Prevalence of ECG abnormalities in an international survey of patients with suspected or confirmed heart failure at death or discharge

Prognosis of patients with nonspecific electrocardiogram findings in a Tanzanian emergency department

BACKGROUND

Nonspecific electrocardiogram (ECG) findings are associated with increased morbidity and mortality in high-income settings. ECGs are increasingly available in emergency departments (EDs) in low- and middle-income countries (LMICs), however the prognostic value of nonspecific ECG findings in resource-limited settings, particularly in sub-Saharan Africa, remains unclear.

OBJECTIVE

To assess the association between nonspecific ECG findings and 30-day mortality among patients presenting with chest pain and shortness of breath to a Tanzanian ED.

METHODS

Patient demographics and initial ECGs were collected from patients presenting with chest pain or shortness of breath to an ED in Moshi, Tanzania from January 2019 through January 2023. Two independent adjudicators interpreted ECGs using standardized criteria. Unadjusted and adjusted (adjusting for age and gender) odds ratios were calculated, and Pearson's chi-squared test was used to assess the association of each ECG finding with 30-day mortality.

RESULTS

Among 1,111 participants, 231 (20.8%) died within 30 days of ED presentation. T-wave inversions (aOR 1.60, 95% CI 1.19-2.15, P = .002), resting tachycardia (aOR 1.57, 95% CI 1.16-2.13, P = .003), non-sinus rhythms (aOR 1.93, 95% CI 1.26-2.96, P = .003), and ST depressions (aOR 1.73, 95% CI 1.17-2.56, P = .006) were significantly associated with increased mortality. There was no significant association between 30-day mortality and left ventricular hypertrophy, bundle branch blocks, or Q waves. Patients with any abnormal ECG finding had higher mortality compared to those with normal ECGs (OR 1.53, 95% CI, 1.08-2.21, P = .019).

CONCLUSION

Certain nonspecific ECG findings are associated with increased risk of 30-day mortality. Locally tailored risk stratification tools and increased attention to nonspecific ECG changes may enhance ED care in LMICs.

Epidemiology of heart failure in diabetes: a disease in disguise

Left ventricular diastolic dysfunction (LVDD) without symptoms, and heart failure (HF) with preserved ejection fraction (HFpEF) represent the most common phenotypes of HF in individuals with type 2 diabetes mellitus, and are more common than HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF) and left ventricular systolic dysfunction (LVSD) in these individuals. However, diagnostic criteria for HF have changed over the years, resulting in heterogeneity in the prevalence/incidence rates reported in different studies. We aimed to give an overview of the diagnosis and epidemiology of HF in type 2 diabetes, using both a narrative and systematic review approach; we focus narratively on diagnosing (using the 2021 European Society of Cardiology [ESC] guidelines) and screening for HF in type 2 diabetes. We performed an updated (2016-October 2022) systematic review and meta-analysis of studies reporting the prevalence and incidence of HF subtypes in adults ≥18 years with type 2 diabetes, using echocardiographic data. Embase and MEDLINE databases were searched and data were assessed using random-effects meta-analyses, with findings presented as forest plots. From the 5015 studies found, 209 were screened using the full-text article. In total, 57 studies were included, together with 29 studies that were identified in a prior meta-analysis; these studies reported on the prevalence of LVSD (n=25 studies, 24,460 individuals), LVDD (n=65 studies, 25,729 individuals), HFrEF (n=4 studies, 4090 individuals), HFmrEF (n=2 studies, 2442 individuals) and/or HFpEF (n=8 studies, 5292 individuals), and on HF incidence (n=7 studies, 17,935 individuals). Using Hoy et al's risk-of-bias tool, we found that the studies included generally had a high risk of bias. They showed a prevalence of 43% (95% CI 37%, 50%) for LVDD, 17% (95% CI 7%, 35%) for HFpEF, 6% (95% CI 3%, 10%) for LVSD, 7% (95% CI 3%, 15%) for HFrEF, and 12% (95% CI 7%, 22%) for HFmrEF. For LVDD, grade I was found to be most prevalent. Additionally, we reported a higher incidence rate of HFpEF (7% [95% CI 4%, 11%]) than HFrEF 4% [95% CI 3%, 7%]). The evidence is limited by the heterogeneity of the diagnostic criteria over the years. The systematic section of this review provides new insights on the prevalence/incidence of HF in type 2 diabetes, unveiling a large pre-clinical target group with LVDD/HFpEF in which disease progression could be halted by early recognition and treatment.Registration PROSPERO ID CRD42022368035.

Electrocardiography changes and different stages of heart failure in central Iran: A cross-sectional study from Yazd Health Study

Background and Aims

Electrocardiography (ECG) is a widely accessible, noninvasive, and cost-effective diagnostic instrument used to evaluate patients with suspected heart failure (HF). The aim of this study is to investigate electrocardiographic changes in patients with different stages of HF in a random population of Yazd city.

Methods

This prospective cross-sectional study included 319 individuals, randomly selected, aged 40 years and more, registered in the Yazd Health Study was conducted from March 2022 to May 2023 at Afshar Hospitals. In accordance with the AHA/ACC guidelines, HF was classified into four stages (A, B, C, and D).

Results

The 159 individuals were classified in the stage 0 group, 77 were in Stage A, 65 were in Stage B, and 18 were in Stage C of HF. In the Stage 0, the PR interval (PRi) was 130.5 ± 18.1 ms, while in Stage C, it was 143.3 ± 21.9 ms, with a significant difference (p = 0.047). Similarly, the QRS interval (QRSi) increased with HF staging (p = 0.001). The frequency of diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLP), chronic heart disease, alcoholism, and PRi, QRSi, QT interval levels were independent predictors of HF stage in multivariate regression analysis.

Conclusion

The prevalence of HF stages, as classified by the AHA/ACC guidelines, was observed, with significant correlations between ECG parameters and HF progression. abnormal rhythms, left bundle branch block, ischemia, hypertrophy, and left atrial enlargement increased with higher HF stages. Major risk factors like DM and HTN exhibited a heightened prevalence in advanced HF stages, accentuating their pivotal role in the progression of HF.

Atrial Fibrillation Detection With an Analog Smartwatch: Prospective Clinical Study and Algorithm Validation

BACKGROUND

Atrial fibrillation affects approximately 4% of the world's population and is one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity. It can be difficult to diagnose when asymptomatic or in the paroxysmal stage, and its natural history is not well understood. New wearables and connected devices offer an opportunity to improve on this situation.

OBJECTIVE

We aimed to validate an algorithm for the automatic detection of atrial fibrillation from a single-lead electrocardiogram taken with a smartwatch.

METHODS

Eligible patients were recruited from 4 sites in Paris, France. Electrocardiograms (12-lead reference and single lead) were captured simultaneously. The electrocardiograms were reviewed by independent, blinded board-certified cardiologists. The sensitivity and specificity of the algorithm to detect atrial fibrillation and normal sinus rhythm were calculated. The quality of single-lead electrocardiograms (visibility and polarity of waves, interval durations, heart rate) was assessed in comparison with the gold standard (12-lead electrocardiogram).

RESULTS

A total of 262 patients (atrial fibrillation: n=100, age: mean 74.3 years, SD 12.3; normal sinus rhythm: n=113, age: 61.8 years, SD 14.3; other arrhythmia: n=45, 66.9 years, SD 15.2; unreadable electrocardiograms: n=4) were included in the final analysis; 6.9% (18/262) were classified as Noise by the algorithm. Excluding other arrhythmias and Noise, the sensitivity for atrial fibrillation detection was 0.963 (95% CI lower bound 0.894), and the specificity was 1.000 (95% CI lower bound 0.967). Visibility and polarity accuracies were similar (1-lead electrocardiogram: P waves: 96.9%, QRS complexes: 99.2%, T waves: 91.2%; 12-lead electrocardiogram: P waves: 100%, QRS complexes: 98.8%, T waves: 99.5%). P-wave visibility accuracy was 99% (99/100) for patients with atrial fibrillation and 95.7% (155/162) for patients with normal sinus rhythm, other arrhythmias, and unreadable electrocardiograms. The absolute values of the mean differences in PR duration and QRS width were <3 ms, and more than 97% were <40 ms. The mean difference between the heart rates from the 1-lead electrocardiogram calculated by the algorithm and those calculated by cardiologists was 0.55 bpm.

CONCLUSIONS

The algorithm demonstrated great diagnostic performance for atrial fibrillation detection. The smartwatch's single-lead electrocardiogram also demonstrated good quality for physician use in daily routine care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04351386; http://clinicaltrials.gov/ct2/show/NCT04351386.

Methodology for the nocturnal cardiac arrhythmia ancillary study of the ADVENT-HF trial in patients with heart failure with reduced ejection fraction and sleep-disordered breathing

Background

Sleep disordered breathing (SDB) may trigger nocturnal cardiac arrhythmias (NCA) in patients with heart failure with reduced ejection fraction (HFrEF). The NCA ancillary study of the ADVENT-HF trial will test whether, in HFrEF-patients with SDB, peak-flow-triggered adaptive servo-ventilation (ASVpf) reduces NCA. To this end, accurate scoring of NCA from polysomnography (PSG) is required.

Objective

To develop a method to detect NCA accurately from a single-lead electrocardiogram (ECG) recorded during PSG and assess inter-observer agreement for NCA detection.

Methods

Quality assurance of ECG analysis included training of the investigators, development of standardized technical quality, guideline-conforming semi-automated NCA-scoring via Holter-ECG software and implementation of an arrhythmia adjudication committee. To assess inter-observer agreement, the ECG was analysed by two independent investigators and compared for agreement on premature ventricular complexes (PVC) /h, premature atrial complexes/h (PAC) as well as for other NCA in 62 patients from two centers of the ADVENT-HF trial.

Results

The intraclass correlation coefficients for PVC/h and PAC/h were excellent: 0.99 (95%- confidence interval [CI]: 0.99-0.99) and 0.99 (95%-CI: 0.97-0.99), respectively. No clinically relevant difference in inter-observer classification of other NCA was found. The detection of non-sustained ventricular tachycardia (18% versus 19%) and atrial fibrillation (10% versus 11%) was similar between the two investigators. No sustained ventricular tachycardia was detected.

Conclusion

These findings indicate that our methods are very reliable for scoring NCAs and are adequate to apply for the entire PSG data set of the ADVENT-HF trial.

Management and outcomes of acute myocardial infarction in patients with pre-existing heart failure: an analysis of 2 million patients from the national inpatient sample

BACKGROUND

Inpatient management and outcomes of patients presenting with acute myocardial infarction (AMI) with a history of heart failure (HF) have not been well characterized.

METHODS

: Hospitalizations for AMI from the Nationwide Inpatient Sample (2015-2018) were categorized according to a pre-existing diagnosis of HF with preserved ejection fraction (HFpEF), reduced ejection fraction (HFrEF), or absence of HF. Utilization of invasive management and in-hospital outcomes were analyzed.

RESULTS

: Among 2,434,639 hospitalizations with an AMI, 19.8% had a history of HFrEF and 11.9% had a history of HFpEF. Coronary angiography and PCI respectively were performed significantly less among patients with HF (36.6% and 17.4% in HFpEF, 51.1% and 24.6% in HFrEF, and 64.4% and 42.3% among patients without HF, all p<0.0001). Mortality was more common among patients with HFrEF (10.3%) and HFpEF (8.3%) when compared to patients without a history of HF (6.4%), p<0.0001. In multivariable analyses compared to patients without HF, mortality was higher among patients with HFrEF (aOR 1.27, CI 1.26-1.29, p<0.0001) but not different among patients with HFpEF.

CONCLUSION

HF is a common pre-existing comorbidity among patients presenting with AMI and is associated with lower utilization of invasive procedures and higher complications including mortality, particularly among those with HFrEF.

Electrocardiography Score for Left Ventricular Systolic Dysfunction in Non-ST Segment Elevation Acute Coronary Syndrome

Background: Few studies have characterized electrocardiography (ECG) patterns correlated with left ventricular (LV) systolic dysfunction in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS).

Objectives: This study aims to develop ECG pattern-derived scores to predict LV systolic dysfunction in NSTE-ACS patients.

Methods: A total of 466 patients with NSTE-ACS were retrospectively enrolled. LV ejection fraction (LVEF) was assessed by echocardiography within 72 h after the first triage ECG acquisition; there was no coronary intervention in between. ECG score was developed to predict LVEF < 40%. Performance of LVEF, the Global Registry of Acute Coronary Events (GRACE), Thrombolysis in Myocardial Infarction (TIMI) and ECG scores to predict 24-month all-cause mortality were analyzed. Subgroups with varying LVEF, GRACE and TIMI scores were stratified by ECG score to identify patients at high risk of mortality.

Results: LVEF < 40% was present in 20% of patients. We developed the PQRST score by multivariate logistic regression, including poor R wave progression, QRS duration > 110 ms, heart rate > 100 beats per min, and ST-segment depression ≥ 1 mm in ≥ 2 contiguous leads, ranging from 0 to 6.5. The score had an area under the curve (AUC) of 0.824 in the derivation cohort and 0.899 in the validation cohort for discriminating LVEF < 40%. A PQRST score ≥ 3 could stratify high-risk patients with LVEF ≥ 40%, GRACE score > 140, or TIMI score ≥ 3 regarding 24-month all-cause mortality.

Conclusions: The PQRST score could predict LVEF < 40% in NSTE-ACS patients and identify patients at high risk of mortality in the subgroups of patients with LVEF ≥ 40%, GRACE score > 140 or TIMI score ≥ 3.

Powering Implantable and Ingestible Electronics

Implantable and ingestible biomedical electronic devices can be useful tools for detecting physiological and pathophysiological signals, and providing treatments that cannot be done externally. However, one major challenge in the development of these devices is the limited lifetime of their power sources. The state-of-the-art of powering technologies for implantable and ingestible electronics is reviewed here. The structure and power requirements of implantable and ingestible biomedical electronics are described to guide the development of powering technologies. These powering technologies include novel batteries that can be used as both power sources and for energy storage, devices that can harvest energy from the human body, and devices that can receive and operate with energy transferred from exogenous sources. Furthermore, potential sources of mechanical, chemical, and electromagnetic energy present around common target locations of implantable and ingestible electronics are thoroughly analyzed; energy harvesting and transfer methods befitting each energy source are also discussed. Developing power sources that are safe, compact, and have high volumetric energy densities is essential for realizing long-term in-body biomedical electronics and for enabling a new era of personalized healthcare.

Artificial Intelligence Algorithm for Screening Heart Failure with Reduced Ejection Fraction Using Electrocardiography

Although heart failure with reduced ejection fraction (HFrEF) is a common clinical syndrome and can be modified by the administration of appropriate medical therapy, there is no adequate tool available to perform reliable, economical, early-stage screening. To meet this need, we developed an interpretable artificial intelligence (AI) algorithm for HFrEF screening using electrocardiography (ECG) and validated its performance. This retrospective cohort study included two hospitals. An AI algorithm based on a convolutional neural network was developed using 39,371 ECG results from 17,127 patients. The internal validation included 3,470 ECGs from 2,908 patients. Furthermore, we conducted external validation using 4,362 ECGs from 4,176 patients from another hospital to verify the applicability of the algorithm across different centers. The end-point was to detect HFrEF, defined as an ejection fraction <40%. We also visualized the regions in 12 lead ECG that affected HFrEF detection in the AI algorithm and compared this to the previously documented literature. During the internal and external validation, the areas under the curves of the AI algorithm using a 12 lead ECG for detecting HFrEF were 0.913 (95% confidence interval, 0.902-0.925) and 0.961 (0.951-0.971), respectively, and the areas under the curves of the AI algorithm using a single-lead ECG were 0.874 (0.859-0.890) and 0.929 (0.911-0.946), respectively. The deep learning-based AI algorithm performed HFrEF detection well using not only a 12 lead but also a single-lead ECG. These results suggest that HFrEF can be screened not only using a 12 lead ECG, as is typical of a conventional ECG machine, but also with a single-lead ECG performed by a wearable device employing the AI algorithm, thereby preventing irreversible disease progression and mortality.

Advances in cardiac resynchronization and implantable cardioverter/defibrillator therapy: Medtronic Cobalt and Crome

Cardiovascular implantable electronic devices have revolutionized the management of heart failure with reduced ejection fraction. New device generations tend to be launched every few years, with incremental improvements in performance and safety and with an expectation that these will improve patient management and outcomes while remaining cost-effective. As a result, today's cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillator devices are quite different from the pioneering but often bulky devices of the late 20th century. This review discusses new and improved features developed to target specific needs in managing heart failure patients, some of which are especially pertinent to the current worldwide healthcare situation, with focus on the latest generation of CRTs with defibrillator (CRT-Ds) and implantable cardioverter defibrillators from Medtronic.

Electrocardiogram lead selection for intelligent screening of patients with systolic heart failure

Electrocardiogram (ECG)-based intelligent screening for systolic heart failure (HF) is an emerging method that could become a low-cost and rapid screening tool for early diagnosis of the disease before the comprehensive echocardiographic procedure. We collected 12-lead ECG signals from 900 systolic HF patients (ejection fraction, EF < 50%) and 900 individuals with normal EF in the absence of HF symptoms. The 12-lead ECG signals were converted by continuous wavelet transform (CWT) to 2D spectra and classified using a 2D convolutional neural network (CNN). The 2D CWT spectra of 12-lead ECG signals were trained separately in 12 identical 2D-CNN models. The 12-lead classification results of the 2D-CNN model revealed that Lead V6 had the highest accuracy (0.93), sensitivity (0.97), specificity (0.89), and f1 scores (0.94) in the testing dataset. We designed four comprehensive scoring methods to integrate the 12-lead classification results into a key diagnostic index. The highest quality result among these four methods was obtained when Leads V5 and V6 of the 12-lead ECG signals were combined. Our new 12-lead ECG signal–based intelligent screening method using straightforward combination of ECG leads provides a fast and accurate approach for pre-screening for systolic HF.

Diagnostic and prognostic values of the QRS-T angle in patients with suspected acute decompensated heart failure

AIMS

The aim of this study was to investigate the diagnostic and prognostic utility of the QRS-T angle, an electrocardiogram (ECG) marker quantifying depolarization-repolarization heterogeneity, in patients with suspected acute decompensated heart failure (ADHF).

METHODS AND RESULTS

We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of ADHF. The QRS-T angle was automatically derived from a standard 12-lead ECG recorded at presentation. The primary diagnostic endpoint was a final adjudicated diagnosis of ADHF. The primary prognostic endpoint was all-cause mortality during 2 years of follow-up. Among the 1915 patients enrolled, those with higher QRS-T angles were older, were more commonly male, and had a higher rate of co-morbidities such as arterial hypertension, coronary artery disease, or chronic kidney disease. ADHF was the final adjudicated diagnosis in 1140 (60%) patients. The QRS-T angle in patients with ADHF was significantly larger than in patients with non-cardiac causes of dyspnoea {median 110° [inter-quartile range (IQR) 46-156°] vs. median 33° [IQR 15-57°], P < 0.001}. The diagnostic accuracy of the QRS-T angle as quantified by the area under the receiver operating characteristic curve (AUC) was 0.75 [95% confidence interval (CI) 0.73-0.77, P < 0.001], which was inferior to N-terminal pro-B-type natriuretic peptide (AUC 0.93, 95% CI 0.92-0.94, P < 0.001), but similar to that of high-sensitivity troponin T (AUC 0.78, 95% CI 0.76-0.80, P = 0.09). The AUC of the QRS-T angle for discrimination between ADHF and non-cardiac dyspnoea remained similarly high in subgroups of patients known to be diagnostically challenging, including patients older than 75 years [0.71 (95% CI 0.67-0.74)], renal failure [0.79 (95% CI 0.71-0.87)], and atrial fibrillation at presentation [0.68 (95% CI 0.60-0.76)]. Mortality rates according to QRS-T angle tertiles were 4%, 6%, and 10% after 30 days (P < 0.001) and 24%, 31%, and 43% after 2 years (P < 0.001). After adjustment for clinical, laboratory, and ECG parameters, the QRS-T angle remained an independent predictor for 2 year mortality with a 4% increase in mortality for every 20° increase in QRS-T angle (P = 0.02).

CONCLUSIONS

The QRS-T angle is a readily available and inexpensive marker that can assist in the discrimination between ADHF and non-cardiac causes of acute dyspnoea and may aid in the risk stratification of these patients.

Nonpharmacological Treatment of Atrial Fibrillation: What Is the Role of Device Therapy?

Atrial fibrillation is the most common arrhythmia in the adult population, and its incidence and prevalence are still rising. Cardiac devices are widely used in clinical practice in the management of various rhythm disturbances and heart failure treatment. Many patients who receive a pacemaker, implantable cardioverter-defibrillator, or cardiac resynchronization therapy also experience atrial fibrillation in the course of their life. Therefore, this review aims to describe the role of these devices in the treatment and prevention of atrial fibrillation in the device recipients. In addition, all these implantable devices also serve as permanent ECG (electrocardiogram) monitors, thus providing important information about the presence and characteristics of atrial fibrillation that may or may not be detected by the patient but can modify our therapeutical approach with regard to the stroke prevention.

The role of implantable cardioverter-defibrillators and sudden cardiac death prevention: indications, device selection, and outcome

Multiple randomized multicentre clinical trials have established the role of the implantable cardioverter-defibrillator (ICD) as the mainstay in the treatment of ventricular tachyarrhythmias and sudden cardiac death (SCD) prevention. These trials have focused mainly on heart failure patients with advanced left ventricular dysfunction and were mostly conducted two decades ago, whereas a more recent trial has provided conflicting results. Therefore, much remains to be determined on how best to balance the identification of patients at high risk of SCD together with who would benefit most from ICD implantation in a contemporary setting. Implantable cardioverter-defibrillators have also evolved from the simple, defibrillation-only devices implanted surgically to more advanced technologies of multi-chamber devices, with physiologic bradycardic pacing, including cardiac resynchronization therapy, atrial and ventricular therapeutic pacing algorithms, and subcutaneous ICDs. These multiple options necessitate individualized approach to device selection and programming. This review will focus on the current knowledge on selection of patients for ICD treatment, device selection and programming, and future directions of implantable device therapy for SCD prevention.

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Electrocardiographic characteristics in patients with heart failure and normal ejection fraction: A systematic review and meta-analysis

BACKGROUND

Little is known about ECG abnormalities in patients with heart failure and normal ejection fraction (HeFNEF) and how they relate to different etiologies or outcomes.

METHODS AND RESULTS

We searched the literature for peer-reviewed studies describing ECG abnormalities in HeFNEF other than heart rhythm alone. Thirty five studies were identified and 32,006 participants. ECG abnormalities reported in patients with HeFNEF include atrial fibrillation (prevalence 12%-46%), long PR interval (11%-20%), left ventricular hypertrophy (LVH, 10%-30%), pathological Q waves (11%-18%), RBBB (6%-16%), LBBB (0%-8%), and long JTc (3%-4%). Atrial fibrillation is more common in patients with HeFNEF compared to those with heart failure and reduced ejection fraction (HeFREF). In contrast, long PR interval, LVH, Q waves, LBBB, and long JTc are more common in patients with HeFREF. A pooled effect estimate analysis showed that QRS duration ≥120 ms, although uncommon (13%-19%), is associated with worse outcomes in patients with HeFNEF.

CONCLUSIONS

There is high variability in the prevalence of ECG abnormalities in patients with HeFNEF. Atrial fibrillation is more common in patients with HeFNEF compared to those with HeFREF. QRS duration ≥120 ms is associated with worse outcomes in patients with HeFNEF. Further studies are needed to address whether ECG abnormalities correlate with different phenotypes in HeFNEF.

Gender-Based Differences in Cardiac Resynchronization Therapy Response

Cardiac resynchronization therapy (CRT) has been shown to have a multitude of beneficial effects in select patients with systolic heart failure, by enhancing reverse remodeling, improving quality of life and functional status, reducing risk of heart failure admission, and most importantly, improving survival. Although women were underrepresented in the clinical trials, they were demonstrated to derive greater therapeutic benefit from CRT compared with men. Importantly, women were noted to derive benefit at a lesser degree of QRS prolongation than men, well below the now generally accepted cutoff of QRS ≥150 milliseconds.

Cardiac resynchronization therapy: a comprehensive review

Despite improved understanding of heart failure (HF) and advances in medical treatments, its prevalence continues to rise, and the role of implantable devices continues to evolve. While cardiac resynchronization therapy (CRT) is an accepted form of treatment for many suffering from HF, there is an ever-evolving body of evidence examining novel indications, optimization of lead placement and device programming, with several competing technologies now also on the horizon. This review aims to take a clinical perspective on the major trials, current indications, controversies and emerging aspects of CRT in the treatment of HF.

A novel ventricular restraint device (ASD) repetitively deliver Salvia miltiorrhiza to epicardium have good curative effects in heart failure management

A novel ventricular restraint is the non-transplant surgical option for the management of an end-stage dilated heart failure (HF). To expand the therapeutic techniques we design a novel ventricular restraint device (ASD) which has the ability to deliver a therapeutic drug directly to the heart. We deliver a Traditional Chinese Medicine (TCM) Salvia miltiorrhiza (Danshen Zhusheye) through active hydraulic ventricular support drug delivery system (ASD) and we hypothesize that it will show better results in HF management than the restraint device and drug alone. SD rats were selected and divided into five groups (n=6), Normal, HF, HF+SM (IV), HF+ASD, HF+ASD+SM groups respectively. Post myocardial infarction (MI), electrocardiography (ECG) showed abnormal heart function in all groups and HF+ASD+SM group showed a significant therapeutic improvement with respect to other treatment HF, HF+ASD, and HF+SM (IV) groups on day 30. The mechanical functions of the heart such as heart rate, LVEDP, and LVSP were brought to normal when treated with ASD+SM and show significant (P value<0.01) compared to other groups. BNP significantly declines in HF+ASD+SM group animals compared with other treatment groups. Masson's Trichrome staining was used to study histopathology of cardiac myocytes and quantification of fibrosis was assessed. The large blue fibrotic area was observed in HF, HF+ASD, and HF+SM (IV) groups while HF+ASD+SM showed negligible fibrotic myocyte at the end of study period (30days). This study proves that novel ASD device augments the therapeutic effect of the drug and delivers Salvia miltiorrhiza to the cardiomyocytes significantly as well as provides additional support to the dilated ventricle by the heart failure.

Wave intensity of aortic root pressure as diagnostic marker of left ventricular systolic dysfunction

Background

Systolic left ventricular function strongly influences the blood pressure waveform. Therefore, pressure-derived parameters might potentially be used as non-invasive, diagnostic markers of left ventricular impairment. The aim of this study was to investigate the performance of pressure-based parameters in combination with electrocardiography (ECG) for the detection of left ventricular systolic dysfunction defined as severely reduced ejection fraction (EF).

Methods and results

Two populations, each comprising patients with reduced EF and pressure-matched controls, were included for the main analysis (51/102 patients) and model testing (44/88 patients). Central pressure was derived from radial readings and used to compute blood flow. Subsequently, pulse wave analysis and wave intensity analysis were performed and the ratio of the two peaks of forward intensity (SDR) was calculated as a novel index of ventricular function. SDR was significantly decreased in the reduced EF group (2.5 vs. 4.4, P<0.001), as was central pulse pressure, augmentation index and ejection duration (ED), while the QRS-duration was prolonged. SDR and ED were independent predictors of ventricular impairment and when combined with QRS in a simple decision tree, a reduced EF could be detected with a sensitivity of 92% and a specificity of 80%. The independent power of ED, SDR and QRS to predict reduced EF was furthermore confirmed in the test population.

Conclusion

The detection or indication of reduced ejection fraction from pressure-derived parameters seems feasible. These parameters could help to improve the quality of cardiovascular risk stratification or might be used in screening strategies in the general population.

Predictors of response to cardiac resynchronization therapy: A prospective cohort study

INTRODUCTION

Cardiac resynchronization therapy (CRT) has modified the prognosis of chronic heart failure (HF) with left ventricular systolic dysfunction. However, 30% of patients do not have a favorable response. The big question is how to determine predictors of response.

AIMS

To identify baseline characteristics that might influence echocardiographic response to CRT.

METHODS AND RESULTS

We performed a prospective single-center hospital-based cohort study of consecutive HF patients selected to CRT (NYHA class II-IV, left ventricular ejection fraction (LVEF) <35% and QRS complex ≥120 ms). Responders were defined as those with a ≥5% absolute increase in LVEF at six months. Clinical, electrocardiographic, laboratory, echocardiographic, autonomic, endothelial and cardiopulmonary function parameters were assessed before CRT device implantation. Logistic regression models were used. Seventy-nine patients were included, 54 male (68.4%), age 68.1 years (standard deviation 10.2), 19 with ischemic etiology (24%). At six months, 51 patients (64.6%) were considered responders. Although by univariate analysis baseline tricuspid annular plane systolic excursion (TAPSE) and serum creatinine were significantly different in responders, on multivariate analysis only TAPSE was independently associated with response, with higher values predicting a positive response to CRT (OR=1.13; 95% CI: 1.02-1.26; p=0.020). TAPSE ≥15 mm was strongly associated with response, and TAPSE <15 mm with non-response (p=0.005). Responders had no TAPSE values below 10 mm.

CONCLUSION

From a range of clinical and technical baseline characteristics, multivariate analysis only identified TAPSE as an independent predictor of CRT response, with TAPSE <15 mm associated with non-response. This study highlights the importance of right ventricular dysfunction in CRT response. ClinicalTrials.gov identifier: NCT02413151.

Automated diagnosis of congestive heart failure using dual tree complex wavelet transform and statistical features extracted from 2s of ECG signals

Identification of alarming features in the electrocardiogram (ECG) signal is extremely significant for the prediction of congestive heart failure (CHF). ECG signal analysis carried out using computer-aided techniques can speed up the diagnosis process and aid in the proper management of CHF patients. Therefore, in this work, dual tree complex wavelets transform (DTCWT)-based methodology is proposed for an automated identification of ECG signals exhibiting CHF from normal. In the experiment, we have performed a DTCWT on ECG segments of 2s duration up to six levels to obtain the coefficients. From these DTCWT coefficients, statistical features are extracted and ranked using Bhattacharyya, entropy, minimum redundancy maximum relevance (mRMR), receiver-operating characteristics (ROC), Wilcoxon, t-test and reliefF methods. Ranked features are subjected to k-nearest neighbor (KNN) and decision tree (DT) classifiers for automated differentiation of CHF and normal ECG signals. We have achieved 99.86% accuracy, 99.78% sensitivity and 99.94% specificity in the identification of CHF affected ECG signals using 45 features. The proposed method is able to detect CHF patients accurately using only 2s of ECG signal length and hence providing sufficient time for the clinicians to further investigate on the severity of CHF and treatments.

Effect of Gender on Outcomes After Cardiac Resynchronization Therapy in Patients With a Narrow QRS Complex

Background—

In EchoCRT, a randomized controlled trial evaluating the effect of cardiac resynchronization therapy (CRT) in patients with a QRS duration of <130 ms and echocardiographic evidence of left ventricular dyssynchrony, the primary outcome (death from any cause or first hospitalization for worsening heart failure) occurred more frequently in the CRT-ON when compared with the control group. In this prespecified subgroup analysis, we evaluated the effect of sex on clinical outcome in EchoCRT.

Methods and Results—

In EchoCRT, 585 (72%) of included patients were men. At baseline, male patients had a higher incidence of ischemic cardiomyopathy and longer QRS duration. On uni- and multivariable analysis, no significant interaction was observed regarding sex for the primary or any of the secondary end points. Numerically, a higher all-cause mortality was observed in male patients randomized to CRT-ON versus CRT-OFF on univariable analysis (hazard ratio, 1.83; 95% confidence interval, 1.08–3.12); however, no statistically significant interaction compared with females randomized to CRT-ON versus CRT-OFF was noted (hazard ratio, 0.99; P interaction, 0.56). There was no difference in the primary safety end point of system-related complications, including CRT system- and implantation-related events.

Conclusions—

The largest hazard for all-cause mortality in EchoCRT was observed in men randomized to CRT-ON; the comparison with women did not reach statistical significance, which may be because of the premature termination of the trial and the limited data. These results suggest that male sex may be a risk factor for harm by CRT in patients with narrow QRS width, an observation which deserves further investigation.

Clinical Trial Registration—

URL: https://clinicaltrials.gov . Unique identifier: NCT00683696.

ECG low QRS voltage and wide QRS complex predictive of centenarian 360-day mortality

We examined the electrocardiographic (ECG) findings of centenarians and associated them with >360-day survival. Physical and functional assessment, resting electrocardiogram and laboratory tests were performed on 86 study participants 101.9 ± 1.2 years old (mean ± SD) (70 women, 16 men) and followed for at least 360 days. Centenarian ECGs were assessed for left ventricular hypertrophy (LVH) according to the Romhilt-Estes score, Sokolow-Lyon criteria and Cornell voltage criteria which were positive for 12.8, 6.98, and 10.5 % of participants, respectively. Fifty-two study participants (60 %) survived ≥360 days. Multivariate logistic regression analysis revealed a negative relationship between 360-day survival and the following: R II <0.45 mV adjusted for CRP (odds ratio (OR) = 0.108, 95 % confidence interval (CI) = 0.034-0.341, P < .001), R aVF < 0.35 mV adjusted for CRP (OR = 0.151, 95 % CI = 0.039-0.584, P < .006), Sokolow-Lyon voltage <1.45 mV adjusted for CRP (OR = 0.178, 95 % CI = 0.064-0.492, P = .001), QRS ≥90 ms adjusted for CRP (OR = 0.375, 95 % CI = 0.144-0.975, P = .044), and Romhilt-Estes score ≥5 points adjusted for sex and Barthel Index (OR = 0.459, 95 % CI = 0.212-0.993, P = .048) in single variable ECG models. QRS voltage correlated positively with systolic and pulse pressure, serum vitamin B12 level, sodium, calcium, phosphorous, TIMP-1, and eGFR. QRS voltage correlated negatively with BMI, WHR, serum leptin, IL-6, TNF-α, and PAI-1 levels. QRS complex duration correlated positively with CRP; QTc correlated positively with TNF-α. Results suggest that Romhilt-Estes LVH criteria scores ≥5 points, low ECG QRS voltages (Sokolow-Lyon voltage <1.45 mV), and QRS complexes ≥90 ms are predictive of centenarian 360-day mortality.

ECG as a first step in the detection of left ventricular systolic dysfunction in the elderly

Aims

Due to the demographic development there is an increasing number of senior citizens with left ventricular systolic dysfunction (LVSD), defined as ejection fraction (EF) < 40%. Unfortunately there are under‐diagnosis and under‐treatment in the elderly of this serious condition. Echocardiography is the gold standard to diagnose LVSD, but access is limited. Simple screening methods may ensure reduction of undetected cases, and this study investigates if electrocardiogram (ECG) can be used to screen for LVSD in the geriatric population.

Methods and results

A total of 260 persons aged 75 to 92 years had an echocardiography, a 12 leads ECG, and NT‐proBNP; 61 had EF < 40%, and of these 60 had an abnormal ECG. EF < 40% was significantly related to atrial fibrillation (A), pacing (P), LBBB (L), Q‐waves (Q), and QRS duration ≥ 120 ms (D). EF < 40%, atrial fibrillation, pacing, and LBBB were related to NT‐proBNP > 35 pmol/L. When APL was absent, NT‐proBNP had discriminatory value regarding LVSD in the presence of Q‐waves or QRS duration > 120 ms. Algorithms to screen for LVSD had sensitivity >90% and specificity >80% and claimed at least one of five (A/P/L/Q/D), one of 4 (A/P/L/Q), or one of three (A/Q/D) ECG changes. The optimal algorithm to reduce the need for diagnostic echocardiographies included four (A/P/L/Q) ECG changes and measurement of NT‐proBNP when Q‐waves were the only ECG change present.

Conclusions

Ninety percent of LVSD may be detected, and when there is atrial fibrillation, pacing or LBBB, or QRS ≥ 120 ms/Q‐waves and NT‐proBNP>35 pmol/L, a diagnostic echocardiography should be considered.

[Diagnosis of systolic and diastolic heart failure]

In this review, heart failure is confined to etiologies not due to rhythm disturbances or valvular heart disease. Besides measurement of natriuretic peptides, echocardiography is established as an important diagnostic procedure. Echocardiography is especially helpful in discriminating between heart failure with preserved ejection fraction (HF-PEF) and reduced ejection fraction (HF-REF). Because of its ease to be performed, the 6 min walk test continues to be a standard diagnostic procedure. Cardiopulmonary exercise testing provides more detailed information regarding differential diagnostic and prognostic considerations.

Epidemiological and evolutionary characteristics of heart failure in patients with left bundle branch block - A Moroccan center-based study

BACKGROUND

In patients with heart failure, left bundle branch block (LBBB) seems to be associated with an increased risk of cardiovascular mortality.

PURPOSE

The purpose of this study is to determine the in-hospital outcome of congestive heart failure patients with LBBB versus those without.

METHODS

We conducted a prospective observational study at the Department of Intensive Care and Rhythmology at the Mohammed V Military Hospital of Rabat, where 330 patients were admitted for heart failure between January 2008 and September 2012. Screening out patients with missing data yielded a cohort of 274 patients. Among the 274 patients, only 110 had LBBB and a left ventricular ejection fraction lower than 50%. We randomly selected a subset of 110 patients diagnosed as non-LBBB to ensure a significant statistical comparison between LBBB and non-LBBB patients. We therefore considered two groups in our analysis: 110 heart failure (HF) patients with LBBB and 110 HF patients without LBBB. Patients with incomplete records were excluded.

RESULTS

Male gender was dominant in both groups (82.7% vs. 66.7%, p = 0.005). Patients with LBBB had a higher prevalence of idiopathic dilated cardiomyopathy (39.1% vs. 4.8%, p < 0.001); and a higher prevalence of previous hospitalization for heart failure (64.5% vs. 23.3%, p < 0.001). The left ventricular ejection fraction was significantly lower in the group with LBBB (25.49% vs. 39.53%, p < 0.001). Age, cardiovascular risk factors, rhythmic and thromboembolic complications did not significantly differ. In patients with LBBB, 61.8% received cardiac resynchronization therapy performed both during the index hospital stay (50.9%) and previously (10.9%). Hospital outcome was marked by 20 in-hospital deaths in the group with LBBB and eight deaths in the group without LBBB (p = 0.008).

CONCLUSION

Our analysis emphasizes increased in-hospital mortality and higher disease severity, over a short period of stay, in heart failure patients with left bundle branch block.

Ischemic Electrocardiographic Abnormalities and Prognosis in Decompensated Heart Failure

Background—

Identification of coronary ischemia may enable targeted diagnostic and therapeutic strategies for acute heart failure. We determined the risk of 30-day mortality associated with ischemic ECG abnormalities in patients with acute heart failure.

Methods and Results—

Among 8772 patients (53.4% women, median 78 years [Q1, Q3: 68,84]) presenting with acute heart failure to 86 hospital emergency departments in Ontario, Canada, Q-waves, T-wave inversion, or ST-depression were present in 51.8% of subjects. However, presence of ST-depression was the only finding associated with 30-day mortality with adjusted odds ratio 1.24 (95% confidence interval [CI], 1.02–1.50). Using continuous net reclassification improvement, addition of ST-depression to the Emergency Heart failure Mortality Risk Grade model reclassified 16.9% of patients overall, and 29.3% of those with a history of ischemic heart disease (both P <0.001). By adding ST-depression to the model, the Emergency Heart failure Mortality Risk Grade was extended to predict 30-day death with high discrimination ( c -statistic 0.801), with 0.57% mortality rate in the lowest risk decile. Adjusted odds ratios for 30-day mortality were 2.81 (95% CI, 1.48–5.31; P =0.002) in quintile 2, 7.41 (95% CI, 4.13–13.30; P <0.001) in quintile 3, and 14.47 (95% CI, 8.20–25.54; P <0.001) in quintile 4 compared with the lowest risk quintile. When the highest risk quintile was subdivided into 2 equally sized risk strata (deciles 9 and 10), the adjusted odds ratios for 30-day mortality were 27.20 (95% CI, 15.33–48.27; P <0.001) in decile 9 and 58.96 (95% CI, 33.54–103.65; P <0.001) in highest risk decile 10.

Conclusions—

Presence of ST-depression on the ECG reclassified risk of 30-day mortality in patients with acute heart failure, identifying both high- and low-risk subsets.

Role of nuclear cardiology for guiding device therapy in patients with heart failure

Heart failure is a dynamic condition with high morbidity and mortality and its prognosis should be reassessed frequently, particularly in patients for whom critical treatment decisions may depend on the results of prognostication. In patients with heart failure, nuclear cardiology techniques are useful to establish the etiology and the severity of the disease, while fewer studies have explored the potential capability of nuclear cardiology to guide cardiac resynchronization therapy (CRT) and to select patients for implantable cardioverter defibrillators (ICD). Left ventricular synchrony may be assessed by radionuclide angiography or gated single-photon emission computed tomography myocardial perfusion scintigraphy. These modalities have shown promise as predictors of CRT outcome using phase analysis. Combined assessment of myocardial viability and left ventricular dyssynchrony is feasible using positron emission tomography and could improve conventional response prediction criteria for CRT. Preliminary data also exists on integrated positron emission tomography/computed tomography approach for assessing myocardial viability, identifying the location of biventricular pacemaker leads, and obtaining left ventricular functional data, including contractile phase analysis. Finally, cardiac imaging with autonomic radiotracers may be useful in predicting CRT response and for identifying patients at risk for sudden cardiac death, therefore potentially offering a way to select patients for both CRT and ICD therapy. Prospective trials where imaging is combined with image-test driven therapy are needed to better define the role of nuclear cardiology for guiding device therapy in patients with heart failure.