred nineteen WQCT 12-lead ECGs were randomly divided into development cohort (n = 165) and testing cohort (n = 54) data sets. The development cohort was split into a training group (n = 115) and an internal validation group (n = 50). Forty ECG features extracted from the 219 WQCT ECGs are fed into 9 iteratively trained ML algorithms. This novel ML algorithm was also compared with four published algorithms.

RESULTS

In the development cohort, the Gradient Boosting Machine (GBM) model displayed the maximum area under curve (AUC) (0.91, 95% confidence interval (CI) 0.81-1.00). In the testing cohort, the GBM model had a higher AUC of 0.97 compared to 4 validated ECG algorithms, namely, Brugada (0.68), avR (0.62), RWPTII (0.72), and LLA algorithms (0.70). Accuracy, sensitivity, specificity, negative predictive value, and positive predictive value of the GBM model were 0.94, 0.97, 0.90, 0.94, and 0.95, respectively.

CONCLUSIONS

A GBM ML model contributes to distinguishing SVT from VT based on surface ECG features. In addition, we were able to identify important indicators for distinguishing WQCT.

Mid-term outcome of catheter ablation of idiopathic non-outflow tract ventricular arrhythmias

BACKGROUND

Catheter ablation is recommended in patients with frequent and symptomatic ventricular arrhythmias (VAs) in an otherwise normal heart. Right or left outflow tract (OT) are the most common origins, and catheter ablation is highly effective with low complication rates. However, outcome of catheter ablation of VAs other than the OT (non-OTVAs) is limited. The aim of this single-center study was to assess the safety and mid-term outcome of catheter ablation for non-OTVAs.

METHOD AND RESULTS

From 2013 to 2018, 251 patients who underwent catheter ablation for idiopathic non-OTVAs were enrolled and grouped according to the origins including His-Purkinje system (HPS, n = 108), papillary muscle / moderator band (PM/MB, n = 47), tricuspid annulus (TA, n = 70), and mitral annulus (MA, n = 26), 244 (97.2%) had acute elimination of VAs. The time of VAs recurrence of the single procedure was 1.69 (0.12,9.72) months, with 66% occurring within the first 3 months. The recurrence rate was significantly higher in the PM/MB group than in the TA (p = 0.025) and MA groups (p = 0.023). The single procedure success rate in all patients was 70.1%, in which 66.7%, 59.6%, 80%, and 76.9% were achieved in the HPS, PM/MB, TA, and MA groups, respectively (p = 0.284). After multiple procedures, the total success rate was 76.5% at the follow-up of 4.38 ± 2.42 years. The rate was significantly lower in the PM/MB group than in the TA group (p = 0.035). In subgroup analysis, no significant difference was observed in the recurrence rate of single procedure in patients with different VA origins within the PM/MB (log-rank test, p = 0.546).

CONCLUSION

Despite a certain percentage of recurrences observed in the mid-term follow-up, catheter ablation remained feasible and effective for idiopathic non-OTVAs.

Obstructive sleep apnea and temporal changes in cardiac repolarization in patients undergoing coronary artery bypass grafting

STUDY OBJECTIVES

In coronary artery bypass grafting (CABG), abnormal cardiac repolarization is associated with adverse cardiovascular events that can be measured via the QTc interval. We investigated the impact of obstructive sleep apnea on the change in repolarization after CABG and the association of change in repolarization with the occurrence of major adverse cardiac and cerebrovascular events.

METHODS

A total of 1,007 patients from 4 hospitals underwent an overnight sleep study prior to a nonemergent CABG. Electrocardiograms of 954 patients (median age: 62 years; male: 86%; mean follow-up: 2.1 years) were acquired prospectively within 48 hours before CABG (T1) and within 24 hours after CABG (T2). QTc intervals were measured using the BRAVO algorithm by Analyzing Medical Parameters for Solutions LLC. The change in T2 from T1 for QTc (ΔQTc) was derived, and Cox regression was performed.

RESULTS

Compared with those without, patients who developed major adverse cardiac and cerebrovascular events (n = 115) were older and had (1) a higher prevalence of smoking, hypertension, diabetes mellitus, and chronic kidney disease; (2) a higher apnea-hypopnea index and oxygen desaturation index; and (3) a smaller ΔQTc. Cox regression analysis demonstrated a smaller ΔQTc to be an independent risk factor for major adverse cardiac and cerebrovascular events (hazard ratio: 0.997; P = .032). In the multivariable regression model, a higher oxygen desaturation index was independently associated with a smaller ΔQTc (correlation coefficient: -0.58; P < .001).

CONCLUSIONS

A higher preoperative oxygen desaturation index was an independent predictor of a smaller ΔQTc. ΔQTc within 24 hours after CABG could be a novel predictor of occurrence of major adverse cardiac and cerebrovascular events at medium-term follow-up.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Undiagnosed Sleep Apnea and Bypass OperaTion (SABOT); URL: https://classic.clinicaltrials.gov/ct2/show/NCT02701504; Identifier: NCT02701504.

CITATION

Teo YH, Yong CL, Ou YH, et al. Obstructive sleep apnea and temporal changes in cardiac repolarization in patients undergoing coronary artery bypass grafting. J Clin Sleep Med. 2024;20(1):49-55.

Half versus normal saline irrigation during catheter ablation of outflow tract ventricular arrhythmias (HALF): a multi-center, parallel, open-label, randomized controlled study

BACKGROUND

Animal studies demonstrated that deeper lesions could be achieved during radio-frequency catheter ablation (RFCA) by using half saline (HS) compared to normal saline (NS) as irrigation.

OBJECTIVES

This study sought to compare the efficiency and safety of HS and NS for irrigation during RFCA of idiopathic outflow tract ventricular arrhythmia (OT-VA).

METHODS

In this multicenter, randomized controlled study, 167 patients undergoing RFCA of OT-VA were randomized 1:1 to receive HS- or NS-irrigated ablation. Acute success was defined as the absence of induced targeted premature ventricular contraction (PVC) at the end of the procedure. The 6-month success was defined as a ≥ 80% reduction of pre-procedural PVC burden.

RESULTS

There were no differences of baseline characteristics between the HS and NS group. Patients in HS group had shorter total ablation time (259.5 ± 155.5 S vs. 355.6 ± 230.7 S, P = 0.04) than that in NS group. The acute and 6-month success rates were similar between the HS and NS group (92.8 vs. 91.7%, P = 0.79; 90.9 vs. 92.1%, P = 0.79, respectively). No significant difference was observed in the incidence of steam pops between the HS and NS group (2.4 vs. 1.2%, P = 0.62).

CONCLUSIONS

The ablation using HS irrigation achieved similar success rate and safety compared to that using NS irrigation but was associated with a shorter total ablation time.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2200059205).

Large-bore suction thrombectomy for sub-massive pulmonary embolism during second trimester of pregnancy: a case report

Background

Pregnancy-associated pulmonary embolism (PAPE) remains a significant cause of maternal mortality. Anticoagulation remains the mainstay of therapy for most pulmonary embolism (PE)-related pregnancies. However, in patients with haemodynamic compromise or those refractory to anticoagulation, management is challenging. Systemic thrombolysis is associated with a substantial risk of maternal bleeding and fetal loss. In non-pregnant PE patients, large bore catheter-directed suction thrombectomy is a proven and important technique to manage intermediate or high-risk PE, allowing for normalization of pulmonary pressures, avoidance of haemodynamic deterioration, without the need for thrombolytics, major surgery, significant blood loss, or prolonged hospitalization.

Case summary

A primigravid patient in her second trimester of pregnancy, initially diagnosed with a deep vein thrombosis refractory to heparin, presents with near-syncope due to sub-massive pulmonary embolism. The various management options including thrombolysis and surgical embolectomy etc. were discussed in detail by a multi-disciplinary PE team. She underwent large bore suction thrombectomy with complete thrombi removal, normalization of right heart strain, without the need for thrombolytics or surgery, minimal blood loss and was discharged after a short length of stay. She gave birth at term to a healthy infant.

Conclusion

Suction thrombectomy is an important consideration for physicians managing high-risk PAPE and is likely to be associated with much a lower risk of maternal and fetal mortality compared to thrombolysis or surgery.

2023 HRS/EHRA/APHRS/LAHRS expert consensus statement on practical management of the remote device clinic

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

Comparison of Pacing Performance and Clinical Outcomes Between Left Bundle Branch and His Bundle Pacing

BACKGROUND

Left bundle branch (LBBP) and His-bundle pacing (HBP) provide physiological ventricular activation.

OBJECTIVES

This study investigated differences in feasibility, device performance, and clinical outcomes between LBBP and HBP.

METHODS

Consecutive patients with LBBP and HBP from 2018 to 2021 in 2 centers were prospectively studied. The primary endpoint was optimal device performance during follow-up, defined as the presence of pacing thresholds <2.5 V, R-wave amplitude ≥5 V, and absence of conduction system pacing (CSP)-related complications. The secondary endpoint was the composite of heart failure hospitalizations or all-cause mortality.

RESULTS

Among 338 patients, 282 underwent successful CSP (119 HBP, 163 LBBP). Success rates, CSP-related complications, and need for reoperations did not differ between LBBP and HBP (P > 0.05). Pacing thresholds were lower, whereas R-wave amplitudes and lead impedance were higher in LBBP (P < 0.05). The primary endpoint was more frequent in LBBP than HBP (79% vs 34%; P < 0.001), with LBBP independently associated with 9-fold increased odds of optimal device performance (adjusted OR: 9.31; 95% CI: 5.14-16.86). LBBP was less likely to have increased pacing thresholds by >1 V (1% vs 19% HBP, P < 0.001). The secondary outcome was less frequent in LBBP than HBP (9% vs 24%, P = 0.001), with LBBP trending towards higher event-free survival (HR: 0.62; 95% CI: 0.31-1.23). The secondary outcome was independent of pacing burden or pacing indication.

CONCLUSIONS

Despite similar feasibility and safety profiles, LBBP confers additional benefits in pacing performance and reliability, shows trends towards improved survival compared to HBP, and should be the preferred first-line CSP modality of choice.

Stroke Recurrence in Embolic Stroke of Undetermined Source Without Atrial Fibrillation on Invasive Cardiac Monitoring

BACKGROUND

More than half of patients with embolic stroke of undetermined source (ESUS) suffer from recurrent ischaemic stroke, despite the absence of atrial fibrillation (AF) on invasive cardiac monitoring (ICM). This study investigated the predictors and prognosis of recurrent stroke in ESUS without AF on ICM.

METHOD

This prospective study included patients with ESUS at two tertiary hospitals from 2015 to 2021 who underwent comprehensive neurological imaging, transthoracic echocardiography, and inpatient continuous electrographic monitoring for ≥48 hours prior to ICM for definitive exclusion of AF. Recurrent ischaemic stroke, all-cause mortality, and functional outcome by the modified Rankin scale (mRS) at 3 months were evaluated in patients without AF.

RESULTS

Of 185 consecutive patients with ESUS, AF was not detected in 163 (88%) patients (age 62±12 years, 76% men, 25% prior stroke, median time to ICM insertion 26 [7, 123] days), and stroke recurred in 24 (15%) patients. Stroke recurrences were predominantly ESUS (88%), within the first 2 years (75%), and involved a different vascular territory from qualifying ESUS (58%). Pre-existing cancer was the only independent predictor of recurrent stroke (adjusted hazard ratio [AHR] 5.43, 95% CI 1.43-20.64), recurrent ESUS (AHR 5.67, 95% CI 1.15-21.21), and higher mRS score at 3 months (ß 1.27, 95% CI 0.23-2.42). All-cause mortality occurred in 17 (10%) patients. Adjusting for age, cancer, and mRS category (≥3 vs <3), recurrent ESUS was independently associated with more than four times greater hazard of death (AHR 4.66, 95% CI 1.76-12.34).

CONCLUSIONS

Patients with recurrent ESUS are a high-risk subgroup. Studies elucidating optimal diagnostic and treatment strategies in non-AF-related ESUS are urgently required.

Impact of a rapid access chest pain clinic in Singapore to improve evaluation of new-onset chest pain

BACKGROUND

Chest pain (CP) accounts for 5% of emergency department (ED) visits, unplanned hospitalisations and costly admissions. Conversely, outpatient evaluation requires multiple hospital visits and longer time to complete testing. Rapid access chest pain clinics (RACPCS) are established in the UK for timely, cost-effective CP assessment. This study aims to evaluate the feasibility, safety, clinical and economic benefits of a nurse-led RACPC in a multiethnic Asian country.

METHODS

Consecutive CP patients referred from a polyclinic to the local general hospital were recruited. Referring physicians were left to their discretion to refer patients to the ED, RACPC (launched in April 2019) or outpatients. Patient demographics, diagnostic journey, clinical outcomes, costs, HEART (History, ECG, Age, Risk Factors, Troponin) scores and 1-year overall mortality were recorded.

RESULTS

577 CP patients (median HEAR score of 2.0) were referred; 237 before the launch of RACPC. Post RACPC, fewer patients were referred to the ED (46.5% vs 73.9%, p < 0.01), decreased adjusted bed days for CP, more non-invasive tests (46.8 vs 39.2 per 100 referrals, p = 0.07) and fewer invasive coronary angiograms (5.6 vs 12.2 per 100 referrals, p < 0.01) were performed. Time from referral to diagnosis was shortened by 90%, while requiring 66% less visits (p < 0.01). System cost to evaluate CP was reduced by 20.7% and all RACPC patients were alive at 12 months.

CONCLUSIONS

An Asian nurse-led RACPC expedited specialist evaluation of CP with less visits, reduced ED attendances and invasive testing whilst saving costs. Wider implementation across Asia would significantly improve CP evaluation.

2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

Mandibular advancement device versus CPAP in lowering 24-hour blood pressure in patients with obstructive sleep apnoea and hypertension: the CRESCENT trial protocol

INTRODUCTION

Although treatment of obstructive sleep apnoea (OSA) using continuous positive airway pressure (CPAP) reduces blood pressure (BP), adherence to CPAP is often suboptimal. A mandibular advancement device (MAD) is a guideline-endorsed alternative therapy for OSA. Still, there is limited evidence on the relative efficacy between MAD and CPAP on BP reduction. We evaluate whether treatment of moderate-to-severe OSA using MAD can improve BP and other health-related outcomes compared with CPAP.

METHODS AND ANALYSIS

This is a randomised, controlled, non-inferiority trial conducted. We will recruit 220 Asians with a history of hypertension and high cardiovascular risk for an overnight polysomnography screening. Those with moderate-to-severe OSA (apnoea-hypopnoea index ≥15 events/hour) will be randomised to treatment with either MAD or CPAP in a 1:1 ratio. Stratified by age (60 vs <60 years old), body mass index (25 vs <25 kg/m²) and apnoea-hypopnoea index (30 vs <30 events/hour), an adaptive randomisation scheme with permuted blocks constructed in real-time is implemented to restrict imbalance. The overall study duration is 12 months. The primary endpoint is the 24-hour mean arterial BP difference between baseline and 6-month follow-up. The secondary endpoints include other measures of ambulatory BP monitoring, arrhythmia based on a 4-day electrocardiographic monitoring, biomarker and proteomic analysis, cardiovascular magnetic resonance-derived myocardial fibrosis and remodelling and quality-of-life questionnaires. Recruitment began in October 2019 and ended in December 2022. Comparison between MAD and CPAP will be performed using covariance (ANCOVA) analysis of the changes in 24-hour mean arterial BP while adjusting for the baseline 24-hour mean arterial BP. We will compare the 95% CIs around the treatment difference point estimate with the prespecified non-inferiority margin (1.5 mm Hg). If the upper limit of the 95% CI is <1.5 mm Hg and crosses 0, non-inferiority of the MAD relative to CPAP will be established.

ETHICS AND DISSEMINATION

The Domain Specific Review Board-C, National Healthcare Group under approved the study protocol (NHG DSRB Ref: 2019/00359, approved on 28 August 2019). Study findings will be disseminated to various local, national, and international audiences through abstract presentations and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04119999.

2023 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Practical Management of the Remote Device Clinic

Remote monitoring is beneficial for the management of patients with cardiovascular implantable electronic devices by impacting morbidity and mortality. With increasing numbers of patients using remote monitoring, keeping up with higher volume of remote monitoring transmissions creates challenges for device clinic staff. This international multidisciplinary document is intended to guide cardiac electrophysiologists, allied professionals, and hospital administrators in managing remote monitoring clinics. This includes guidance for remote monitoring clinic staffing, appropriate clinic workflows, patient education, and alert management. This expert consensus statement also addresses other topics such as communication of transmission results, use of third-party resources, manufacturer responsibilities, and programming concerns. The goal is to provide evidence-based recommendations impacting all aspects of remote monitoring services. Gaps in current knowledge and guidance for future research directions are also identified.

First use of large-bore suction thrombectomy for acute pulmonary embolism in Asia-Pacific: feasibility and short-term clinical outcomes

Clinical outcomes for intermediate or high-risk pulmonary emboli (PE) remain sub-optimal, with limited improvements in survival for the past 15 years. Anticoagulation alone results in slow thrombus resolution, persistent right ventricular (RV) dysfunction, patients remaining at risk of haemodynamic decompensation and increased likelihood of incomplete recovery. Thrombolysis elevates risk of major bleeding and is thus reserved for high-risk PE. Thus, a huge clinical need exists for an effective technique to restore pulmonary perfusion with minimal risk and avoidance of lytic therapy. In 2021, large bore suction thrombectomy (ST) was introduced in Asia for the first time and this study assessed the feasibility and short-term outcomes of Asian patients undergoing ST for acute PE. 40 consecutive patients (58% male, mean age of 58.3 ± 16.6 years) with intermediate (87.5%) or high-risk PE (12.5%) were enrolled in this prospective registry. 20% had prior VTE, 42.5% had contraindications to thrombolysis, and 10% failed to respond to thrombolysis. PE was idiopathic in 40%, associated with active cancer in 15% and post-operative status in 12.5%. Procedural time was 124 ± 30 min. Emboli were aspirated in all patients without the need for thrombolytics, resulting in a 21.4% reduction in mean pulmonary arterial pressures and 123% increase TASPE-PASP ratio, a prognostic measure of RV-arterial coupling. (both p < 0.001) Procedural complications were 5% and 87.5% patients survived to discharge without symptomatic VTE recurrence during 184 days of mean follow-up. ST affords an effective reperfusion option for PE without thrombolytics, normalises RV overload and provides excellent short-term clinical outcomes.

Conduction system versus biventricular pacing in heart failure with non-left bundle branch block

INTRODUCTION

The benefits of cardiac resynchronization therapy (CRT) with biventricular pacing (BiV) is significantly lower when applied to heart failure (HF) patients with non-left bundle branch block (LBBB) conduction delay. We investigated clinical outcomes of conduction system pacing (CSP) for CRT in non-LBBB HF.

METHODS

Consecutive HF patients with non-LBBB conduction delay undergoing CSP were propensity matched for age, sex, HF-etiology, and atrial fibrillation (AF) in a 1:1 ratio to BiV from a prospective registry of CRT recipients. Echocardiographic response was defined as an increase in left ventricular ejection fraction (LVEF) by ≥10%. The primary outcome was the composite of HF-hospitalizations or all-cause mortality.

RESULTS

A total of 96 patients were recruited (mean age 70 ± 11years, 22% female, 68% ischemic HF and 49% AF). Significant reductions in QRS duration and LV dimensions were seen only after CSP, while LVEF improved significantly in both groups (p < 0.05). Echocardiographic response occurred more frequently in CSP than BiV (51% vs. 21%, p < 0.01), with CSP independently associated with four-fold increased odds (adjusted odds ratio 4.08, 95% confidence interval [CI] 1.34-12.41). The primary outcome occurred more frequently in BiV than CSP (69% vs. 27%, p < 0.001), with CSP independently associated with 58% risk reduction (adjusted hazard ratio [AHR] 0.42, 95% CI 0.21-0.84, p = 0.01), driven by reduced all-cause mortality (AHR 0.22, 95% CI 0.07-0.68, p < 0.01), and a trend toward reduced HF-hospitalization (AHR 0.51, 95% CI 0.21-1.21, p = 0.12).

CONCLUSIONS

CSP provided greater electrical synchrony, reverse remodeling, improved cardiac function and survival compared to BiV in non-LBBB, and may be the preferred CRT strategy for non-LBBB HF.

Clinical Outcomes in Conduction System Pacing Compared to Right Ventricular Pacing in Bradycardia

BACKGROUND

Conduction system pacing (CSP) provides more physiological ventricular activation than right ventricular pacing (RVP).

OBJECTIVES

This study evaluated the differences in clinical outcomes in patients receiving CSP and RVP.

METHODS

Consecutive patients with pacemakers implanted for bradycardia from 2016 to 2021 in 2 centers were prospectively followed for the primary composite outcome of heart failure (HF) hospitalizations, upgrade to biventricular pacing, or all-cause mortality, stratified by ventricular pacing burden (Vp) .

RESULTS

Among 860 patients (mean age 74 ± 11 years, 48% female, 48% atrioventricular block), 628 received RVP and 231 received CSP (95 His-bundle pacing, 136 left bundle branch pacing). The primary outcome occurred in 217 (25%) patients, more commonly in patients with RVP than CSP (30% vs 13%, P < 0.001). In multivariable analyses, CSP was independently associated with 47% reduction of the primary outcome (adjusted hazard ratio [AHR]: 0.53; 95% CI: 0.29-0.97; P = 0.04) and HF hospitalization alone (AHR: 0.40; 95% CI: 0.17-0.95; P = 0.04), among only patients with Vp >20%. The incidence of the primary outcome was highest among RVP with Vp >20% and lowest in CSP with Vp >20% (35% vs 10%, P < 0.001). Compared with RVP with Vp >20%, both CSP with Vp >20% (AHR: 0.51; 95% CI: 0.28-0.91; P = 0.02) and all patients with Vp ≤20% (AHR: 0.73; 95% CI: 0.54-0.99; P = 0.04) were independently associated with reduced primary outcome, driven primarily by reductions in HF hospitalizations (P < 0.05). Event-free survival was similar between CSP with Vp >20% and those needing ≤20% Vp.

CONCLUSIONS

CSP significantly reduced adverse clinical outcomes for bradycardic patients requiring ventricular pacing and should be the preferred pacing modality of choice.

Machine learning for distinguishing right from left premature ventricular contraction origin using surface electrocardiogram features

BACKGROUND

Precise localization of the site of origin of premature ventricular contractions (PVCs) before ablation can facilitate the planning and execution of the electrophysiological procedure.

OBJECTIVE

The purpose of this study was to develop a predictive model that can be used to differentiate PVCs between the left ventricular outflow tract and right ventricular outflow tract (RVOT) using surface electrocardiogram characteristics.

METHODS

A total of 851 patients undergoing radiofrequency ablation of premature ventricular beats from January 2015 to March 2022 were enrolled. Ninety-two patients were excluded. The other 759 patients were enrolled into the development (n = 605), external validation (n = 104), or prospective cohort (n = 50). The development cohort consisted of the training group (n = 423) and the internal validation group (n = 182). Machine learning algorithms were used to construct predictive models for the origin of PVCs using body surface electrocardiogram features.

RESULTS

In the development cohort, the Random Forest model showed a maximum receiver operating characteristic curve area of 0.96. In the external validation cohort, the Random Forest model surpasses 4 reported algorithms in predicting performance (accuracy 94.23%; sensitivity 97.10%; specificity 88.57%). In the prospective cohort, the Random Forest model showed good performance (accuracy 94.00%; sensitivity 85.71%; specificity 97.22%).

CONCLUSION

Random Forest algorithm has improved the accuracy of distinguishing the origin of PVCs, which surpasses 4 previous standards, and would be used to identify the origin of PVCs before the interventional procedure.

Late pacemaker implantation after atrioventricular nodal reentrant tachycardia ablation: A systematic review and meta-analysis

INTRODUCTION

Catheter ablation (CA) of atrioventricular nodal reentrant tachycardia (AVNRT) is associated with late pacemakers for AV block (AVB). We performed a systematic review and meta-analysis of the pooled incidence of late pacemakers for AVB after CA of AVNRT.

METHODS AND RESULTS

Relevant studies were identified from 4 electronic databases (PubMed, EMBASE, Scopus, Cochrane Trial Register) from inception to 2022. A random effects model was used to calculate the odds of late pacemakers in CA of AVNRT compared to atrioventricular reentrant tachycardia (AVRT). Of 533 articles screened, 13 were included in systematic review. CA for AVNRT was performed in 16,471 patients (mean age 54±17 years, 63% females), of which 68 (0.4%) underwent pacemaker implantation for late AVB. Meta-analysis was performed in 5 of the 13 studies (mean follow-up duration 7±4 years). Patients who underwent CA of AVNRT were older (58±17 vs 52±20 years, p<0.001), and more likely female (60% vs 41%, p<0.001) than AVRT. Pooled estimates of late pacemakers for AVB were higher in CA of AVNRT than AVRT (0.5% vs 0.2%, p=0.006), with CA in AVNRT associated with almost 2-fold increased odds of late pacemakers indicated for AVB (OR 1.94, 95%CI 1.08-3.47, p=0.027) compared to AVRT.

CONCLUSION

AVNRT ablation is safe but associated with a low but definitely increased risk of requiring pacing in the later years due to AVB. This association is confirmed by pooling over 16,000 AVNRT patients receiving clinically indicated ablation and is helpful in providing informed consent for prospective patients undergoing ablation for AVNRT. This article is protected by copyright. All rights reserved.

Asian Pacific Society of Cardiology Consensus Statements on the Diagnosis and Management of Obstructive Sleep Apnoea in Patients with Cardiovascular Disease

Obstructive sleep apnoea (OSA) is strongly associated with cardiovascular disease (CVD). However, evidence supporting this association in the Asian population is scarce. Given the differences in the epidemiology of CVD and cardiovascular risk factors, as well as differences in the availability of healthcare resources between Asian and Western countries, an Asian Pacific Society of Cardiology (APSC) working group developed consensus recommendations on the management of OSA in patients with CVD in the Asia-Pacific region. The APSC expert panel reviewed and appraised the available evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Consensus recommendations were developed and put to an online vote. Consensus was reached when 80% of votes for a given recommendation were in support of ‘agree’ or ‘neutral.’ The resulting statements provide guidance on the assessment and treatment of OSA in patients with CVD in the Asia-Pacific region. The APSC hopes for these recommendations to pave the way for screening, early diagnosis and treatment of OSA in the Asia-Pacific region.

Use of extendable helix leads for conduction system pacing: differences in lead handling and performance: Conclusion

INTRODUCTION

Pacing leads with extendable-retractable helix (EHL) are alternatives to fixed-helix leads (FHL) for conduction system pacing (CSP), but data on handling characteristics are limited. This study evaluated a dual-center experience of lead handling and performance during CSP.

METHODS AND RESULTS

Consecutive patients with His-bundle pacing (HBP) or left bundle branch pacing (LBBP) were evaluated for the primary outcome of lead failure, defined as structural damage to the lead necessitating lead replacement. Differences in pacing characteristics were compared. Among 280 patients (mean age 74±11 years, 44% male, 50% LBBP), 246 (88%) received FHL and 34 (12%) received EHL. Of 299 leads used, lead failure occurred more frequently among patients with EHL than FHL (29% vs 2%, p<0.001), regardless of CSP modality. Majority of damaged leads (89%) in the form of helix deformation were successfully removed, with failure occurring in only 2 patients, both EHL, leading to helix fracture and retention within the septal myocardium. EHL, compared to FHL, was associated with 25-fold increased odds of lead failure (odds ratio 25.21, 95% confidence interval 7.35-86.51), and persisted after adjustment in turn for age, pacing modality and indication. CSP implant success rates did not differ by lead design (FHL 80% vs EHL 71%, p=0.18), with similar pacing thresholds at implant and follow-up. This article is protected by copyright. All rights reserved.

Acute procedural outcomes of his bundle pacing with or without electrophysiology mapping system: a multicenter study

Funding Acknowledgements

Type of funding sources: None.

Introduction

His bundle pacing (HBP) is associated with improved clinical outcomes compared to right ventricular apical pacing. However, it can be technically challenging and may result in prolonged fluoroscopy and procedural time.

Purpose

We sought to compare the feasibility of performing HBP with or without electrophysiology mapping (EP) system, focusing on evaluating acute procedural success, complication rates and short-term outcomes.

Methods

HBP patients at 3 hospitals were recruited between August 2018 to December 2020. HBP was performed with EP mapping system in 1 center, and without EP mapping in the other 2 centers. Acute procedural success was defined as either selective or non-selective His bundle capture with a threshold of less than or equal to 1.5V at 1ms at the end of procedure implantation.

Results

A total of 233 patients were recruited, of which HBP was performed with EP mapping in 77 patients (33.0%) and without EP mapping in 156 patients (67.0%). Both groups were similar in age (73.2 ± 11.0 years vs 75.3 ± 9.5 years, p = 0.125) and male sex (58.4% vs 48.1%, p = 0.136). There were more patients with ischemic heart disease (45.5% vs 22.4%, p &lt; 0.01) and reduced left ventricular ejection fraction ≤ 40% (28.6% vs 10.9%, p &lt; 0.01) in the group with EP mapping. The indications for HBP was for high-grade atrioventricular block (55.8%), sick sinus syndrome (35.6%) and cardiac resynchronization therapy (CRT) (8.6%). There were more patients who required CRT in the center with EP mapping (18.2% vs 3.8%, p &lt; 0.01). HBP was successful in 39 patients (50.6%) with EP mapping and 93 patients (59.6%) without EP mapping (p= 0.382). The median R wave at implant was similar in both groups [4.0 (2.9 – 6.2) mV vs 4.3 (4.3 – 7.0) mV, p = 0.808]. Impedance at implant (607 ± 195 ohms vs 547 ± 166 ohms, p &lt; 0.01) and selective His bundle bipolar threshold at implant [1.25 (0.75-1.75) V vs 0.7 (0.5 – 1.25) V, p = 0.01] was higher in patients with EP mapping while non-selective His bundle bipolar threshold at implant [1.75 (1.0 – 3.0) V vs 1.5 (0.9 – 2.2) V, p = 0.133] and paced QRS duration (116.4 ± 25.4 ms vs 114.4 ± 24.2 ms, p =0.655) were similar. There were no differences in procedural or fluoroscopy time between groups (111 ± 36.9 min vs 107 ± 40.7 min, p = 0.479; and 10.3 ± 8.9 min vs 12.1± 14.0 min, p = 0.328 respectively). There was a similar rate of acute procedural complications (5.2% vs 1.3%, p = 0.076) and patients requiring wound or lead revision (6.8% vs 1.9%, p = 0.115) after a median follow up duration of 205 days (67-397). The prevalence of new onset paroxysmal atrial fibrillation  (11.7% vs 4.2%, p = 0.037) and all cause mortality (12.3% vs 3.2%, p = 0.029) was increased in patients who underwent HBP with EP mapping.

Conclusion

HBP in centers with or without EP mapping showed similar acute procedure success and complication rates. The use of EP mapping system was not shown to affect procedural or fluoroscopy duration.

Impact of a rapid access chest pain clinic in Singapore to improve evaluation of new-onset chest pain

BACKGROUND

Chest pain (CP) accounts for 5% of emergency department (ED) visits, unplanned hospitalisations and costly admissions. Conversely, outpatient evaluation requires multiple hospital visits and longer time to complete testing. Rapid access chest pain clinics (RACPCS) are established in the UK for timely, cost-effective CP assessment. This study aims to evaluate the feasibility, safety, clinical and economic benefits of a nurse-led RACPC in a multiethnic Asian country.

METHODS

Consecutive CP patients referred from a polyclinic to the local general hospital were recruited. Referring physicians were left to their discretion to refer patients to the ED, RACPC (launched in April 2019) or outpatients. Patient demographics, diagnostic journey, clinical outcomes, costs, HEART (History, ECG, Age, Risk Factors, Troponin) scores and 1-year overall mortality were recorded.

RESULTS

577 CP patients (median HEAR score of 2.0) were referred; 237 before the launch of RACPC. Post RACPC, fewer patients were referred to the ED (46.5% vs 73.9%, p < 0.01), decreased adjusted bed days for CP, more non-invasive tests (46.8 vs 39.2 per 100 referrals, p = 0.07) and fewer invasive coronary angiograms (5.6 vs 12.2 per 100 referrals, p < 0.01) were performed. Time from referral to diagnosis was shortened by 90%, while requiring 66% less visits (p < 0.01). System cost to evaluate CP was reduced by 20.7% and all RACPC patients were alive at 12 months.

CONCLUSIONS

An Asian nurse-led RACPC expedited specialist evaluation of CP with less visits, reduced ED attendances and invasive testing whilst saving costs. Wider implementation across Asia would significantly improve CP evaluation.

Submammary placement of implantable cardioverter defibrillators: a Singapore plastic surgeon experience

The use of implantable cardioverter defibrillators (ICDs) in young women has been increasing in recent years owing to greater awareness about inherited cardiac conditions that increase the risk of sudden death. Traditional placement of ICDs in the infraclavicular region among young women often leads to visible scars, a constant prominence that causes irritation from purse or bra straps and can result in body image concerns and device-related emotional distress. In this case series, two women with long QT syndrome required placement of ICDs for prevention of sudden cardiac death. Submammary placement of ICDs was performed in collaboration with electrophysiologists. We describe our local experience and technique in submammary placement of ICDs as well as the challenges faced.

Prevalence, types and treatment of bradycardia in obstructive sleep apnea - A systematic review and meta-analysis

BACKGROUND

The association of obstructive sleep apnea (OSA) with bradycardia is not well-characterized, which may confer significant morbidity and mortality if left untreated. We sought to clarify the prevalence of comorbid OSA and bradycardia, and the effect of continuous positive airway pressure (CPAP) therapy on bradycardia outcomes.

METHODS

We systematically searched four electronic databases (PubMed, Embase, Cochrane Library, Scopus) for randomized or observational studies reporting the co-prevalence of sleep apnea and bradycardia or evaluated the use of CPAP on the incidence of bradycardias. We used random-effects models in all meta-analyses and evaluated heterogeneity using I².

RESULTS

We included 34 articles from 7204 records, comprising 4852 patients. Among patients with OSA, the pooled prevalence of daytime and nocturnal bradycardia were 25% (95% CI: 18.6 to 32.7) and 69.8% (95% CI: 41.7 to 88.2) respectively. Among patients with bradycardia, the pooled prevalence of OSA was 56.8% (95% CI: 21.5 to 86.3). CPAP treatment, compared to those without, did not significantly reduce the risk of daytime (two randomized trials; RR: 0.50; 95% CI: 0.11 to 2.21) or nocturnal bradycardia (one randomized-controlled trial and one cohort study; RR: 0.76; 95% CI: 0.48 to 1.20).

CONCLUSIONS

This meta-analysis demonstrates a high comorbid disease burden between OSA and bradycardia. Future research should explore the treatment effect of CPAP on bradycardia incidence, as compared to placebo.

Adopting permanent His bundle pacing: learning curves and medium-term outcomes

AIMS

This study aims to determine procedural characteristics, acute success rates, and medium-term outcomes of consecutive patients undergoing His bundle pacing (HBP); and learning curves of experienced electrophysiologists adopting HBP.

METHODS AND RESULTS

Consecutive HBP patients at three hospitals were recruited. Clinical characteristics, acute procedural details, and medium-term outcomes were extracted from electronic medical records. Two hundred and thirty-three patients [mean age 74.6 ± 10.1 years, 48% female, 68% narrow QRS, 71% normal left ventricular ejection fraction (LVEF), 55.8% atrioventricular block] underwent HBP. Acute procedural success was 81.1% (mean procedural and fluoroscopic times of 105.5 ± 36.5 and 13.8 ± 9.3 min). Broad QRS was associated with lower HBP success (odds ratio 0.39, P = 0.02). Fluoroscopic and procedural times decreased and plateaued after 30-40 cases per operator. Implant HBP threshold was 1.3 ± 0.7 V at 1.0 ± 0.2 ms and R wave was 5.0 ± 3.9 mV. During follow-up, loss of HBP occurred in a further 12.4% and 11.3% of patients experienced a ≥1 V increase in HBP threshold. Five (2.6%) patients required HBP revision for pacing difficulties. About 8.6% of patients had a >50% decrease in R wave but lead revision for sensing issues was not necessary. On an intention to treat basis, 56.7% of patients in whom HBP was attempted had persisting HBP capture and thresholds of <2 V.

CONCLUSION

Physicians adopting HBP should be cognizant of the learning curve and preferentially select non-dependent patients with normal QRS and LVEF, to minimize risk of lead revision. Further rises in HBP threshold may increase battery drain and need for reoperations, important considerations when choosing HBP for cardiac resynchronization therapy.

Outcomes of supraventricular tachycardia ablation: Results from the Singapore ablation and cardiac devices registry

BACKGROUND

The Singapore Cardiac Databank was designed to monitor the performance and outcomes of catheter ablation. We investigated the outcomes of paroxysmal supraventricular tachycardia (PSVT)-ablation in a prospective, nationwide, cohort study.

METHODS

Atrioventricular nodal re-entrant tachycardia (AVNRT), atrioventricular re-entry tachycardia (AVRT), or atrial tachycardia (AT)-ablations in Singapore from 2010 to 2018 were studied. Outcomes include acute success, periprocedural-complications, postoperative pacing requirement, arrhythmic recurrence and 1-year all-cause mortality.

RESULTS

Among 2260 patients (mean age 45 ± 18 years, 50% female, 57% AVNRT, 37% AVRT, 6% AT), overall acute success rates of PSVT-ablation was 98.4% and increased in order of AT, AVRT, and AVNRT (p < .001). Periprocedural cardiac tamponade occurred in two AVRT patients. A total of 15 pacemakers (6 within first 30-days, 9 after 30-days) were implanted (seven AV block, eight sinus node dysfunction [SND]), with the highest incidence of pacemaker implantation after AT-ablation (5% vs. 0.6% AVNRT vs. 0.1% AVRT, p < .001). Repeat ablations (0.9% AVNRT, 7% AVRT, 4% AT, p < .001) were performed in 78 (3.5%) patients and 13 (0.6%) patients died within a year of ablation. Among outcomes considered adjusting for age, sex, PSVT-type and procedure-time, AT was independently associated with 6-fold increased odds of total (adjusted odds ratio [AOR] 6.32, 95% confidence interval [CI] 1.95-20.53) and late (AOR 6.38, 95% CI 1.39-29.29) pacemaker implantation, while AVRT was associated with higher arrhythmic recurrence with repeat ablations (AOR 4.72, 95% CI 2.36-9.44) compared to AVNRT.

CONCLUSIONS

Contemporary PSVT ablation is safe with high acute success rates. Long-term outcomes differed by nature of the PSVT.

Model-Based Risk Prediction of Rivaroxaban with Amiodarone for Moderate Renal Impaired Elderly Population

PURPOSE

Increased bleeding risk was found associated with concurrent prescription of rivaroxaban and amiodarone. We previously recommended dose adjustment for rivaroxaban utilizing a physiologically based pharmacokinetic (PBPK) modeling approach. Our subsequent in vitro studies discovered the pivotal involvement of human renal organic anion transporter 3 (hOAT3) in the renal secretion of rivaroxaban and the inhibitory potency of amiodarone. This study aimed to redefine the disease-drug-drug interactions (DDDI) between rivaroxaban and amiodarone and update the potential risks.

METHODS

Prospective simulations were conducted with updated PBPK models of rivaroxaban and amiodarone incorporating hOAT3-related parameters.

RESULTS

Simulations to recapitulate previously explored DDDI in renal impairment showed a higher bleeding tendency in all simulation scenarios after integrating hOAT3-mediated clearance into PBPK models. Further sensitivity analysis revealed that both hOAT3 dysfunction and age could affect the extent of DDDI, and age was shown to have a more pivotal role on rivaroxaban in vivo exposure. When amiodarone was prescribed along with our recommended dose reduction of rivaroxaban to 10 mg in moderate renal impaired elderly people, it could result in persistently higher rivaroxaban peak concentrations at a steady state. To better manage the increased bleeding risk among such a vulnerable population, a dose reduction of rivaroxaban to 2.5 mg twice daily resulted in its acceptable in vivo exposure.

CONCLUSION

Close monitoring of bleeding tendency is essential for elderly patients with moderate renal impairment receiving co-prescribed rivaroxaban and amiodarone. Further dose reduction is recommended for rivaroxaban to mitigate this specific DDDI risk.

Effects of Sodium/Glucose Cotransporter Inhibitors on Atrial Fibrillation and Stroke: A Meta-Analysis

OBJECTIVES

Recent clinical trials have shown the potential of sodium glucose cotransporter (SGLT) 2 inhibitors to reduce the risk of atrial fibrillation but not stroke. We conducted a systematic review and meta-analysis to clarify if SGLT2 or combined SGLT1/2 inhibitors affect the risk of atrial fibrillation and stroke in patients regardless of diabetic status.

MATERIALS AND METHODS

Four electronic databases were searched on 21st November 2020 for studies evaluating outcomes of stroke and atrial fibrillation with SGLT2 or combined SGLT1/2 inhibitors in both diabetic and non-diabetic patients. Both random and fixed effect, pair-wise meta-analysis models were used to summarize the results of the studies.

RESULTS

A total of 13 placebo-controlled, randomized-controlled trials were included. Eight trials comprising 35,702 patients were included in the analysis of atrial fibrillation outcomes and eight trials comprising 47,910 patients were included in the analysis of stroke outcomes. Patients on SGLT inhibitors, particularly SGLT2 inhibitors, had lower odds of atrial fibrillation (Peto odds ratio [95% confidence interval] = 0.76 [0.63-0.92]) compared to placebo. This effect remained significant with a follow-up duration longer than 1 year, in studies utilizing dapagliflozin, patients with type 2 diabetes mellitus, and patients with cardiovascular disease. No difference was observed in the odds of atrial fibrillation in patients with baseline heart failure. No effect was seen on the risk of stroke in patients taking SGLT inhibitors.

CONCLUSIONS

SGLT2 inhibitors significantly reduced the odds of atrial fibrillation in diabetic patients. However, SGLT inhibitors did not significantly affect the risk of stroke.

Prevalence and Predictors of Additional Ablation Beyond Pulmonary Vein Isolation in Patients With Paroxysmal Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an effective strategy in the treatment of paroxysmal atrial fibrillation (PAF). Yet, there are limited data on additional ablation beyond PVI. In this study, we sought to assess the prevalence, predictors, and outcomes of additional ablation in PAF patients.

Methods: A total of 537 consecutive patients with PAF were retrospectively evaluated for the index procedure. PVI was successfully conducted in all patients, after which electrophysiological study and drug provocation were performed, and additional ablations were delivered for concomitant arrhythmias, non-PV triggers, and low voltage zone (LVZ). The prevalence, predictors, and outcomes of additional ablation were analyzed.

Results: Among 537 consecutive patients, 372 addition ablations were performed in 241 (44.88%) patients, including 252 (67.74%) concomitant arrhythmias in 198 (36.87%) patients, 56 (15.05%) non-PV triggers in 52 (9.68%) patients and 64 (17.20%) LVZ modification in 47 (8.75%) patients. Lower LVEF (OR = 0.937, p = 0.015), AF episode before procedure (OR = 2.990, p = 0.001), AF episode during procedure (OR = 1.998, p = 0.002) and AF episode induced after PVI (OR = 15.958, p < 0.001) were independent predictors of additional ablation. Single-procedure free from atrial arrhythmias at 58.36 ± 7.12 months post-ablation was 70.48%.

Conclusions: Additional ablations were common in patients with PAF for index procedure. Lower LVEF and AF episodes before, during the procedure, and induced after PVI predicts additional ablation.

Identification of 27 abnormalities from multi-lead ECG signals: an ensembled SE_ResNet framework with Sign Loss function

Objective. Cardiovascular disease is a major threat to health and one of the primary causes of death globally. The 12-lead ECG is a cheap and commonly accessible tool to identify cardiac abnormalities. Early and accurate diagnosis will allow early treatment and intervention to prevent severe complications of cardiovascular disease. Our objective is to develop an algorithm that automatically identifies 27 ECG abnormalities from 12-lead ECG databases.Approach. Firstly, a series of pre-processing methods were proposed and applied on various data sources in order to mitigate the problem of data divergence. Secondly, we ensembled two SE_ResNet models and one rule-based model to enhance the performance of various ECG abnormalities' classification. Thirdly, we introduce a Sign Loss to tackle the problem of class imbalance, and thus improve the model's generalizability.Main results. In the PhysioNet/Computing in Cardiology Challenge (2020), our proposed approach achieved a challenge validation score of 0.682, and a full test score of 0.514, placed us 3rd out of 40 in the official ranking.Significance. We proposed an accurate and robust predictive framework that combines deep neural networks and clinical knowledge to automatically classify multiple ECG abnormalities. Our framework is able to identify 27 ECG abnormalities from multi-lead ECG signals regardless of discrepancies in data sources and the imbalance of data labeling. We trained our framework on five datasets and validated it on six datasets from various countries. The outstanding performance demonstrate the effectiveness of our proposed framework.

Sleep apnea and recurrent heart failure hospitalizations after coronary artery bypass grafting

STUDY OBJECTIVES

Sleep apnea is prevalent in patients undergoing coronary artery bypass grafting (CABG). We investigated the relationship between sleep apnea and recurrent heart failure hospitalizations in patient undergoing non-urgent CABG.

METHODS

Between November 2013 and December 2018, 1007 patients completed a sleep study prior to CABG and were followed up until April 2020. Recurrent heart failure hospitalizations were analyzed by Poisson, negative binomial, Andersen-Gill, and joint frailty models, with partial and full adjustment for covariates.

RESULTS

At an average follow-up of 3.3 years, the number of patients with 0, 1, or ≥2 heart failure hospitalizations were 908 (90.2%), 62 (6.2%), and 37 (3.7%), respectively. The total number of heart failure hospitalizations was 179, comprising 62 (35%) first and 117 (65%) repeat events. The numbers of heart failure hospitalizations for the sleep apnea (n = 513, 50.9%) and non-sleep apnea groups were 127 and 52, respectively. Negative binomial regression demonstrated that sleep apnea was associated with recurrent heart failure hospitalizations (fully adjusted rate ratio, 1.71; 95% confidence interval [CI], 1.12-2.62; p = 0.013). Similar results were found in Poisson (1.63; 95%CI, 1.15-2.31; p = 0.006), Andersen-Gill (1.66; 95% CI, 1.01-2.75; p = 0.047), and joint frailty models (1.72; 95% CI, 1.00-3.01; p = 0.056).

CONCLUSIONS

In patients after CABG, repeat events accounted for two-thirds of heart failure hospitalizations. Sleep apnea was independently associated with recurrent heart failure hospitalizations.

Association of Global Cardiac Calcification with Atrial Fibrillation and Recurrent Stroke in Patients with Embolic Stroke of Undetermined Source

BACKGROUND

Calcium deposits in the heart have been associated with cardiovascular events, mortality, stroke, and atrial fibrillation (AF). However, there is no accepted standard method for scoring cardiac calcifications. Existing methods have also not been validated for the assessment of patients with embolic stroke of undetermined source (ESUS). The aim of this study was to evaluate the association of various cardiac calcification scores with new-onset AF and stroke recurrence in a cohort of patients with ESUS.

METHODS

In this study, 181 consecutive patients with stroke diagnosed with ESUS were identified and evaluated. They were followed for new-onset AF and ischemic stroke recurrence for a median duration of 2.1 years. Various echocardiographic cardiac calcification scores were assessed on transthoracic echocardiography performed during the evaluation of ESUS and subsequently assessed for their relation to AF detection and recurrent stroke. The echocardiographic calcium scores assessed were the (1) global cardiac calcium score (GCCS), (2) echocardiographic calcium score (eCS), (3) echocardiographic calcification score, (4) echocardiographic composite cardiac calcium score, and (5) total heart calcification score. Only two of these scoring schemes, GCCS and eCS, quantified the cardiac calcium burden.

RESULTS

Higher calcium scores as measured by GCCS and eCS were found to be significantly associated with subsequent AF detection as well as recurrent ischemic stroke in patients with ESUS. The association with recurrent stroke remained significant even after adjustment for comorbidities and AF.

CONCLUSIONS

Higher cardiac calcification measured using the GCCS and eCS is independently associated with AF detection and recurrent ischemic stroke in patients with ESUS, and these scores can be useful markers for further risk stratification in patients with ESUS.

Association of Electrocardiographic P-Wave Markers and Atrial Fibrillation in Embolic Stroke of Undetermined Source

BACKGROUND

Several P-wave indices are thought to represent underlying atrial remodeling and have been associated with ischaemic stroke even in the absence of atrial fibrillation (AF). However, the utility of these P-wave indices in predicting outcomes in patients with embolic stroke of undetermined source (ESUS) has not been studied. The aim of this study is to examine these different P-wave indices towards predicting new-onset AF and stroke recurrence in a cohort of patients with ESUS, thereby demonstrating the value of these electrocardiographic markers for stroke risk stratification.

METHODS

Between October 2014 and October 2017, consecutive patients diagnosed with ESUS were followed for new-onset AF and ischaemic stroke recurrence. The various P-wave indices, namely, the P-terminal force in the precordial lead V1 (PTFV1), P-wave duration, P-wave dispersion, interatrial blocks, and P-wave axis, were assessed on the initial electrocardiogram on presentation and studied for their relation to eventual AF detection and recurrent stroke.

RESULTS

181 ischaemic stroke patients with ESUS were recruited and followed up for a median duration of 2.1 years. An abnormal PTFV1 was associated with occult AF detection but not with recurrent ischaemic strokes. No significant association was observed between the other P-wave indices with either occult AF or stroke recurrence.

CONCLUSION

PTFV1 is associated with AF detection but not recurrent strokes in ESUS patients and can be a useful electrocardiographic marker for further risk stratification in ESUS patients.

Impact of the COVID-19 Pandemic on Door-to-Balloon Time for Primary Percutaneous Coronary Intervention - Results From the Singapore Western STEMI Network

BACKGROUND

Little is known about the effect of the coronavirus disease 2019 (COVID-19) pandemic and the outbreak response measures on door-to-balloon time (D2B). This study examined both D2B and clinical outcomes of patients with STEMI undergoing primary percutaneous coronary intervention (PPCI).Methods and Results:This was a retrospective study of 303 STEMI patients who presented directly or were transferred to a tertiary hospital in Singapore for PPCI from October 2019 to March 2020. We compared the clinical outcomes of patients admitted before (BOR) and during (DOR) the COVID-19 outbreak response. The study outcomes were in-hospital death, D2B, cardiogenic shock and 30-day readmission. For direct presentations, fewer patients in the DOR group achieved D2B time <90 min compared with the BOR group (71.4% vs. 80.9%, P=0.042). This was more apparent after exclusion of non-system delay cases (DOR 81.6% vs. BOR 95.9%, P=0.006). Prevalence of both out-of-hospital cardiac arrest (9.5% vs. 1.9%, P=0.003) and acute mitral regurgitation (31.6% vs. 17.5%, P=0.006) was higher in the DOR group. Mortality was similar between groups. Multivariable regression showed that longer D2B time was an independent predictor of death (odds ratio 1.005, 95% confidence interval 1.000-1.011, P=0.029).

CONCLUSIONS

The COVID-19 pandemic and the outbreak response have had an adverse effect on PPCI service efficiency. The study reinforces the need to focus efforts on shortening D2B time, while maintaining infection control measures.

Left Atrial Volume Index Predicts New-Onset Atrial Fibrillation and Stroke Recurrence in Patients with Embolic Stroke of Undetermined Source

INTRODUCTION

It is unclear which surrogate of atrial cardiopathy best predicts the risk of developing a recurrent ischemic stroke in embolic stroke of undetermined source (ESUS). Left atrial diameter (LAD) and LAD index (LADi) are often used as markers of left atrial enlargement in current ESUS research, but left atrial volume index (LAVi) has been found to be a better predictor of cardiovascular outcomes in other patient populations.

OBJECTIVE

We aim to compare the performance of LAVi, LAD, and LADi in predicting the development of new-onset atrial fibrillation (AF) and stroke recurrence in ESUS.

METHODS

Between October 2014 and October 2017, consecutive patients diagnosed with ESUS were followed for new-onset AF, ischemic stroke recurrence, and a composite outcome of occult AF and stroke recurrence. LAVi and LADi were measured by transthoracic echocardiogram; "high" LAVi was defined as ≥35 mL/m2 in accordance with American Society of Echocardiography guidelines.

RESULTS

185 ischemic stroke patients with ESUS were recruited and followed for a median duration of 2.1 years. Increased LAVi was associated with new-onset AF detection (aOR 1.08; 95% CI 1.03-1.14; p = 0.003) and stroke recurrence (aOR 1.05; 95% CI 1.01-1.10; p = 0.026). Patients with "high" LAVi had a higher likelihood of developing a composite of AF detection and stroke recurrence (HR 3.45; 95% CI 1.55-7.67; p = 0.002). No significant association was observed between LADi and either occult AF or stroke recurrence.

CONCLUSIONS

LAVi is associated with new-onset AF and stroke recurrence in ESUS patients and may be a better surrogate of atrial cardiopathy.

Sleep apnoea and cardiovascular outcomes after coronary artery bypass grafting

OBJECTIVE

Patients with advanced coronary artery disease are referred for coronary artery bypass grafting (CABG) and it remains unknown if sleep apnoea is a risk marker. We evaluated the association between sleep apnoea and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing non-emergent CABG.

METHODS

This was a prospective cohort study conducted between November 2013 and December 2018. Patients from four public hospitals referred to a tertiary cardiac centre for non-emergent CABG were recruited for an overnight sleep study using a wrist-worn Watch-PAT 200 device prior to CABG.

RESULTS

Among the 1007 patients who completed the study, sleep apnoea (defined as apnoea-hypopnoea index ≥15 events per hour) was diagnosed in 513 patients (50.9%). Over a mean follow-up period of 2.1 years, 124 patients experienced the four-component MACCE (2-year cumulative incidence estimate, 11.3%). There was a total of 33 cardiac deaths (2.5%), 42 non-fatal myocardial infarctions (3.7%), 50 non-fatal strokes (4.9%) and 36 unplanned revascularisations (3.2%). The crude incidence of MACCE was higher in the sleep apnoea group than the non-sleep apnoea group (2-year estimate, 14.7% vs 7.8%; p=0.002). Sleep apnoea predicted the incidence of MACCE in unadjusted Cox regression analysis (HR 1.69; 95% CI 1.18 to 2.43), and remained statistically significant (adjusted HR 1.57; 95% CI 1.09 to 2.25), after adjustment for age, sex, body mass index, left ventricular ejection fraction, diabetes mellitus, hypertension, chronic kidney disease and excessive daytime sleepiness.

CONCLUSION

Sleep apnoea is independently associated with increased MACCE in patients undergoing CABG.

TRIAL REGISTRATION NUMBER

NCT02701504.