Intravenous Diltiazem Versus Metoprolol in Acute Rate Control of Atrial Fibrillation/Flutter and Rapid Ventricular Response: A Meta-Analysis of Randomized and Observational Studies

BACKGROUND

Atrial fibrillation (AF) and/or atrial flutter (AFL) with rapid ventricular response (RVR) is a condition that often requires urgent treatment. Although guidelines have recommendations regarding chronic rate control therapy, recommendations on the best choice for acute heart rate (HR) control in RVR are unclear.

METHODS

A systematic search across multiple databases was performed for studies evaluating the outcome of HR control (defined as HR less than 110 bpm and/or 20% decrease from baseline HR). Included studies evaluated AF and/or AFL with RVR in a hospital setting, with direct comparison between intravenous (IV) diltiazem and metoprolol and excluded cardiac surgery and catheter ablation patients. Hypotension (defined as systolic blood pressure less than 90 mmHg) was measured as a secondary outcome. Two authors performed full-text article review and extracted data, with a third author mediating disagreements. Random effects models utilizing inverse variance weighting were used to calculate odds ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the I2 test.

RESULTS

A total of 563 unique titles were identified through the systematic search, of which 16 studies (7 randomized and 9 observational) were included. In our primary analysis of HR control by study type, IV diltiazem was found to be more effective than IV metoprolol for HR control in randomized trials (OR 4.75, 95% CI 2.50-9.04 with I2 = 14%); however, this was not found for observational studies (OR 1.26, 95% CI 0.89-1.80 with I2 = 55%). In an analysis of observational studies, there were no significant differences between the two drugs in odds of hypotension (OR 1.12, 95% CI 0.51-2.45 with I2 = 18%).

CONCLUSION

While there was a trend toward improved HR control with IV diltiazem compared with IV metoprolol in randomized trials, this was not seen in observational studies, and there was no observed difference in hypotension between the two drugs.

Comparison of cardiac magnetic resonance imaging and fluorodeoxyglucose positron emission tomography in the assessment of myocardial viability: meta-analysis and systematic review

AIM

Contrast-enhanced cardiac magnetic resonance (Ce-CMR) and Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) are frequently utilized in clinical practice to assess myocardial viability. However, studies evaluating direct comparison between Ce-CMR and FDG-PET have a smaller sample size, and no clear distinction between the two imaging modalities has been defined. To address this gap, we conducted a meta-analysis of studies comparing Ce-CMR and FDG-PET for the assessment of myocardial viability.

METHODS

We searched PubMed, EMBASE, Scopus, and Web of Science databases from their inception to 4/20/2022 with search terms "viability" AND "heart diseases" AND "cardiac magnetic resonance imaging" AND "positron-emission tomography." We extracted patient characteristics, segment level viability assessment according to Ce-CMR and FDG-PET, and change in regional wall motion abnormalities (RWMA) at follow-up.

RESULTS

We included four studies in the meta-analysis which provided viability assessment with Ce-CMR and FDG-PET in all patients and change in RWMA at follow-up. There were 82 patients among the four included studies, and 585 segments were compared for viability assessment. There were 59 (72%) males, and mean age was 65 years. The sensitivity (95% confidence interval-CI) and specificity (CI) of Ce-CMR for predicting myocardial recovery were 0.88 (0.66-0.96) and 0.64 (0.49-0.77), respectively. The sensitivity (CI) and specificity (CI) of FDG-PET for predicting myocardial recovery were 0.91 (0.63-0.99) and 0.67 (0.49-0.81), respectively.

CONCLUSION

FDG-PET and Ce-CMR have comparable diagnostic parameters in myocardial viability assessment and are consistent with prior research.

Comparison of cardiac magnetic resonance imaging and fluorodeoxyglucose positron emission tomography in the assessment of cardiac sarcoidosis: Meta-analysis and systematic review

AIM

Fluorine-18 fluorodeoxyglucose-positron emission tomography (FDG-PET) and cardiac magnetic resonance (CMR) are frequently used advanced cardiac imaging to diagnose cardiac sarcoidosis (CS). We conducted a meta-analysis and systematic review to compare diagnostic parameters of FDG-PET and CMR in the diagnosis of cardiac sarcoidosis (CS).

METHODS

We searched PubMed, EMBASE, and Scopus databases from their inception to 9/30/2021 with search terms "cardiac sarcoidosis" AND "cardiac magnetic resonance imaging" AND "positronemission tomography". We extracted patient characteristics, results of the FDG-PET and CMR, and adverse outcomes from the included studies. Adverse outcomes served as a reference standard for the evaluation of FDG-PET and CMR.

RESULTS

We included 4 studies in the meta-analysis which provided adverse outcomes and all patients underwent FDG-PET and CMR. There were 237 patients, 60.3% male, and ages ranged from 50-53 years. There were 45 events in 237 patients from four studies included in the meta-analyses. The pooled sensitivity (95% confidence interval-CI) and specificity (CI) of CMR in predicting an adverse event were 0.94 (0.79-0.98) and 0.49 (0.40-0.59), respectively. The pooled sensitivity (CI) and specificity (CI) of FDG-PET in predicting an adverse event were 0.51 (0.26-0.75) and 0.60 (0.35-0.81), respectively.

CONCLUSION

CMR was more sensitive but less specific than FDG-PET in predicting adverse events; however, the study population and definition of a positive test need to be considered while interpreting the results.

Is Virtual Learning Here to Stay? A Multispecialty Survey of Residents, Fellows, and Faculty

The transition to virtual learning during the coronavirus disease 2019 pandemic marks a paradigm shift in graduate medical education (GME). From June to September 2021, we conducted a dual-center, multispecialty survey of residents, fellows, and faculty members to determine overall perceptions about virtual learning and assess its benefits, drawbacks, and future role in GME. We discovered a mainly positive view of virtual education among trainees (138/207, 0.67, 95% CI 0.59-0.73) and faculty (180/278, 0.65, 0.59-0.70). Large group sessions, such as didactic lectures, grand rounds, and national conferences, were ranked best-suited for the virtual environment, whereas small groups and procedural training were the lowest ranked. Major benefits and drawbacks to virtual learning was identified. A hybrid approach, combining in-person and virtual sessions, was the preferred format among trainees (167/207, 0.81, 0.75-0.86) and faculty (229/278, 0.82, 0.77-0.87). Virtual learning offers a valuable educational experience that should be retained in postpandemic GME curriculums.

Novel Machine Learning Approach to Predict and Personalize Length of Stay for Patients Admitted with Syncope from the Emergency Department

Background: Syncope, a common problem encountered in the emergency department (ED), has a multitude of causes ranging from benign to life-threatening. Hospitalization may be required, but the management can vary substantially depending on specific clinical characteristics. Models predicting admission and hospitalization length of stay (LoS) are lacking. The purpose of this study was to design an effective, exploratory model using machine learning (ML) technology to predict LoS for patients presenting with syncope. Methods: This was a retrospective analysis using over 4 million patients from the National Emergency Department Sample (NEDS) database presenting to the ED with syncope between 2016−2019. A multilayer perceptron neural network with one hidden layer was trained and validated on this data set. Results: Receiver Operator Characteristics (ROC) were determined for each of the five ANN models with varying cutoffs for LoS. A fair area under the curve (AUC of 0.78) to good (AUC of 0.88) prediction performance was achieved based on sequential analysis at different cutoff points, starting from the same day discharge and ending at the longest analyzed cutoff LoS ≤7 days versus >7 days, accordingly. The ML algorithm showed significant sensitivity and specificity in predicting short (≤48 h) versus long (>48 h) LoS, with an AUC of 0.81. Conclusions: Using variables available to triaging ED clinicians, ML shows promise in predicting hospital LoS with fair to good performance for patients presenting with syncope.

Predicting adverse cardiac events in sarcoidosis: deep learning from automated characterization of regional myocardial remodeling

Recognizing early cardiac sarcoidosis (CS) imaging phenotypes can help identify opportunities for effective treatment before irreversible myocardial pathology occurs. We aimed to characterize regional CS myocardial remodeling features correlating with future adverse cardiac events by coupling automated image processing and data analysis on cardiac magnetic resonance (CMR) imaging datasets. A deep convolutional neural network (DCNN) was used to process a CMR database of a 10-year cohort of 117 consecutive biopsy-proven sarcoidosis patients. The maximum relevance - minimum redundancy method was used to select the best subset of all the features-24 (from manual processing) and 232 (from automated processing) left ventricular (LV) structural/functional features. Three machine learning (ML) algorithms, logistic regression (LogR), support vector machine (SVM) and multi-layer neural networks (MLP), were used to build classifiers to categorize endpoints. Over a median follow-up of 41.8 (inter-quartile range 20.4-60.5) months, 35 sarcoidosis patients experienced a total of 43 cardiac events. After manual processing, LV ejection fraction (LVEF), late gadolinium enhancement, abnormal segmental wall motion, LV mass (LVM), LVMI index (LVMI), septal wall thickness, lateral wall thickness, relative wall thickness, and wall thickness of 9 (out of 17) individual LV segments were significantly different between patients with and without endpoints. After automated processing, LVEF, end-diastolic volume, end-systolic volume, LV mass and wall thickness of 92 (out of 216) individual LV segments were significantly different between patients with and without endpoints. To achieve the best predictive performance, ML algorithms selected lateral wall thickness, abnormal segmental wall motion, septal wall thickness, and increased wall thickness of 3 individual segments after manual image processing, and selected end-diastolic volume and 7 individual segments after automated image processing. LogR, SVM and MLP based on automated image processing consistently showed better predictive accuracies than those based on manual image processing. Automated image processing with a DCNN improves data resolution and regional CS myocardial remodeling pattern recognition, suggesting that a framework coupling automated image processing with data analysis can help clinical risk stratification.

The role of electrophysiology study in risk stratification of cardiac sarcoidosis patients: Meta-analyses and systemic review

BACKGROUND

The utility of an electrophysiologic study (EPS) in the risk stratification of cardiac sarcoidosis (CS) patients is not clear. We conducted a systemic review and meta-analysis to evaluate the utility of EPS in the risk stratification of CS patients.

METHODS

We searched PubMed, Embase, and Scopus databases from their inception to 12/4/2020 with search terms "Cardiac sarcoidosis" And "Electrophysiological studies OR ablation". The first and second authors reviewed all the studies. We extracted the data of positive and negative EPS, and outcomes defined as ventricular arrhythmias, implantable cardioverter defibrillator therapy, death, left ventricular assist device placement, or heart transplantation. Risk of bias assessment was done by the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Subgroup analysis of patients with left ventricular ejection fraction (LVEF) >35%, and probable CS, no prior ventricular tachycardia (VT) and LVEF >35% were performed.

RESULTS

We found 544 articles after removing duplicates. A total of 52 full articles were reviewed, and eight studies were included in the meta-analysis. The pooled sensitivity and specificity (95% confidence interval) of EPS in predicting clinical outcomes were 0.70 (0.51-0.85) and 0.93 (0.85-0.97), respectively. Subgroup analysis of patients with LVEF >35% resulted in pooled sensitivity of 0.63 (0.29-0.88) and pooled specificity of 0.97 (0.92-0.99), and subgroup analysis of patients with probable CS, no prior VT, and LVEF >35% resulted in pooled sensitivity of 0.71 (0.33-0.93) and pooled specificity of 0.96 (0.88-0.99) in predicting adverse clinical outcomes.

CONCLUSIONS

EPS is an effective risk stratification tool in patients with CS across all subgroups with high sensitivity and specificity.

Regional Myocardial Remodeling Characteristics Correlates With Cardiac Events in Sarcoidosis

BACKGROUND

The poor prognosis of cardiac sarcoidosis (CS) underscores the need for risk stratification.

PURPOSE

To investigate the prognostic significance of ventricular/myocardial remodeling features in sarcoidosis.

STUDY TYPE

Retrospective.

POPULATION

In all, 132 biopsy-proven sarcoidosis patients imaged from 2008 to 2018. The primary endpoint was a composite of cardiac mortality, new onset arrhythmias, hospitalization for heart failure, and device implantation.

FIELD STRENGTH/SEQUENCE

No field strength or sequence restrictions.

ASSESSMENT

Global and regional ventricular/myocardial remodeling features were assessed by standard volumetric measurements and automated function imaging postprocessing analysis.

STATISTICAL TESTS

Student's t-test or Mann-Whitney test (chi² test or Fisher's exact test for categorical variables) were used for comparisons. Cox-proportional hazards regression model, univariate /multivariate analyses, and receiver operating characteristic were performed to relate clinical/lab data, imaging parameters to the endpoints.

RESULTS

Over a median follow-up of 40.7 (interquartile range 18.8-60.5) months, 41 (31.1%) patients developed adverse cardiac events. Abnormal left ventricular (LV) geometric remodeling alterations (measured by LV mass index and relative wall thickness) occurred 3.66-fold more frequently in patients with endpoints than patients without. The ratio of patients with endpoints increased as ventricular remodeling phenotype progressed. In patients with endpoints, regional myocardial wall thickness (RMWT) was significantly (P = 0.022) increased in six clustered LV segments located in the middle interventricular septum and basal/middle anterolateral walls. In all of the abnormal ventricular remodeling stages, patients with endpoints constantly had higher mean RMWT than those without. Among clinical, electrocardiographic, and imaging parameters, LV mass index (hazard ratio [HR] 1.010 95% confidence interval [CI] 1.002-1.018, P = 0.017) and mean RMWT (HR 3.482 95% CI 1.679-7.223, P = 0.001) were independently associated with endpoints. Sarcoidosis patients without this RMWT distribution pattern were significantly (P < 0.001) more likely to be free of the occurrence of subsequent cardiac events.

DATA CONCLUSION

Regional myocardial remodeling characteristics are associated with subsequent adverse cardiac events in sarcoidosis.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2 J. Magn. Reson. Imaging 2020;52:499-509.

Temporal Trends in the Use of Therapeutic Hypothermia for Out-of-Hospital Cardiac Arrest

IMPORTANCE

Despite evidence that therapeutic hypothermia improves patient outcomes for out-of-hospital cardiac arrest, use of this therapy remains low.

OBJECTIVE

To determine whether the use of therapeutic hypothermia and patient outcomes have changed after publication of the Targeted Temperature Management trial on December 5, 2013, which supported more lenient temperature management for out-of-hospital cardiac arrest.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort was conducted between January 1, 2013, and December 31, 2016, of 45 935 US patients in the Cardiac Arrest Registry to Enhance Survival who experienced out-of-hospital cardiac arrest and survived to hospital admission.

EXPOSURES

Calendar time by quarter year.

MAIN OUTCOMES AND MEASURES

Use of therapeutic hypothermia and patient survival to hospital discharge.

RESULTS

Among 45 935 patients (17 515 women and 28 420 men; mean [SD] age, 59.3 [18.3] years) who experienced out-of-hospital cardiac arrest and survived to admission at 649 US hospitals, overall use of therapeutic hypothermia during the study period was 46.4%. In unadjusted analyses, the use of therapeutic hypothermia dropped from 52.5% in the last quarter of 2013 to 46.0% in the first quarter of 2014 after the December 2013 publication of the Targeted Temperature Management trial. Use of therapeutic hypothermia remained at or below 46.5% through 2016. In segmented hierarchical logistic regression analysis, the risk-adjusted odds of use of therapeutic hypothermia was 18% lower in the first quarter of 2014 compared with the last quarter of 2013 (odds ratio, 0.82; 95% CI, 0.71-0.94; P = .006). Similar point-estimate changes over time were observed in analyses stratified by presenting rhythm of ventricular tachycardia or ventricular fibrillation (odds ratio, 0.89; 95% CI, 0.71-1.13, P = .35) and pulseless electrical activity or asystole (odds ratio, 0.75; 95% CI, 0.63-0.89; P = .001). Overall risk-adjusted patient survival was 36.9% in 2013, 37.5% in 2014, 34.8% in 2015, and 34.3% in 2016 (P < .001 for trend). In mediation analysis, temporal trends in use of hypothermia did not consistently explain trends in patient survival.

CONCLUSIONS AND RELEVANCE

In a US registry of patients who experienced out-of-hospital cardiac arrest, the use of guideline-recommended therapeutic hypothermia decreased after publication of the Targeted Temperature Management trial, which supported more lenient temperature thresholds. Concurrent with this change, survival among patients admitted to the hospital decreased, but was not mediated by use of hypothermia.

Abstract 113: Temporal Trends in the Use of Therapeutic Hypothermia for Out-of-Hospital Cardiac Arrest: Insights From the CARES Registry

Background: Despite evidence that therapeutic hypothermia improves patient outcomes for out-of-hospital cardiac arrest, use of this therapy remains low. It is unknown if the use of therapeutic hypothermia and patient outcomes have changed following publication of a trial that supported more lenient temperature management.

Methods: In the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 45,935 U.S. patients who experienced out-of-hospital cardiac arrest and survived to admission at 649 hospitals between 2013 and 2016. Using segmented hierarchical logistic regression, we determined risk-adjusted trends in the use of therapeutic hypothermia overall and stratified by presenting rhythm of ventricular tachycardia or ventricular fibrillation (VT/VF) vs pulseless electrical activity or asystole (PEA/asystole). We used mediation analysis to assess the impact of temporal trends in the use of therapeutic hypothermia on risk-adjusted survival trends at a patient- and hospital-level.

Results: Overall use of therapeutic hypothermia was 46.4%. In unadjusted analyses, the use of therapeutic hypothermia dropped from 52.5% in the last quarter of 2013 to 46.0% in the first quarter of 2014 after publication of a trial that supported more lenient temperature management. Use of therapeutic hypothermia remained at or below 46.5% through 2016. After risk-adjustment, these trends in use persisted (see Figure). Compared with the last quarter of 2013, the risk-adjusted odds of therapeutic hypothermia was 18% lower in the first quarter of 2014 (OR 0.82, 95% CI 0.71, 0.94, P=0.006). Similar findings were observed in analyses stratified by presenting rhythm (see Figure). Overall risk-adjusted patient survival was 36.9% in 2013, 37.5% in 2014, 34.8% in 2015, and 34.3% in 2016 (P for trend<0.001). Trends in hypothermia use did not explain trends in survival.

Conclusions: In a U.S. registry of out-of-hospital cardiac arrest, the use of therapeutic hypothermia decreased after publication of a study supporting more lenient temperature thresholds. Concurrent to this change, overall risk-adjusted survival of cardiac arrest decreased, but was not attributed to lower use of therapeutic hypothermia.

Does acute care for the elderly (ACE) unit decrease the incidence of falls?

To determine whether acute care for the elderly (ACE) units decrease the incidence of patient falls compared to general medical and surgical (GMS) units, a non-concurrent prospective study included individuals aged 65 and older admitted to ACE or GMS units over a 2-year span was done. There were 7069 admissions corresponded to 28,401 patient-days. A total of 149 falls were reported for an overall incidence rate (IR) of 5.2 falls per 1000 patient-days, 95% CI, 4.4/1000-6.1/1000 patient-days. The falls IR ratio for patients in ACE unit compared to those in non-ACE units after adjusting for age, sex, prescribed psychotropics and hypnotics, and Morse Fall Score was 0.27/1000 patient-days; 95% CI, 0.13-0.54; p < 0.001. So, an estimated 73% reduction in patient falls between ACE unit and non-ACE units. Hospitals may consider investing in ACE units to decrease the risk of falls and the associated medical and financial costs.