Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association

Population Pharmacokinetic Modelling of Apixaban in End-Stage Kidney Disease Patients with Atrial Fibrillation Receiving Haemodialysis

BACKGROUND AND OBJECTIVE

Apixaban is increasingly being used for stroke prevention in patients with end-stage kidney disease with atrial fibrillation undergoing haemodialysis, but no pharmacostatistical model is available for dosage adjustment. This study aimed to develop a population pharmacokinetic model of apixaban in these patients to characterise its dialytic clearance and determine optimal dosing regimens and discontinuation timing before surgery.

METHODS

Patients received 2.5 mg of apixaban twice daily for 9 days, followed by 5 mg twice daily for 8 days after a 5-day washout period (NCT02672709). Apixaban concentrations were measured on and off dialysis. A population pharmacokinetic model was developed using parametric and non-parametric methods. Simulations were performed to assess plasmatic exposure and the time to reach clinically relevant apixaban concentrations after treatment discontinuation for seven dosing regimens and 13 dialysis schedules.

RESULTS

A total of 289 apixaban concentrations were measured, including 85 during haemodialysis. The best model was a two-compartment model with first-order elimination. Dialytic clearance was estimated at 1.20 L/h with high inter-individual variability. Apixaban daily exposure was proportional to the total daily dose, independent of dosing frequency and dialysis timing. The standard discontinuation period of 48-72 h before surgery was insufficient to achieve clinically negligible concentrations in patients undergoing haemodialysis.

CONCLUSIONS

We propose the first pharmacokinetic model to characterise apixaban clearance in patients with end-stage kidney disease with atrial fibrillation undergoing haemodialysis. Simulations suggest that dialysis timing is not critical for monitoring apixaban, and the discontinuation period before surgery should be extended beyond current recommendations.

Non-Medical Characteristics Affect Referral for Advanced Heart Failure Services: a Retrospective Review

BACKGROUND

Patients with advanced heart failure (AHF) are extensively evaluated before heart transplantation or left ventricular assist device (LVAD) eligibility. Patients are assessed for medical need and psychosocial or economic factors that may affect success post-treatment. For patients to be evaluated, however, they first must be referred. This study investigated social and economic factors affecting AHF referral, specialist visits, or treatment.

METHODS

Patients with heart failure (n = 24,258) were reviewed at one large hospital system over 4 years. Independent variables age, sex, marital status, race/ethnicity, preferred language, smoking, and insurance status were assessed for the outcomes of referral, clinic visit, and treatment by Chi-square and ANOVA. In-house and 1-year mortality were evaluated by logistic regression, and time-to-event was assessed by the Cox proportional hazards model.

RESULTS

Younger (HR 0.934, 95% CI 0.925-0.943), male (HR 2.216, 95% CI 1.544-3.181), and publicly insured (HR 1.298 [95% CI 1.038, 1.623]) patients were more likely to be referred, while unmarried (HR 0.665, 95% CI 0.488-0.905) and smoking (HR 0.549, 95% CI 0.389-0.776) patients had fewer referrals. Younger, married, and nonsmoking patients were more likely to have a clinic visit. Younger age, White race, and Hispanic/Latino ethnicity were associated with receiving a heart transplant, and LVAD recipients were more likely Hispanic/Latino ethnicity. Advanced age, Hispanic/Latino ethnicity, and smoking were associated with 1-year mortality after heart failure diagnosis.

CONCLUSIONS

Disparities in access exist before evaluation for AHF therapies. Improving access at the levels of referral and evaluation is a necessary step toward achieving equity in organ allocation.

Spontaneous echo contrast in the left atrial appendage is linked to a higher risk of thromboembolic events and mortality in patients with atrial fibrillation

Background

Cardioversion, a rhythm control treatment for atrial fibrillation (AF), requires ruling out cardiac embolic sources, often originating from the left atrial appendage (LAA). Transesophageal echocardiography (TEE) is used for LAA evaluation, but it is invasive and not widely available. This study aimed to identify cardiovascular risk factors linked to LAA abnormalities and predictors of thromboembolic events and all-cause mortality.

Methods

A single-center retrospective analysis included AF patients admitted to the University Hospital Würzburg between 2009 and 2018 undergoing TEE.

Results

Among 2400 AF patients (median age 72; 36 % women), 469 (20 %) had LAA abnormalities: 282 (60 %) had spontaneous echo contrast (SEC), 72 (15 %) had thrombus formation (THR), and 115 (25 %) had both. Predictors of LAA abnormalities included age (OR 1.04; p = 0.002), congestive heart failure (OR 1.70; p = 0.009), diabetes (OR 1.74; p = 0.007), stroke history (OR 3.36; p = 0.001), vascular disease (OR 1.57; p = 0.026), elevated alkaline phosphatase (OR 1.15; p = 0.003), prior VKA intake (OR 1.53; p = 0.002), and DOAC intake (OR 0.57; p = 0.038). SEC with or without THR independently predicted thromboembolic events (HR 1.74, p = 0.031 and HR 1.53, p = 0.006) and all-cause mortality (HR 1.77, p = 0.011 and HR 1.57, p = 0.002), adjusted for cardiovascular risk factors, anticoagulation, and laboratory data.

Conclusions

In AF patients undergoing TEE, SEC, often overlooked in cardioversion decisions, independently predicted thromboembolic events and mortality.

Evaluation of risk factors for long-term atrial fibrillation development in patients undergoing typical atrial flutter ablation: a multicenter pilot study

BACKGROUND

Atrial flutter (AFL) and atrial fibrillation (AF) are the most commonly detected supraventricular arrhythmias and share similar pathophysiological mechanisms. After the successful ablation of AFL, AF frequently occurs in the long-term follow-up. As emphasized in some studies, certain mechanisms seem to predispose to the development of AF in AFL patients, and approximately 20% of these patients have accompanying AFL.

PURPOSE

We aimed to analyze independent risk factors that predict the development of AF in patients who underwent typical AFL ablation.

METHODS

This was a multicenter, cross-sectional, and retrospective study. A total of 442 patients who underwent typical AFL ablation at three different centers between January 1, 2018 and January 1, 2022 were included retrospectively. After the ablation procedure the patients were divided into those who developed AF and those who did not. The patients were followed up for an average of 12 (4-20) months. In the post-procedural period, atrial arrhythmias were investigated with 24‑h Holter and ECG at 1 month, 6 months, and 12 months and then at 6‑month intervals thereafter.

RESULTS

Overall, AF developed in 206 (46.6%) patients in the long-term follow-up. Age, hypertension (HT), obstructive sleep apnea syndrome (OSAS), previous cerebrovascular accident (CVA), left atrium anteroposterior diameter, severe mitral regurgitation, hemoglobin, blood glucose, and HbA1c values were found to be significant in univariable analysis. According to multivariable analysis, HT (p = 0.014; HR: 1.483 [1.084-2.030]), OSAS (p = 0.008; HR: 1.520 [1.117-2.068]) and previous CVA (p = 0.038; HR: 1.749 [1.031-2.968]) were independently associated with the development of AF in AFL patients who underwent ablation procedure.

CONCLUSION

In the present study, we found that HT, OSAS, and previous CVA were independently correlated with the development of AF in the long-term follow-up of patients who underwent typical AFL ablation. We consider that AFL patients with such risk factors should be followed up closely following cavotricuspid isthmus ablation for the development of AF.

Interaction between chronic kidney disease and atrial fibrillation on incident stroke and all-cause mortality: Matched cohort study of 49,594 patients

BACKGROUND AND AIMS

The interaction between full-spectrum chronic kidney disease (CKD) and atrial fibrillation (AF) on ischemic stroke and all-cause mortality risk, particularly in stage 4 and 5 CKD, remains undetermined.

METHODS

This matched cohort study identified incident AF patients using the International Classification of Disease codes and electrocardiograms from the Clinical Research Data Repository of China Medical University Hospital between 2003 and 2020. For each AF patient, we selected four controls without AF and matched them by age, sex, eGFR within 10 mL/min/1.73 m2, end-stage kidney disease (ESKD) vintage, and diagnosis year. Multivariable Cox proportional hazard models were utilized to assess the interaction between AF and CKD on three-year ischemic stroke and all-cause mortality outcomes.

RESULTS

Within a total of 10,155 patients and 39,439 controls, incidence rates were 3.03 % and 1.48 % for ischemic stroke and 15.6 % and 9.53 % for overall mortality, respectively. In AF, the stroke risk was the highest among patients with stage 4 and 5-ND (non-dialysis) CKD with adjusted hazard ratio (aHR) of 3.31 (95 % CI, 2.46-4.45) and 2.73 (1.88-3.96), respectively. The mortality risk difference varied between 45% and 177 % with the highest difference noted in ESKD (aHR 3.36 [95 % CI, 2.84-3.98] in AF vs. 1.59 [95 % CI, 1.28-1.96] in non-AF; interaction p < 0.001). Anticoagulation therapy significantly lowered the mortality risk among patients with AF and advanced CKD (3-way interaction p < 0.001).

CONCLUSIONS

The risk of ischemic stroke and overall mortality was particularly high among patients with concurrent AF and stage 4 and 5-ND CKD, underscoring the urgent evidence to optimize prognosis.

Autonomous Powered Ankle Exoskeleton Improves Foot Clearance and Knee Hyperextension After Stroke: A Case Study

Hemiparetic gait is often characterized by ankle weakness, resulting in decreased propulsion and clearance, as well as knee hyperextension. These gait deviations reduce speed and efficiency while increasing the risk of falls and osteoarthritis. Powered ankle exoskeletons have the potential to address these issues. However, only a handful of studies have investigated their effects on hemiparetic gait. The results are often inconsistent, and the biomechanical analysis rarely includes the knee or hip joint or a direct clearance measure. In this case study, we assess the ankle, knee, and hip biomechanics with and without a new autonomous powered ankle exoskeleton across different speeds and inclines. Exoskeleton assistance resulted in more normative kinematics at the subject's self-selected walking speed. The paretic ankle angle at heel strike increased from 10° plantarflexed without the exoskeleton to 0.5° dorsiflexed with the exoskeleton, and the peak plantarflexion angle during swing decreased from 28° without the exoskeleton to 12° with the exoskeleton. Furthermore, stance knee flexion increased from 7° without the exoskeleton to 20° with the exoskeleton. Finally, foot clearance increased with the exoskeleton for all conditions between 3.1 cm and 5.4 cm. This case study highlights new mechanisms for powered ankle exoskeletons to improve hemiparetic gait.

Global Research Progress on Radiofrequency Ablation in Cardiology

Radiofrequency ablation (RFA) has become a cornerstone in treating cardiac arrhythmias, offering a minimally invasive approach to managing conditions such as atrial fibrillation, ventricular tachycardia, and other rhythm disorders. The historical evolution of RFA, from its early inception to its current state, underscores the technological advancements that have significantly enhanced its efficacy and safety. Global trends indicate a steady increase in the adoption of RFA, with notable research contributions from North America, Europe, and Asia. Comparative studies reveal outcome variability driven by differences in patient populations, procedural techniques, and healthcare infrastructures. Despite its success, RFA faces challenges, including complications related to the procedure, patient selection, and long-term efficacy. Emerging technologies, such as integrating artificial intelligence and enhanced imaging modalities, hold promise for overcoming these barriers and further refining the procedure. Gaps in current research are identified, particularly in understanding the long-term outcomes of RFA and its application in complex arrhythmias. The critical role of RFA in modern cardiology is emphasized, along with the potential for future innovations that could expand its therapeutic utility. This synthesis of the latest evidence provides valuable insights for optimizing the use of RFA in managing cardiac arrhythmias.

Occult Ventricular Fibrillation Visualized by Echocardiogram During Cardiac Arrest: A Retrospective Observational Study From the Real-Time Evaluation and Assessment for Sonography-Outcomes Network (REASON)

Objectives

Cardiac arrest patients with a shockable rhythm are more likely to survive an out-of-hospital cardiac arrest (OHCA) compared with a nonshockable rhythm. An electrocardiogram (ECG) is the most common way to identify a shockable rhythm, but it can miss patients with clinically significant ventricular fibrillation (vfib). We sought to determine the percentage of nonshockable OHCA patients that demonstrated vfib on echo.

Methods

Secondary analysis of echo images recorded from a prior study from our group, Real-Time Evaluation and Assessment for Sonography-Outcomes Network (REASON), a multicenter, observational study of OHCA patients presenting to the emergency department with nonshockable rhythms. Using ECG and echocardiogram images recorded during the initial cardiopulmonary resuscitation (CPR) pause, 2 independent emergency physicians determined the presence of vfib. Two experienced emergency physicians (R.G. and T.G.) reviewed echo images with adjudication by a third if necessary. ECG interpretation was unblinded to patient information. The primary outcome was the proportion of patients in occult vfib.

Results

During the first CPR pause, reviewers noted occult vfib in 22/685 (3.2%; 95% CI, 2.1%-4.8%) subjects. Patients with ECG vfib (n = 55) were defibrillated immediately during the first pause in CPR, but no patients with occult vfib during the first pause in CPR were defibrillated. Subsequently, 50% (11 of 22) of occult vfib patients were defibrillated when ECG vfib was recognized during an ensuing pause in CPR.

Conclusion

One in 33 OHCAs with a nonshockable ECG rhythm exhibits VF on echocardiogram. Patients presenting to the emergency department in a presumed nonshockable rhythm following OHCA may benefit from prompt defibrillation if personnel recognize occult vfib on echo.

Performance of the High-STEACS Early Rule Out Pathway Using hs-cTnT at 30 Days in a Multisite US Cohort

BACKGROUND

The High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) pathway risk stratifies emergency department patients with possible acute coronary syndrome. This study aims to determine if the High-STEACS hs-cTnT (high-sensitivity cardiac troponin T) pathway can achieve the ≥99% negative predictive value (NPV) safety threshold for 30-day cardiac death or myocardial infarction (CDMI) in a multisite US cohort of patients with and without known coronary artery disease (CAD).

METHODS

A secondary analysis of the STOP-CP (High-Sensitivity Cardiac Troponin T [Gen 5 STAT Assay] to Optimize Chest Pain Risk Stratification) cohort, which enrolled adult emergency department patients with possible acute coronary syndrome at 8 US sites (January 25, 2017-September 6, 2018). Participants were classified into outpatient and admission dispositions using the High-STEACS hs-cTnT pathway. Known CAD was defined as prior MI, coronary revascularization, or ≥70% coronary stenosis. Outcomes included 30-day CDMI and efficacy, defined as the proportion identified for outpatient disposition. NPVs and negative likelihood ratios for 30-day CDMI were calculated. NPVs were compared between CAD subgroups using a Fisher exact test.

RESULTS

Among 1351 patients, 53.2% (719/1351) were male, 31.4% (424/1351) had known CAD, and the mean age was 57.4±12.8 years. At 30 days, CDMI occurred in 13.8% (187/1351). High-STEACS classified 63.4% (857/1351) to outpatient disposition, of which 2.0% (17/857) had 30-day CDMI, corresponding to an NPV of 98.0% (95% CI, 96.8-98.8) and negative likelihood ratio of 0.13 (95% CI, 0.08-0.20). In patients with CAD, 46.9% (199/424) were classified to outpatient disposition, of which 4.0% (8/199) had 30-day CDMI. Among patients without CAD, 71.0% (658/927) were classified to outpatient disposition with 1.4% (9/658) having 30-day CDMI. The NPV for 30-day CDMI was 96.0% (95% CI, 92.2-98.2) in patients with CAD versus 98.6% (95% CI, 97.4-99.4) among patients without CAD (P=0.04). The negative likelihood ratio for 30-day CDMI among patients with CAD was 0.16 (95% CI, 0.08-0.31) and 0.12 (95% CI, 0.06-0.22) among patients without CAD.

CONCLUSIONS

The High-STEACS hs-cTnT pathway had high efficacy but was unable to achieve the ≥99% NPV safety threshold for 30-day CDMI.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436.

Impact of Diagnosis to Ablation Time on Recurrence of Atrial Fibrillation and Clinical Outcomes After Catheter Ablation: A Systematic Review and Meta-Analysis With Reconstructed Time-to-Event Data

BACKGROUND

Current clinical guidelines emphasize the significance of rhythm control with catheter ablation but lack guidance on the timing of atrial fibrillation (AF) ablation relative to the diagnosis time. We aim to investigate the latest evidence on the impact of diagnosis to ablation time (DAT) on clinical outcomes after AF ablation.

METHODS

We searched PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials through August 2024. Pairwise, prognostic, and reconstructed time-to-event data meta-analyses were conducted using R V. 4.3.1. Our primary end point was time to first AF recurrence, with secondary end points of all-cause mortality, tamponade, stroke, and heart failure.

RESULTS

Our cohort included 23 studies with 43 711 patients. Shorter DAT was significantly associated with reduced AF recurrence across both paroxysmal and persistent AF subgroups (P<0.01). There was a significant decrease in benefit for paroxysmal AF over time and a slight decrease in benefit for persistent AF over time. However, the benefit remained significant in both over time. DAT per year was significantly associated with a 10% increased risk of AF recurrence. Reconstructed Kaplan-Meier analysis showed that DAT >1 year was significantly associated with a 70% increased risk of AF recurrence in paroxysmal AF and 30% in persistent AF. DAT ≤1 year was significantly associated with decreased all-cause mortality (P<0.01) and showed a trend toward an association with a lower incidence of stroke (P=0.08). However, there was no significant difference in heart failure between DAT ≤1 year and DAT >1 year.

CONCLUSIONS

Early ablation is more beneficial in paroxysmal AF, with a notable decrease in benefit over time, while in persistent AF, the benefit remains significant but slightly decreases over time. Shorter DAT was significantly associated with decreased all-cause mortality and showed a trend toward an association with a lower incidence of stroke.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/display_record.php?; Unique identifier: CRD42024525542.

Evaluating the Real-World Safety of Icosapent Ethyl Versus Omega-3 Polyunsaturated Fatty Acid in Nationwide US Veterans Cohort: Examining Atrial Fibrillation and Bleeding Endpoints

PURPOSE

The REDUCE-IT randomized trial demonstrated a cardiovascular benefit of icosapent ethyl (IPE) but also raised potential safety signals for atrial fibrillation (AF) and serious bleeding. We aimed to evaluate the real-world safety of IPE versus mixed omega-3 polyunsaturated fatty acid (OM-3) formulations.

METHODS

This retrospective active comparator new-user cohort study compared rates of new-onset AF and major bleeding (MB) among adult new users of IPE versus OM-3 in 2020-2024 US Veterans Affairs data. Daily drug exposure was determined via prescription dispensing dates. AF and MB outcomes were identified via validated algorithms based on the International Statistical Classification of Diseases and Related Health Problems, 10th revision, clinical modification. Confounding was accounted for via nearest-neighbor pairwise propensity score (PS) matching. The PS, constructed via logistic regression, was informed by expert-identified variables meeting the disjunctive cause criterion. Cox regression was used to estimate adjusted hazard ratios (aHRs), interpretable as average treatment effects for the treated.

RESULTS

Cohorts for analyses of AF and MB endpoints included 1927 and 2015 people, respectively, in each of the IPE and OM-3 exposure groups. The median age was 70 years, and the groups exhibited a predominance of white (80%) males (93%). The median follow-up time was 1.29 years per person. Baseline covariates were well balanced by treatment arm after PS matching. Incidence rates for AF were 7.29 versus 7.48 per 100 person-years among new users of IPE versus OM-3. The aHR for AF was 1.15 (95% confidence interval 0.82-1.63). Incidence rates for MB were 3.27 versus 3.35 per 100 person-years among new users of IPE versus OM-3. The aHR for MB was 1.22 (95% confidence interval 0.87-3.02).

CONCLUSIONS

Our measures of association were consistent with the null, but we were unable to rule out harms from IPE (vs. OM-3) more modest than a 63% increased rate of AF and threefold increased rate of MB.

Global impact of PM2.5 on cardiovascular disease: Causal evidence and health inequities across region from 1990 to 2021

PM2.5 is an important environmental risk factor for cardiovascular disease (CVD) and poses a threat to global health. This study combines bibliometric analysis, Mendelian randomization (MR), and Global Burden of Disease (GBD) data to comprehensively explore the relationship between PM2.5 exposure and CVD. MR analyses provided strong evidence for causality, reinforcing findings from traditional observational studies. The estimated global burden of PM2.5-related CVD indicated, that there exist significant impacts on the elderly, men, and populations in low and medium socio-demographic index (SDI) areas. This study further found that population growth and aging are the main drivers of this burden with large inequities, although medical advances have mitigated some of the effects. Overall, the opportunity to reduce the burden of CVD remains significant, particularly in medium SDI countries. Projections to 2045 suggested that the absolute burden will increase, while age-standardized rates will decline due to improvements in air quality and health care. These findings emphasized the urgent need for targeted interventions to mitigate the deleterious effects of PM2.5 on global cardiovascular health and to address health inequalities between regions.

Design and validation of Withings ECG Software 2, a tiny neural network based algorithm for detection of atrial fibrillation

BACKGROUND

Atrial Fibrillation (AF) is the most common form of arrhythmia in the world with a prevalence of 1%-2%. AF is also associated with an increased risk of cardiovascular diseases (CVD), such as stroke, heart failure, and coronary artery diseases, making it a leading cause of death. Asymptomatic patients are a common case (30%-40%). This highlights the importance of early diagnosis or screening. Wearable and home devices offer new opportunities in this regard.

METHODS

We present WECG-SW2, a lightweight algorithm that classifies 30-second lead I ECG strips as 'NSR', 'AF', 'Other' or 'Noise'. By detecting the location of QRS complexes in the signal, the information can be organized into a low dimensionality input which is fed to a tiny Convolutional Neural Network (CNN) with only 3,633 parameters. This approach allows for the algorithm to run directly on the ECG acquisition devices, and improves accuracy by making the most out of the training set.

RESULTS

WECG-SW2 was evaluated on a database which combines three clinical studies sponsored by Withings with three hardware devices, as well as the MIT-BIH Arrhythmia Database. On the proprietary clinical database, the sensitivity and specificity of AF detection were 99.63% (95% CI: 99.15-99.84) and 99.85% (95% CI: 99.61-99.94), respectively, based on 4646 strips taken from 1441 participants. On the MIT-BIH Arrhythmia Database, the sensitivity and specificity were 99.87% (95% CI: 99.53, 99.98) and 100% (95% CI: 98.31, 100.0), respectively, across 2624 analyzed segments.

CONCLUSION

WECG-SW2 demonstrates high sensitivity and specificity in the detection of AF using a wide variety of ECG recording hardware. The binary of WECG-SW2 is available upon request to the corresponding author for research purposes.

Major bleeding increases the risk of subsequent cardiovascular events in patients with atrial fibrillation: insights from the SAKURA AF registry and RAFFINE registry

BACKGROUND

Bleeding events are one of the major concerns in patients using oral anticoagulants (OACs). We aimed to evaluate the association between major bleeding and long-term clinical outcomes in atrial fibrillation (AF) patients taking OACs.

METHODS

We analyzed a database comprising two large-scale prospective registries of patients with documented AF: the RAFFINE and SAKURA registries. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), defined as the composite of all-cause death, ischemic stroke, and myocardial infarction. Major bleeding was defined in accordance with the criteria of the International Society on Thrombosis and Hemostasis. Cox multivariate analysis was used to determine the impact of major bleeding on the incidence of MACCE.

RESULTS

The median follow-up period was 39.7 (interquartile range, 33.1-48.1) months. Among 6,633 patients with AF who were taking OAC, 298 (4.5%) had major bleeding and 737 (11.1%) had MACCE. The incidence of MACCE was higher in patients with bleeding than in those without (18.33 and 3.22, respectively, per 100 patient-years; log-rank p < 0.0001). Multivariate logistic regression analysis revealed older age, vitamin K antagonist use, and antiplatelet drug use as independent predictors of major bleeding. Median duration of MACCE occurrence after major bleeding was 41 (interquartile range, 3-300) days. Multivariate Cox hazard regression analysis showed that the risk of MACCE was significantly higher in patients with major bleeding compared to those without (hazard risk, 4.64; 95% confidence interval, 3.62-5.94; p < 0.0001).

CONCLUSIONS

Major bleeding was associated with long-term adverse cardiovascular events among AF patients taking OAC. Therefore, reducing the risk of bleeding is important for improving clinical outcomes in patients with AF.

High-density mapping in catheter ablation for atrial fibrillation in Asia Pacific region: An observational study

Background

Few clinical studies of atrial fibrillation (AF) have focused on Asian patients; data are lacking on current mapping and ablation strategies in the Asia Pacific region (APAC).

Objective

The HD Mapping Observational Study (NCT04022954) was designed to characterize electroanatomic mapping (EAM) with market-released high-density mapping (HDM) catheters in subjects with AF in APAC.

Methods

Subjects undergoing HDM and indicated for radiofrequency ablation (RFA) to treat AF were prospectively enrolled in APAC. Data included mapping strategy and ablation targets. EAM was performed using one of two commercially available HDM catheters (Advisor™ HD Grid, Sensor Enabled™, Abbott [GRID] or Inquiry™ AFocus II™ Double Loop, Abbott [DL]). Procedure-related adverse events were collected.

Results

Two hundred subjects were enrolled at 15 centers: 164 with symptomatic paroxysmal (PAF) and 36 with symptomatic persistent (PersAF) AF for de novo ablation. GRID and DL were used in 186 and 14 cases, respectively. All subjects underwent voltage mapping, with conservative thresholds (low voltage ≤0.5 mV and very low voltage/electrical scar ≤0.1 mV) used in 60.2% and 35.4% of maps, respectively. Focal impulses, rotors, complex fractionated electrograms, and other substrate targets were each searched for in <3% of subjects. Median time to generate a map was 9.0 (Q1: 5.0, Q3: 13.0) minutes. Ablation strategy included pulmonary vein (PV) isolation in all, and non-PV triggers in 75/200 (37.5%) subjects. Five serious adverse events were reported.

Conclusions

The study demonstrated an efficient strategy with the feasibility and safety of using HDM during AF ablation procedures in APAC.

Effectiveness of a nurse practitioner-led collaborative health care model on self-care, functional status, rehospitalization and medical costs in heart failure patients: A randomized controlled trial

BACKGROUND

Heart failure is a serious and common condition that has garnered significant attention in the global public health domain. It often results in impaired function and reduced cardiac function status, leading to difficulties in self-care and diminished quality of life. To effectively address these complex challenges, the collaborative health care model has been proposed. This approach has proven effective in reducing rehospitalization and lowering medical costs.

OBJECTIVE

To evaluate the effects of a nurse practitioner-led collaborative health care model on the self-care, functional status, rehospitalization and medical costs of patients with heart failure.

DESIGN

A randomized controlled trial design.

SETTING

Cardiology department of a regional teaching hospital in Southern Taiwan.

PARTICIPANTS

100 patients diagnosed with heart failure.

METHODS

Patients diagnosed with heart failure were recruited through random allocation and. randomly assigned to two groups. The control group included 50 patients who received routine nursing guidance; the experimental group also included 50 patients who participated in a 12-week collaborative health care program. Key outcomes, including self-care, functional status, rehospitalization, and medical costs, which were evaluated at 12, 16, and 20 weeks post-discharge.

RESULTS

The intervention of the collaborative healthcare program significantly impacted self-care, functional status, rehospitalization, and medical costs. Significant improvements in self-care and functional status were observed at 20 weeks (Self-Care: β = 31.52, 95 % CI: 25.96 to 37.07, p < 0.001; Functional Status: χ2 = 22.42, p < 0.001). Regarding rehospitalization, the average rehospitalization duration for the experimental group significantly increased compared to 1.45 months for the control group, with the experimental group averaging 3.00 months at the 20-week follow-up. Moreover, the experimental group also demonstrated a reduction in rehospitalization medical costs, particularly with significant effects observed in the early stages of intervention (β = -6147.94, 95 % CI: -10,763.99 to -1531.88, p = 0.009).

CONCLUSION

The use of a nurse practitioner-led collaborative health care model significantly improved self-care, function status and reduced rehospitalization while effectively lowering medical costs for patients with heart failure. Through professional team communication and collaboration, this approach provides more effective and comprehensive care, enhances patient self-management capabilities, and improves overall treatment outcomes. These results hold significant implications for clinical practice and provide empirical support for future heart failure care programs, warranting their widespread implementation in clinical settings.

REGISTRATION

This study was registered on ClinicalTrials.gov under the identifier NCT04860596 on April 22, 2021, and participant recruitment was initiated in April 2023.

TWEETABLE ABSTRACT

Effectiveness of a Nurse Practitioner-Led Collaborative Care Model: Reduces rehospitalization and medical costs, while improving self-care and functional status in heart failure patients. A Randomized Controlled Trial. #HeartFailure #HealthCare #SelfCare.

Constraint-Induced Movement Therapy Combined With Anodal Transcranial Direct Current Stimulation and Peripheral Neuromuscular Electrical Stimulation in Poststroke Patients: A Retrospective Study

OBJECTIVES

Although previous studies have shown a certain effect for affected upper extremity motor function for constraint-induced movement therapy (CIMT) with transcranial direct current stimulation (tDCS), there is insufficient evidence to make treatment recommendations. Here, we aimed to determine whether the addition of anodal-tDCS and peripheral neuromuscular electrical stimulation (PNES) to CIMT is superior to CIMT alone for improving upper extremity function in patients with chronic stroke.

METHODS

This retrospective study included patients with chronic hemiparesis following a stroke who underwent CIMT at a college hospital between 2012 and 2018. The participants had either received CIMT alone (five-hour training sessions per day for 10 consecutive weekdays) or CIMT combined with anodal-tDCS and PNES.

RESULTS

A total of 25 patients met all eligibility criteria, and 19 and 6 patients were included in the CIMT alone and CIMT combined with anodal-tDCS and PNES groups, respectively. Both groups showed significant improvement in all outcomes following CIMT (p < 0.05). The Fugl-Meyer assessment showed a significant difference between the groups in the CIMT combined with anodal-tDCS and PNES group (p = 0.047).

CONCLUSIONS

Preconditioning interventions, including tDCS and PNES, may be good methods for further enhancing the effectiveness of CIMT.

Senolytics rejuvenate aging cardiomyopathy in human cardiac organoids

BACKGROUND

Human cardiac organoids closely replicate the architecture and function of the human heart, offering a potential accurate platform for studying cellular and molecular features of aging cardiomyopathy. Senolytics have shown potential in addressing age-related pathologies but their potential to reverse aging-related human cardiomyopathy remains largely unexplored.

METHODS

We employed human iPSC-derived cardiac organoids (hCOs/hCardioids) to model doxorubicin(DOXO)-induced cardiomyopathy in an aged context. hCardioids were treated with DOXO and subsequently with a combination of two senolytics: dasatinib (D) and quercetin (Q).

RESULTS

DOXO-treated hCardioids exhibited significantly increased oxidative stress, DNA damage (pH2AX), cellular senescence (p16INK4A) and decreased cell proliferation associated with a senescence-associated secretory phenotype (SASP). DOXO-treated hCardioids were considerably deprived of cardiac progenitors and displayed reduced cardiomyocyte proliferation as well as contractility. These distinctive aging-associated characteristics were confirmed by global RNA-sequencing analysis. Treatment with D+Q reversed these effects, reducing oxidative stress and senescence markers, alleviating SASP, and restoring hCardioids viability and function. Additionally, senolytics replenished cardiac progenitors and reversed the cardiomyocyte proliferation deficit.

CONCLUSIONS

Doxorubicin triggers an age-associated phenotype in hCardioids reliably modelling the main cellular and molecular features of aging cardiomyopathy. Senescence is a key mechanism of the aged-hCOs phenotype as senolytics rejuvenated aged-hCardioids restoring their structure and function while reverting the age-associated regenerative deficit.

Cardiovascular disease risk factors in congenital heart disease survivors are associated with heart failure

BACKGROUND

Despite advances in treatment and survival, individuals with congenital heart defects (CHD) have a higher risk of heart failure (HF) compared to the general population.

OBJECTIVE

To evaluate comorbidities associated with HF in patients with CHD with a goal of identifying potentially modifiable risk factors that may reduce HF-associated morbidity and mortality.

METHODS

Five surveillance sites in the United States linked population-based healthcare data and vital records. Individuals with an ICD-9-CM code for CHD aged 11-64 years were included and were stratified by presence of HF diagnosis code. Prevalence of death and cardiovascular risk factors based on diagnosis codes were compared by HF status using log-linear regression.

RESULTS

A total of 25,343 individuals met inclusion/exclusion criteria. HF was documented for 2.2% of adolescents and 12.9% of adults with CHD. Adolescents and adults with HF had a higher mortality than those without HF. In both age groups, HF was positively associated with coronary artery disease, hypertension, obesity, diabetes, and increased healthcare utilization compared to those without HF.

CONCLUSIONS

Within this population-based cohort, over 1 in 50 adolescents and 1 in 8 adults with CHD had HF, which was associated with increased mortality. Modifiable cardiovascular comorbidities were associated with HF.

IMPACT

Five sites in the United States linked population-based healthcare data and vital records to establish surveillance network for identifying the factors which influence congenital heart disease (CHD) outcomes. Survivors of CHD frequently develop heart failure across the lifespan. Over 1 in 50 adolescent and 1 in 8 adult survivors of CHD have heart failure which is associated with increased mortality compared to CHD survivors without heart failure. Heart failure development is associated with potentially modifiable cardiovascular risk factors such as hypertension, coronary artery disease, and diabetes. Controlling modifiable cardiovascular risk factors may serve to lower the risk of heart failure and mortality in survivors of congenital heart disease of all ages.

Symptom prevalence in patients with advanced heart failure and its association with quality of life and activities of daily living

BACKGROUND

Quality of life (QOL) and functional status are two key outcomes for patients with advanced heart failure (HF). We examined the association of eleven symptoms with QOL and functional status impairment in patients with advanced HF.

METHODS AND RESULTS

This was a retrospective analysis of baseline data from a multi-center, cluster-randomized controlled trial (NCT01459744) which enrolled patients with an implanted cardioverter-defibrillator and advanced HF at high-risk for mortality. Study instruments included the Condensed Memorial Symptom Assessment Scale, the Kansas City Cardiomyopathy Questionnaire QOL subscale, and the number of activities of daily living (ADL) patients had difficulties with. The study included 413 subjects. In generalized linear models which were adjusted for baseline characteristics, the total number of symptoms was significantly associated with worse QOL, as was the presence of each individual symptom, except constipation. Lack of energy demonstrated the strongest negative association with QOL. Similarly, the total number of symptoms was associated with a higher number of ADL difficulties (i.e., worse functional status). The presence of pain, lack of energy and drowsiness was individually associated with more ADL difficulties.

CONCLUSION

Among patients with advanced HF, a higher number of symptoms and specific individual symptoms were associated with worse QOL and functional status.

Caregiving for patients with atrial fibrillation: a systematic review of the scientific literature

AIMS

Caregiving processes and outcomes have been increasingly articulated in the cardiovascular literature, particularly in heart failure and coronary artery disease, but there has been no synthesis on caregiving for a patient with atrial fibrillation (AF). This review synthesizes scientific evidence that describes caregiving in the context of AF, with the aim of informing future research priorities for AF caregiving or clinical approaches that may support caregivers.

METHODS AND RESULTS

Informed by PRISMA guidelines, we conducted a mixed-methods systematic review with a data-based convergence design using a thematic synthesis approach. All studies that examined factors related to caregiving for patients with AF, as either a descriptive, predictor, or outcome variable, were included. After the search, data from 13 studies were abstracted; half of the studies (53%) were of low-to-moderate quality. Changes to the family unit and feelings of uncertainty are common post-AF; a subset of caregivers struggle with mental health challenges, particularly those who are unwell themselves or those who provide several hours of care to patients with more advanced symptoms or limitations. Informational support for caregivers appears to be lacking but is desired to better adapt to the changes or consequences incurred from AF.

CONCLUSION

This review complements findings from previous reviews conducted in other cardiovascular disease subgroups. As there is still limited high-quality research on caregiving in an AF context, additional research is required to adequately inform supportive programming for caregivers of patients with AF, if indicated.

REGISTRATION

PROSPERO: CRD4202339778.

A comparative analysis of CNNs and LSTMs for ECG-based diagnosis of arrythmia and congestive heart failure

Cardiac arrhythmias are major global health concern and their early detection is critical for diagnosis. This study comprehensively evaluates the effectiveness of CNNs and LSTMs for the classification of cardiac arrhythmias, considering three PhysioNet datasets. ECG records are segmented to accommodate around ∼10s of ECG data. Followed by transformation to scalograms using DWT for training VGG-16; and WTS for feature extraction and dimensionality reduction for training LSTM network. VGG-16 achieved 96.44% test accuracy while LSTM achieved 92%. Results also highlight the effectiveness of VGG-16 for short-duration ECG analysis, while LSTM excels in long-term monitoring on edge devices for personalized healthcare.

High pulse pressure is associated with an increased risk of prediabetes in hypertensive individuals: A retrospective study based on an adult Chinese population

OBJECTIVES

The pulse pressure (PP) is an important factor influencing the outcomes of diabetes. However, the relationship between the PP and prediabetes has been rarely studied and how this association might be impacted by hypertension is not clear.

METHODS

In this study, we retrospectively included 184,252 adults from 32 regions in China, spanning from 2010 to 2016. Cox regression and sensitivity analysis were used to examine the relationship between PP and prediabetes. For the hypertensive population, Cox proportional hazards regression and smooth curve fitting were performed to explore the non-linear relationship between PP and prediabetes. A two-stage Cox proportional hazards regression model was used to determine the inflection point of PP in relation to the risk of prediabetes.

RESULTS

After adjusting for confounding factors, we found a positive association between PP and prediabetes (HR: 1.11, 95% CI: 1.03-1.19, P = 0.0045). However, we observed that this relationship was not significant in the normal blood pressure group (HR: 1.06, 95% CI: 0.94-1.18, P = 0.3529). We also found a non-linear relationship between PP and the risk of prediabetes in hypertensive individuals. The inflection point of PP was 31 mmHg. When PP ≥ 31 mmHg, there was a positive association with the risk of prediabetes (HR: 1.22, 95% CI: 1.04-2.08, P <0.0001). Conversely, when PP < 31 mmHg, this association was not significant (HR: 0.83, 95% CI: 0.59-1.15, P = 0.2646).

CONCLUSIONS

This study suggests a non-linear relationship between PP and the risk of prediabetes in hypertensive individuals. Maintaining PP within 31 mmHg is crucial for preventing the occurrence of prediabetes.

Exploring Anti-Inflammatory Treatment as Upstream Therapy in the Management of Atrial Fibrillation

Inflammation has been widely recognized as one of the major pathophysiological drivers of the development of atrial fibrillation (AF), which works in tandem with other risk factors of AF including obesity, diabetes, hypertension, and heart failure (HF). Our current understanding of the role of inflammation in the natural history of AF remains elusive; however, several key players, including the NLRP3 (NLR family pyrin domain containing 3) inflammasome, have been acknowledged to be heavily influential on chronic inflammation in the atrial myocardium, which leads to fibrosis and eventual degradation of its electrical function. Nevertheless, our current methods of pharmacological modalities with reported immunomodulatory properties, including well-established classes of drugs e.g., drugs targeting the renin-angiotensin-aldosterone system (RAAS), statins, and vitamin D, have proven effective in reducing the overall risk of developing AF, the onset of postoperative atrial fibrillation (POAF), and reducing overall mortality among patients with AF. This might bring hope for further progress in developing new treatment modalities targeting cellular checkpoints of the NLRP3 inflammasome pathway, or revisiting other well-known anti-inflammatory drugs e.g., colchicine, vitamin C, nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticosteroids, and antimalarial drugs. In our review, we aim to find relevant upstream anti-inflammatory treatment methods for the management of AF and present the most current real-world evidence of their clinical utility.

PEGylated Ultrasmall Iron Oxide Nanoparticles as MRI Contrast Agents for Vascular Imaging and Real-Time Monitoring

Accurate imaging evaluations of pre- and post-treatment of cardiovascular diseases are pivotal for effective clinical interventions and improved patient outcomes. However, current imaging methods lack real-time monitoring capabilities with a high contrast and resolution during treatments. This study introduces PEGylated ultrasmall iron oxide nanoparticles (PUSIONPs), which have undergone comprehensive safety evaluations, boasting an r1 value of 6.31 mM-1 s-1, for contrast-enhanced magnetic resonance angiography (MRA). Systematic comparisons against common clinical methods in rabbits reveal that PUSIONPs-enhanced MRA exhibited improved vascular contrast, clearer vascular boundaries, and superior vessel resolution. Moreover, owing to their nanosize, PUSIONPs demonstrate significantly prolonged blood circulation compared to small molecular contrast agents such as Magnevist and Ultravist. This extended circulation enables captivating real-time monitoring of thrombolysis treatment for up to 4 h in rabbit models postsingle contrast agent injection. Additionally, in larger animal models such as beagles and Bama minipigs, PUSIONPs-enhanced MRA also showcases superior contrast effects, boundary delineation, and microvessel visualization, underscoring their potential to transform cardiovascular imaging, particularly in real-time monitoring and high-resolution visualization during treatment processes.

Therapeutic use of music listening in patients undergoing invasive coronary procedures: A meta-analysis

BACKGROUND

Listening to music has been shown to reduce pain and anxiety before, during, and after invasive coronary procedures.

AIM

To perform a systematic review and meta-analysis to explore the effect of therapeutic use of music on both, perioperative and postoperative outcomes of invasive coronary procedures.

METHODS

An exhaustive literature search of 3 electronic databases (MEDLINE, Scopus, Cochrane CENTRAL) was conducted from inception until 10th December 2023. The results of our analyses are presented as standard mean difference (SMD) or weighted mean difference, with 95%CI and pooled using a random effects model. A P value < 0.05 was considered significant in all cases.

RESULTS

From 21 studies, 2141 participants were included in our analysis. The pooled analysis demonstrated that music listening significantly improves post-procedural pain (SMD = -0.78, 95%CI: -1.34 to -0.23; P = 0.006), anxiety (SMD = -0.86, 95%CI: -1.43 to -0.29; P = 0.003), heart rate [mean difference (MD) = -3.38, 95%CI: -5.51 to -1.25; P = 0.002], and systolic blood pressure (MD = -5.89, 95%CI: -9.75 to -2.02; P = 0.003). There was no significant improvement in diastolic blood pressure (MD = -3.22, 95%CI: -6.58 to 0.14; P = 0.06) or respiratory rate (MD = -0.97, 95%CI: -1.98 to 0.03; P = 0.06).

CONCLUSION

Music listening can be used in healthcare settings for patients undergoing invasive coronary procedures to reduce anxiety levels and improve their physiological parameters.

Effect of Plyometric Exercises of Lower Limb on Strength, Postural Control, and Risk of Falling in Stroke Patients

Background and Objective: Stroke, a major contributor to long-term disability worldwide, often results in significant impairments in motor function. These impairments can include weakness, impaired balance, and decreased coordination, which can have a significant influence on one's quality of life and independence. Finding an effective protocol for rehabilitation to improve these points will decrease the impact of stroke and its coast of rehabilitation. Materials and Methods: This study was conducted to assess the effect of lower limb plyometric exercises on strength, postural control, and risk of falling in stroke patients. Materials and Methods: This study involved 40 chronic left stroke patients randomly divided into two equal groups. The experimental group participated in a 12-week supervised plyometric training program, while the control group received conventional physical therapy program. Lower limb muscle strength was measured using a handheld dynamometer, and balance and fall risk were assessed via the Biodex Balance System (BBS). These measurements were conducted before and after the intervention period to evaluate treatment effects. Results: The results of this study demonstrated significant improvements in muscle strength and balance parameters among stroke patients who underwent plyometric exercise compared to those receiving a conventional program. The plyometric group exhibited significantly greater increases in knee extension strength (p < 0.05), hip abduction strength (p < 0.05), ankle dorsiflexion strength (p < 0.05), and ankle eversion strength (p < 0.05). Furthermore, the plyometric group showed significant improvements in overall stability (p < 0.05), mediolateral stability (p < 0.05), and anteroposterior stability (p < 0.05), as measured by the Biodex Balance System (BBS). Conclusions: The results of this study suggest that plyometric exercise may be an effective intervention for decreased risk of falling and enhancing muscle strength and balance during recovery from stroke.

Prognostic value of coronary plaque composition in symptomatic patients with obstructive coronary artery disease

OBJECTIVES

To determine whether plaque composition analysis defined by cardiac CT can provide incremental prognostic value above coronary artery disease (CAD) burden markers in symptomatic patients with obstructive CAD.

MATERIALS AND METHODS

Between 2009 and 2019, a multicentric registry included all consecutive symptomatic patients with obstructive CAD (at least one ≥ 50% stenosis on CCTA) and was followed for major adverse cardiovascular (MACE) defined by cardiovascular death or nonfatal myocardial infarction. Each coronary segment was scored visually for both the degree of stenosis and composition of plaque, which were classified as non-calcified, mixed, or calcified. To assess the prognostic value of each CCTA findings, different multivariable Cox regression models were used: model 1: clinical (traditional risk factors); model 2: model 1 + CAD burden (number of proximal segments with stenosis ≥ 50% + number of vessels with obstructive CAD); and model 3: model 2 + plaques feature (number of segments with non-calcified plaque).

RESULTS

Of 2312 patients (mean age 70 ± 12 years, 46% men), 319 experienced a MACE (13.8%) (median follow-up: 6.7 years (5.9-9.1)). The number of proximal segments with ≥ 50% stenosis, the number of vessels with obstructive CAD, and the number of segments with non-calcified plaque were all independently associated with MACEs (all p < 0.001). The addition of plaque composition analysis (model 3) showed the best improvement in model discrimination and reclassification (C-statistic improvement = 0.03; net reclassification improvement = 28.6%; integrative discrimination index = 5.4%, all p < 0.001).

CONCLUSIONS

In this population, the analysis of coronary plaque composition had an incremental prognostic value to predict MACEs above a model combining traditional risk factors and CAD burden.

KEY POINTS

Question Several coronary computed tomography angiography (CCTA) studies have shown the potential interest of plaque composition analysis, which can be further evaluated. Findings In symptomatic patients with obstructive coronary artery disease (CAD), plaque composition analysis had an incremental prognostic value above a model combining traditional risk factors and CAD burden. Clinical relevance In symptomatic patients with obstructive CAD, plaque composition analysis using CCTA has a strong incremental prognostic value above a model combining traditional risk factors and CAD burden, thus translating into a more accurate long-term major adverse cardiovascular event prediction.

A systematic review of automated prediction of sudden cardiac death using ECG signals

Background. Sudden cardiac death (SCD) stands as a life-threatening cardiac event capable of swiftly claiming lives. It ranks prominently among the leading causes of global mortality, contributing to approximately 10% of deaths worldwide. The timely anticipation of SCD holds the promise of immediate life-saving interventions, such as cardiopulmonary resuscitation. However, recent strides in the realms of deep learning (DL), machine learning (ML), and artificial intelligence have ushered in fresh opportunities for the automation of SCD prediction using physiological signals. Researchers have devised numerous models to automatically predict SCD using a combination of diverse feature extraction techniques and classifiers. Methods: We conducted a thorough review of research publications ranging from 2011 to 2023, with a specific focus on the automated prediction of SCD. Traditionally, specialists utilize molecular biomarkers, symptoms, and 12-lead ECG recordings for SCD prediction. However, continuous patient monitoring by experts is impractical, and only a fraction of patients seeks help after experiencing symptoms. However, over the past two decades, ML techniques have emerged and evolved for this purpose. Importantly, since 2021, the studies we have scrutinized delve into a diverse array of ML and DL algorithms, encompassing K-nearest neighbors, support vector machines, decision trees, random forest, Naive Bayes, and convolutional neural networks as classifiers.Results. This literature review presents a comprehensive analysis of ML and DL models employed in predicting SCD. The analysis provided valuable information on the fundamental structure of cardiac fatalities, extracting relevant characteristics from electrocardiogram (ECG) and heart rate variability (HRV) signals, using databases, and evaluating classifier performance. The review offers a succinct yet thorough examination of automated SCD prediction methodologies, emphasizing current constraints and underscoring the necessity for further advancements. It serves as a valuable resource, providing valuable insights and outlining potential research directions for aspiring scholars in the domain of SCD prediction.Conclusions. In recent years, researchers have made substantial strides in the prediction of SCD by leveraging openly accessible databases such as the MIT-BIH SCD Holter and Normal Sinus Rhythm, which contains extensive 24 h recordings of SCD patients. These sophisticated methodologies have previously demonstrated the potential to achieve remarkable accuracy, reaching levels as high as 97%, and can forecast SCD events with a lead time of 30-70 min. Despite these promising outcomes, the quest for even greater accuracy and reliability persists. ML and DL methodologies have shown great promise, their performance is intrinsically linked to the volume of training data available. Most predictive models rely on small-scale databases, raising concerns about their applicability in real-world scenarios. Furthermore, these models predominantly utilize ECG and HRV signals, often overlooking the potential contributions of other physiological signals. Developing real-time, clinically applicable models also represents a critical avenue for further exploration in this field.

Machine Learning-Driven Discovery of Structurally Related Natural Products as Activators of the Cardiac Calcium Pump SERCA2a

A key molecular dysfunction in heart failure is the reduced activity of the cardiac sarcoplasmic reticulum Ca2+-ATPase (SERCA2a) in cardiac muscle cells. Reactivating SERCA2a improves cardiac function in heart failure models, making it a validated target and an attractive therapeutic approach for heart failure therapy. However, finding small-molecule SERCA2a activators is challenging. In this study, we used a machine learning-based virtual screening to identify SERCA2a activators among 57,423 natural products. The machine learning model identified ten structurally related natural products from Zingiber officinale, Aframomum melegueta, Alpinia officinarum, Alpinia oxyphylla, and Capsicum (chili peppers) as SERCA2a activators. Initial ATPase assays showed seven of these activate SERCA at low micromolar concentrations. Notably, two natural products, Yakuchinone A and Alpinoid D displayed robust concentration-dependent responses in primary ATPase activity assays, efficient lipid bilayer binding and permeation in atomistic simulations, and enhanced intracellular Ca2+ transport in adult mouse cardiac cells. While these natural products exert off-target effects on Ca2+ signaling, these compounds offer promising avenues for the design and optimization of lead compounds. In conclusion, this study increases the array of calcium pump effectors and provides new scaffolds for the development of novel SERCA2a activators as new therapies for heart failure.

Mutual mediation effects of homocysteine and PCSK9 on coronary lesion severity in patients with acute coronary syndrome: interplay with inflammatory and lipid markers

BACKGROUND

Homocysteine (Hcy) and the proprotein convertase subtilisin/kexin type 9 (PCSK9) significantly contribute to atherosclerosis (AS) as well as coronary lesion severity. Our previous work demonstrated that Hcy upregulates PCSK9, accelerating lipid accumulation and AS. A PCSK9 antagonist reduces plasma Hcy levels in ApoE-/- mice. These findings suggest complex roles for both Hcy and PCSK9 in AS. This study investigated the mutual mediating influence of Hcy together with PCSK9 on coronary lesion severity among individuals diagnosed with acute coronary syndrome (ACS), focusing on their interplay with inflammatory and lipid-related markers.

METHODS

This cross-sectional study encompassed 617 individuals diagnosed with ACS. Baseline characteristics, including inflammatory and lipid-related markers, were compared between individuals with non-severe (SYNTAX score ≤ 22) and severe (SYNTAX score > 22) coronary lesions. To evaluate both the impacts of Hcy and PCSK9 on coronary lesions severity, multivariate logistic regression along with mediation analyses were utilized. The robustness of the findings was validated by conducting subgroup analyses and sensitivity tests.

RESULTS

Patients with severe conditions showed higher levels of Hcy, PCSK9, and inflammatory markers compared to non-severe cases. Both Hcy and PCSK9 levels were independently linked to a heightened risk of severe coronary lesions(ORs: 1.03-1.04 and 1.01-1.02, respectively, all P < 0.001). PCSK9 mediated 34.04% of Hcy's effect on coronary lesion severity, whereas Hcy mediated 31.39% of PCSK9's effect, indicating significant mutual mediation between these biomarkers. Subgroup analyses revealed consistent associations, with notable interactions based on creatinine levels for Hcy and gender, smoking status, and diagnosis for PCSK9. Sensitivity analyses confirmed the robustness of the mediation effects.

CONCLUSIONS

These findings emphasize the mutual mediating effects of Hcy and PCSK9 on coronary lesion severity in patients suffering from ACS. These results highlight the complex interactions between lipid metabolism and inflammation in the pathophysiology of ACS, suggesting that targeting both Hcy and PCSK9 may offer novel therapeutic strategies to mitigate severe coronary lesions among high-risk patients.

Lean body mass and stroke volume, a sex issue

Introduction

Large vessel occlusions (LVO) account for over 60% of stroke-related mortality and disability. Lean body mass (LBM) represents metabolically active body tissue and has been associated with reduced mortality. This study aimed to investigate whether body composition influences LVO stroke perfusion volumes and whether this effect is sex-specific.

Methods

Data were retrospectively collected from all patients admitted between January 2017 and January 2022 with LVO ischemic stroke at the Erasmus Hospital (Brussels), for whom anthropometric and perfusion data were available. Body mass index (BMI) and LBM were calculated using, respectively, the Quetelet's and the James' formula. Correlations between body composition and stroke volumes were investigated using Spearman correlations.

Results

A total of 152 patients were included in this study. Mean age 72 ± 14y, female ratio 62.5%, core volume 26 ± 38 mL, penumbra volume 104 ± 61 mL. LBM correlated significantly with stroke volumes (penumbra and core) in the entire group (core: p = 0.001; penumbra: p = 0.001). There was a significant sex-effect, with a significant correlation observed only in women (core: p = 0.008; penumbra: p = 0.007). BMI did not correlate with perfusion volumes at the group level nor at the sex-level.

Conclusion

LBM significantly impacts LVO stroke volumes, but this effect is observed only in women. LBM may serve as a superior indicator of body composition compared to BMI.

Endometriosis and risk of cardiovascular disease: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate the association between endometriosis and the risk of cardiovascular disease (CVD).

METHODS

A comprehensive literature search was conducted in PubMed (Medline), Scopus, Web of Science, and Embase, covering studies published from January 2000 to April 2023. Cohort and case-control studies investigating the relationship between endometriosis and CVD risk were included. Random-effects or fixed-effects models were used depending on the heterogeneity among studies. Pooled relative risks (RR) with 95% confidence intervals (CIs) were calculated. Study quality was assessed using an appropriate tool, and statistical heterogeneity was evaluated using the I2 statistic. The review was conducted following PRISMA 2020 guidelines.

RESULTS

Six studies were included in the meta-analysis. Women with endometriosis had a 23% higher risk of developing CVD (RR = 1.23; 95% CI: 1.16-1.31) compared to those without endometriosis. Additionally, the risk of hypertension was 13% higher among women with endometriosis (RR = 1.13; 95% CI: 1.10-1.16). Moderate heterogeneity was observed across studies, and a random-effects model was applied.

CONCLUSION

This meta-analysis highlights an increased risk of CVD and hypertension among women with endometriosis. These findings underscore the importance of cardiovascular monitoring and preventive strategies in this population.

TRIAL REGISTRATION

PROSPERO (ID: CRD42023398887).

Fear of progression and quality of life in patients with heart failure: a cross-sectional study on the multiple mediation of psychological distress and resilience

BACKGROUND

Existing research indicates that fear of progression influences the quality of life of patients with various diseases. However, the influence of fear of progression on the quality of life of patients with heart failure and its underlying mechanisms remain unclear. This study aimed to identify the link between fear of progression and quality of life in patients with heart failure and explore the multiple mediating roles of psychological distress and resilience in this association.

METHODS

This multicenter, cross-sectional study was conducted between March and December 2023 across four tertiary hospitals in China. Data on fear of progression, psychological distress (anxiety and depression), resilience, and quality of life were collected. The PROCESS macro in SPSS was used to analyze the multiple mediation model.

RESULTS

The study involved 277 patients. The total indirect effect of fear of progression on quality of life was significant. Fear of progression influenced physical quality of life through two pathways: (i) resilience independently, and (ii) psychological distress-depression and resilience serially. Additionally, fear of progression influenced mental quality of life through three pathways: (i) psychological distress (anxiety and depression) independently, (ii) resilience independently, and (iii) psychological distress (anxiety and depression) and resilience serially. However, psychological distress-anxiety or resilience had no mediating effect on the relationship between fear of progression and physical quality of life in patients with heart failure.

CONCLUSIONS

Fear of progression had a negative association with quality of life in patients with heart failure. In addition, the relationship between fear of progression and quality of life was mediated by psychological distress and resilience. Interventions targeting the reduction of psychological distress and enhancement of resilience may mitigate the impact of fear of progression on quality of life in patients with heart failure.

Cardiovascular Disease Risk Factors in the Native American Population

Native Americans are disproportionately affected by cardiovascular disease in comparison with other racial and ethnic groups in the United States. Previous research has analyzed risk factors, quantified prevalence rates, and examined outcomes of cardiovascular disease in Native Americans, yet few studies have considered the role of societal and psychological factors on the increased burden of cardiovascular disease in Native Americans. Modifiable risk factors for cardiovascular disease, including poor nutrition, reduced physical activity, obesity, and increased substance use, are exacerbated in Native American communities due to cultural and historical factors. Further, Native Americans have endured historical trauma and continue to experience additional financial and healthcare stressors, resulting in increased levels of chronic stress. Chronic activation of stress responses through the hypothalamic-pituitary-adrenal and autonomic nervous system increases inflammation and cardiovascular dysfunction resulting in an increased risk for cardiovascular disease. Therefore, it is critical to examine the connection between these stressors and the cardiovascular health disparities in Native American communities to create effective strategies to improve health outcomes.

Inhibition of p70 Ribosomal S6K1 Protects the Myocardium against Ischemia/Reperfusion-Induced Necrosis through Downregulation of RIP3

BACKGROUND

Myocardial ischemia-reperfusion (I/R) injury refers to cell damage that occurs as a consequence of the restoration of blood circulation following reperfusion therapy for cardiovascular diseases, and it is a primary cause of myocardial infarction. The search for nove therapeutic targets in the context of I/R injury is currently a highly active area of research. p70 ribosomal S6 kinase (S6K1) plays an important role in I/R induced necrosis, although the specific mechanisms remain unclear.

OBJECTIVE

This study aims to explore the effects of inhibiting S6K1 on myocardial I/R injury and its potential mechanisms.

METHODS

A rat myocardial I/R model was created and treated with the S6K1-specific inhibitor PF-4708671. Hematoxylin-eosin (H&E) staining was applied to evaluate the pathological changes in cardiac tissues. 2,3,5-triphenyltetrazolium chloride (TTC) staining was used to measure the area of myocardial infarction (MI). Left ventricular systolic pressure (LVSP), left ventricular end-diastolic pressure (LVEDP), the maximum rate of increase in left ventricular pressure (+dp/dtmax), and the maximum rate of the decrease in left ventricular pressure (-dp/dtmax) were measured using ultrasonic echocardiography. The expression levels of cardiac troponin-1 (cTn-1), lactate dehydrogenase (LDH), creatine kinase MB (CK-MB), and aspartate aminotransferase (AST) were determined by enzyme-linked immunosorbent assay (ELISA). Terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) staining and propidium iodide (PI) staining were used to examine the apoptosis and necrosis of myocardial tissues. The expressions of apoptotic-related proteins, and key molecules of necrosis were detected by western blot. The relationship between S6K1 and receptor-interacting protein kinase 3 (RIP3) was analyzed by immunoprecipitation.

RESULTS

Inhibition of S6K1 reduces I/R-induced myocardial tissue damage, improves myocardial function, and inhibits myocardial tissue necrosis (p < 0.05). In addition, RIP3 is a direct target of S6K1, and activation of RIP3 blocked the protective effect of the S6K1 inhibitor PF-4708671 against myocardial I/R injury (p < 0.05).

CONCLUSION

Inhibition of S6K1 protects against myocardial I/R injury by down-regulating RIP3, suggesting that targeting S6K1 may offer a novel approach for intervention in myocardial I/R injury.

Competitive signaling and cellular communications in myocardial infarction response

Cell communication and competition pathways are malleable to Myocardial Infarction (MI). Key signals, transcriptive regulators, and metabolites associated with apoptotic responses such as Myc, mTOR, and p53 are important players in the myocardium. The individual state of cardiomyocytes, fibroblasts, and macrophages in the heart tissue are adaptable in times of stress. The overlapping communication pathways of Wnt/β-catenin, Notch, and c-Kit exhibit the involvement of important factors in cell competition in the myocardium. Depending on the effects of these pathways on genetic expression and signal amplification, the proliferative capacities of the previously stated cells that make up the myocardium, amplify or diminish. This creates a distinct classification of "fit" and "unfit" cells. Beyond straightforward traits, the intricate metabolite interactions between neighboring cells unveil a complex battle. Strategic manipulation of these pathways holds translational promise for rapid cardiac recovery post-trauma.

The effect of thermoelectric craniocerebral cooling device on protecting brain functions in post-cardiac arrest syndrome

Aim

This study aimed to protect brain functions in patients who experienced in-hospital cardiac arrest through the application of local cerebral hypothermia. By utilizing a specialized thermal hypothermia device, this approach sought to mitigate ischemic brain injury associated with post-cardiac arrest syndrome, enhance survival rates, and improve neurological outcomes as measured by standardized scales.

Methods

A prospective, single-center cohort study was conducted involving patients aged ≥18 years who experienced in-hospital cardiac arrest and achieved return of spontaneous circulation (ROSC). Patients were cooled using a hypothermia helmet to achieve a target temperature of 32°C-34°C, maintained for 36-72 h, followed by controlled rewarming and normothermia for 72 h. Neurological recovery was assessed using the Cerebral Performance Category (CPC) scale, where CPC 1-2 denotes good recovery and CPC 3-5 indicates poor outcomes. Body temperature, hemodynamic parameters, biochemical changes, and survival data were meticulously recorded and analyzed. Statistical analysis included paired t-tests to compare pre- and post-treatment data.

Results

Of 116 cardiac arrest cases, 30 (25.86%) were in-hospital, and 16 (53.33%) of these achieved ROSC. Among the patients, 62.5% underwent emergency coronary angiography due to ST-elevation myocardial infarction (STEMI). The mean time to hypothermia initiation was 32.9 ± 13.5 min, with hypothermia maintained for 58 ± 6.4 h. Neurological outcomes were favorable, with 62.5% of patients achieving CPC scores of 1 or 2, indicating functional recovery and independence. In contrast, CPC scores of 3 or higher were observed in 37.5% of patients, reflecting varying degrees of disability. Biochemical analysis revealed significant decreases in sodium, potassium, calcium, and magnesium levels, alongside increased urea and creatinine concentrations. Hemodynamic improvements included elevated systolic blood pressure and heart rate, while left ventricular ejection fraction remained stable. Overall survival was 75%, and the majority (62.5%) of survivors were discharged without significant neurological deficits.

Conclusion

The findings suggest that early and targeted application of craniocerebral thermal hypothermia has the potential to improve survival and preserve neurological function in post-cardiac arrest syndrome. The high rates of favorable outcomes, as reflected by CPC scores, underscore the neuroprotective effects of localized hypothermia. Further large-scale, multicenter trials are recommended to validate these promising results and refine protocols for optimal clinical application.

Use of mHealth Technology for Improving Exercise Adherence in Patients With Heart Failure: Systematic Review

BACKGROUND

The known and established benefits of exercise in patients with heart failure (HF) are often hampered by low exercise adherence. Mobile health (mHealth) technology provides opportunities to overcome barriers to exercise adherence in this population.

OBJECTIVE

This systematic review builds on prior research to (1) describe study characteristics of mHealth interventions for exercise adherence in HF including details of sample demographics, sample sizes, exercise programs, and theoretical frameworks; (2) summarize types of mHealth technology used to improve exercise adherence in patients with HF; (3) highlight how the term "adherence" was defined and how it was measured across mHealth studies and adherence achieved; and (4) highlight the effect of age, sex, race, New York Heart Association (NYHA) functional classification, and HF etiology (systolic vs diastolic) on exercise adherence.

METHODS

We searched for papers in PubMed, MEDLINE, and CINAHL databases and included studies published between January 1, 2015, and June 30, 2022. The risk of bias was analyzed.

RESULTS

In total, 8 studies (4 randomized controlled trials and 4 quasi-experimental trials) met our inclusion and exclusion criteria. A moderate to high risk of bias was noted in the studies. All studies included patients with HF in NYHA classification I-III, with sample sizes ranging from 12 to 81 and study durations lasting 4 to 26 weeks. Six studies had an equal distribution of male and female participants whose ages ranged between 53 and 73 years. Videoconferencing was used in 4 studies, while 4 studies used smartphone apps. Three studies using videoconferencing included an intervention that engaged participants in a group setting. A total of 1 study used a yoga program, 1 study used a walking program, 1 study combined jogging with walking, 1 study used a cycle ergometer, 2 studies combined walking with cycle ergometry, and 1 study used a stepper. Two studies incorporated resistance exercises in their program. Exercise programs varied, ranging between 3 and 5 days of exercise per week, with exercise sessions ranging from 30 to 60 minutes. The Borg rating of perceived exertion scale was mostly used to regulate exercise intensity, with 3 studies using heart rate monitoring using a Fitbit. Only 1 study implicitly mentions developing their intervention using a theoretical framework. Adherence was reported to the investigator-developed exercise programs. All studies were mostly feasibility or pilot studies, and the effect of age, sex, race, and NYHA classification on exercise adherence with the use of mHealth was not reported.

CONCLUSIONS

The results show some preliminary evidence of the feasibility of using mHealth technology for building exercise adherence in patients with HF; however, theoretically sound and fully powered studies, including studies on minoritized communities, are lacking. In addition, the sustainability of adherence beyond the intervention period is unknown.

Leveraging AI to improve disease screening among American Indians: insights from the Strong Heart Study

Screening tests for disease have their performance measured through sensitivity and specificity, which inform how well the test can discriminate between those with and without the condition. Typically, high values for sensitivity and specificity are desired. These two measures of performance are unaffected by the outcome prevalence of the disease in the population. Research projects into the health of the American Indian frequently develop Machine learning algorithms as predictors of conditions in this population. In essence, these models serve as in silico screening tests for disease. A screening test's sensitivity and specificity values, typically determined during the development of the test, inform on the performance at the population level and are not affected by the prevalence of disease. A screening test's positive predictive value (PPV) is susceptible to the prevalence of the outcome. As the number of artificial intelligence and machine learning models flourish to predict disease outcomes, it is crucial to understand if the PPV values for these in silico methods suffer as traditional screening tests in a low prevalence outcome environment. The Strong Heart Study (SHS) is an epidemiological study of the American Indian and has been utilized in predictive models for health outcomes. We used data from the SHS focusing on the samples taken during Phases V and VI. Logistic Regression, Artificial Neural Network, and Random Forest were utilized as in silico screening tests within the SHS group. Their sensitivity, specificity, and PPV performance were assessed with health outcomes of varying prevalence within the SHS subjects. Although sensitivity and specificity remained high in these in silico screening tests, the PPVs' values declined as the outcome's prevalence became rare. Machine learning models used as in silico screening tests are subject to the same drawbacks as traditional screening tests when the outcome to be predicted is of low prevalence.

Correlation between the white blood cell/platelet ratio and 28-day all-cause mortality in cardiac arrest patients: a retrospective cohort study based on machine learning

Objective

This study aims to evaluate the association between the white blood cell-to-platelet ratio (WPR) and 28-day all-cause mortality among patients experiencing cardiac arrest.

Methods

Utilizing data from 748 cardiac arrest patients in the Medical Information Mart for Intensive Care-IV (MIMIC-IV) 2.2 database, machine learning algorithms, including the Boruta feature selection method, random forest modeling, and SHAP value analysis, were applied to identify significant prognostic biomarkers. Key patient characteristics, encompassing demographic data, comorbidities, hematological and biochemical indices, and vital signs, were extracted using PostgreSQL Administration Tool (pgAdmin) software. The Cox proportional hazards model assessed the impact of WPR on mortality outcomes, while Kaplan-Meier survival curves and restricted cubic spline (RCS) analysis further validated the findings. Subgroup analyses stratified the prognostic value of WPR by demographic and clinical factors.

Results

WPR demonstrated the highest prognostic significance among the variables studied, showing a strong association with 28-day all-cause mortality. In the unadjusted Model 1, hazard ratios (HRs) for WPR quartiles ranged from 1.88 (95% CI: 1.22-2.90) in Q2 to 3.02 (95% CI: 2.04-4.47) in Q4 (Ptrend <0.05). Adjusted models (Models 2-4) confirmed the robustness of these associations, even after accounting for demographic and clinical covariates. Kaplan-Meier and RCS analyses revealed a significant U-shaped relationship between WPR and mortality risk. Subgroup analyses indicated that elevated WPR was particularly associated with increased mortality in males, elderly patients, married individuals, and those with chronic pulmonary disease.

Conclusion

WPR serves as an independent and reliable prognostic biomarker for 28-day mortality in cardiac arrest patients. Its integration into clinical decision-making may enhance the early identification of high-risk patients and guide tailored therapeutic interventions.

Role of miR-181 Family Members in Stroke: Insights into Mechanisms and Therapeutic Potential

Stroke is a major cause of mortality and long-term disability worldwide, making early diagnosis and effective treatment crucial for reducing its impact. In response to the limited efficacy of current treatments, alternative therapeutic strategies, such as novel biomarkers and therapies, are emerging to address this critical unmet medical need. MicroRNAs (miRNAs) are small, non-coding RNAs that regulate gene expression at the post-transcriptional level. Due to their dysregulation, they have been implicated in the onset and progression of various diseases. Recent research highlighted the important role of miR-181 family members in the context of stroke. Polymorphisms such as rs322931 in miR-181b are associated with increased stroke risk. miR-181 family members are aberrantly expressed and related to various aspects of stroke pathology, affecting inflammatory responses or neuronal survival. We provide a comprehensive overview of how alterations in miR-181 expression influence stroke mechanisms and their potential as therapeutic targets.

Variation of retinal and choroidal microvascularization after an exercise stress test in patients with effort angina

PURPOSE

To describe retinal and choroidal vascular changes following an exercise stress test (ET) in patients with effort angina and to determine whether optical coherence tomography angiography (OCT-A) could play a role in the prediction of ischemic cardiac events.

METHODS

Prospective comparative study including patients with effort angina. All patients underwent OCT-A before and after an ET was performed. Blood flow, intercapillary spaces, and vessel density were analyzed in the superficial capillary plexus (SCP) and the deep capillary plexus (DCP). Vessel density in the choriocapillaris and the parameters of the central avascular zone (CAZ) were also analyzed.

RESULTS

Of the 38 eyes included in the study, a decrease in blood flow was found in 39.5% in the large SCP vessels, in 50% in the capillaris of the SCP, and in 81.6% in the DCP. An increase in intercapillary spaces was observed in the SCP in 68.4% of eyes and in the DCP in 55.3% of eyes. A statistically significant decrease in the DCP density was observed after an ET (p = 0.03). There were no significant modifications in the CAZ parameters, the SCP density, nor the choriocapillaris density. Patients with a positive ET had a decreased DCP density in 83.3%. Among patients with an increased DCP density, 92.85% had a negatif ET.

CONCLUSION

This pilot study suggests that DCP density significantly decreases after an ET. The DCP appears to be most affected in patients with effort angina. A larger trial is needed to further investigate these hypotheses.

Artificial intelligence-driven intelligent learning models for identification and prediction of cardioneurological disorders: A comprehensive study

The integration of Artificial Intelligence (AI) and Intelligent Learning Models (ILMs) in healthcare has transformed the field, offering precise diagnostics, remote monitoring, personalized treatment, and more. Cardioneurological disorders (CD), affecting the cardiovascular and neurological systems, present significant diagnostic and management challenges. Traditional testing methods often lack sensitivity and specificity, leading to delayed or inaccurate diagnoses. AI-driven ILMs trained on large datasets offer promise for accurate identification and prediction of CD by analyzing complex data patterns. However, there is a lack of comprehensive studies reviewing AI applications for the diagnosis of CD and inter related disorders. This paper comprehensively reviews existing integrated solutions involving AI and ILMs in CD, examining their clinical manifestations, epidemiology, diagnostic challenges, and therapeutic considerations. The study examines recent research on CD, reviews AI-driven models' landscape, evaluates existing models, addresses practical considerations, and outlines future research directions. Through this work, we aim to provide insights into the transformative potential of AI-driven ILMs in improving clinical practice and patient outcomes for CD.

Increasing adherence and collecting symptom-specific biometric signals in remote monitoring of heart failure patients: a randomized controlled trial

OBJECTIVES

Mobile health (mHealth) regimens can improve health through the continuous monitoring of biometric parameters paired with appropriate interventions. However, adherence to monitoring tends to decay over time. Our randomized controlled trial sought to determine: (1) if a mobile app with gamification and financial incentives significantly increases adherence to mHealth monitoring in a population of heart failure patients; and (2) if activity data correlate with disease-specific symptoms.

MATERIALS AND METHODS

We recruited individuals with heart failure into a prospective 180-day monitoring study with 3 arms. All 3 arms included monitoring with a connected weight scale and an activity tracker. The second arm included an additional mobile app with gamification, and the third arm included the mobile app and a financial incentive awarded based on adherence to mobile monitoring.

RESULTS

We recruited 111 heart failure patients into the study. We found that the arm including the financial incentive led to significantly higher adherence to activity tracker (95% vs 72.2%, P = .01) and weight (87.5% vs 69.4%, P = .002) monitoring compared to the arm that included the monitoring devices alone. Furthermore, we found a significant correlation between daily steps and daily symptom severity.

DISCUSSION AND CONCLUSION

Our findings indicate that mobile apps with added engagement features can be useful tools for improving adherence over time and may thus increase the impact of mHealth-driven interventions. Additionally, activity tracker data can provide passive monitoring of disease burden that may be used to predict future events.

Automated Identification of Heart Failure With Reduced Ejection Fraction Using Deep Learning-Based Natural Language Processing

BACKGROUND

The lack of automated tools for measuring care quality limits the implementation of a national program to assess guideline-directed care in heart failure with reduced ejection fraction (HFrEF).

OBJECTIVES

The authors aimed to automate the identification of patients with HFrEF at hospital discharge, an opportunity to evaluate and improve the quality of care.

METHODS

The authors developed a novel deep-learning language model for identifying patients with HFrEF from discharge summaries of hospitalizations with heart failure at Yale New Haven Hospital during 2015 to 2019. HFrEF was defined by left ventricular ejection fraction <40% on antecedent echocardiography. The authors externally validated the model at Northwestern Medicine, community hospitals of Yale, and the MIMIC-III (Medical Information Mart for Intensive Care III) database.

RESULTS

A total of 13,251 notes from 5,392 unique individuals (age 73 ± 14 years, 48% women), including 2,487 patients with HFrEF (46.1%), were used for model development (train/held-out: 70%/30%). The model achieved an area under receiver-operating characteristic curve (AUROC) of 0.97 and area under precision recall curve (AUPRC) of 0.97 in detecting HFrEF on the held-out set. The model had high performance in identifying HFrEF with AUROC = 0.94 and AUPRC = 0.91 on 19,242 notes from Northwestern Medicine, AUROC = 0.95 and AUPRC = 0.96 on 139 manually abstracted notes from Yale community hospitals, and AUROC = 0.91 and AUPRC = 0.92 on 146 manually reviewed notes from MIMIC-III. Model-based predictions of HFrEF corresponded to a net reclassification improvement of 60.2% ± 1.9% compared with diagnosis codes (P < 0.001).

CONCLUSIONS

The authors developed a language model that identifies HFrEF from clinical notes with high precision and accuracy, representing a key element in automating quality assessment for individuals with HFrEF.

Head-to-Head: Recombinant Human Prourokinase Versus Intravenous Thrombolytics in Acute Ischemic Stroke Within 4.5 Hours - A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

BackgroundIntravenous thrombolytics are essential for achieving timely reperfusion in acute ischemic stroke (AIS), with alteplase historically serving as the standard of care. Emerging alternatives like recombinant human prourokinase (rhPro-UK), reteplase, and tenecteplase offer potential improvements in efficacy, safety, and convenience, necessitating a comparative analysis.MethodsElectronic databases, including PubMed, ScienceDirect, and Cochrane Central, were comprehensively searched from inception till December 2024 for relevant studies. A frequentist network meta-analysis was performed using R software version 4.2.3, and the "netmeta" package was employed. Alteplase 0.9 mg served as the reference group, with P-scores employed to determine the relative rankings of various interventions. The risk of publication bias was evaluated through funnel plots and Egger's regression test.ResultsEighteen trials with 12,950 participants were included in the final analysis. Compared to alteplase 0.9 mg, excellent functional outcome (mRS 0-1) was significantly improved by Reteplase 18 + 18 mg (RR = 1.13, p < 0.01) and Tenecteplase (TNK) 0.25 mg (RR = 1.05, p < 0.01). For a good functional outcome (mRS 0-2), Reteplase 18 + 18 mg (RR = 1.06, p < 0.01) and TNK 0.32 mg (RR = 1.30, p < 0.01) were significantly more effective than alteplase. Safety outcomes, symptomatic intracranial hemorrhage (sICH), and mortality were not significantly different between alteplase and other thrombolytics. According to P-scores, Reteplase 18 + 18 mg ranked the best for excellent functional outcome (P-score = 0.89) and TNK 0.32 mg for good functional outcome (P-score = 0.99), while rhPro-UK 35 mg ranked the best for sICH (P-score = 0.89).ConclusionReteplase 18 + 18 mg and TNK 0.32 mg demonstrated superior functional outcomes compared to alteplase, while rhPro-UK 35 mg showed the best safety profile with the lowest sICH risk.

Decoding the evidence: A synopsis of indications and evidence for catheter ablation in atrial fibrillation (Review)

The present study reviews the role of catheter ablation (CA) in the management of atrial fibrillation (AF), a widespread arrhythmia associated with increased morbidity and mortality. The present review explores current indications and recent evidence supporting CA, assessing patient outcomes and identifying common complications associated with the procedure. Emphasis is placed on optimizing risk factors prior to ablation, including weight control and hypertension management, as these measures can significantly enhance post-procedural outcomes. The present review also discusses the use of antiarrhythmic and anticoagulant therapies following CA to minimize recurrence and reduce stroke risk. Additionally, the cost-effectiveness of CA is discussed, comparing its long-term economic impact with that of medical therapy alone. The present comprehensive review provides insight into best practices for AF management, supporting CA as a promising approach when integrated with targeted lifestyle modifications and pharmacological support for improved, patient-centered outcomes.