Electrocardiography score based on the Minnesota code classification system predicts cardiovascular mortality in an asymptomatic low-risk population

BACKGROUND

The use of a single abnormal finding on electrocardiography (ECG) is not recommended for stratifying the risk of cardiovascular (CV) events in low-risk general populations because of its low discriminative power. However, the value of a scoring system containing multiple abnormal ECG findings for predicting CV death has not been sufficiently evaluated.

METHODS

In a prospective community-based cohort study, 8417 participants without atherosclerotic CV diseases (ASCVDs) and any related symptoms were followed for 18 years. The standard 12-lead ECGs were recorded at baseline and the ECG findings were categorized using the Minnesota code classification. CV deaths were defined as death from myocardial infarction (MI), chronic ischemic heart disease, heart failure, fatal arrhythmia, cerebrovascular event, pulmonary thromboembolism, peripheral vascular disease and sudden cardiac arrest and identified using the Korean National Statistical Office (KOSTAT) database.

RESULTS

In a multivariate Cox proportional hazard (CPH) model, major and minor ST-T wave abnormalities, atrial fibrillation (AF), Q waves in the anterior leads, the lack of Q waves in the posterior leads, high amplitudes of the left and right precordial leads, left axis deviation and sinus tachycardia were associated with higher risks of CV deaths. The ECG score consisted of these findings showed modest predictive values represented by C-statistics that ranged from 0.632 to 760 during the follow-up and performed better in the early follow-up period. The ECG score independently predicted CV death after adjustment for relevant covariates in a multivariate model, and improved the predictive performance of the 10-year ASCVD risk estimator and a model of conventional risk factors including age, diabetes and current smoking. The combined ECG score (Harrell's C-index: 0.852, 95% confidence interval [CI], 0.828-0.876) composed of the ECG score and the conventional risk factors outperformed the 10-year ASCVD risk estimator (Harrell's C-index: 0.806; 95% CI, 0.780-0.833) and the model of the conventional risk factors (Harrell's C-index: 0.841, 95% CI, 0.817-0.865) and exhibited an excellent goodness of fit between the predicted and observed probabilities of CV death.

CONCLUSIONS

The ECG score could be useful to predict CV death independently and may add value to the conventional CV risk estimators regarding the risk stratification of CV death in asymptomatic low-risk general populations.

Electrocardiogram Risk Score and Prevalence of Subclinical Atherosclerosis: A Cross-Sectional Study

Integrated abnormal electrocardiogram (ECG) parameters predict the risk of cardiovascular disease (CVD); however, its relationship with subclinical CVD is unknown. We aimed to evaluate the association between the integrated ECG risk score and the prevalence of coronary artery calcium (CAC). A cross-sectional study comprised 134,802 participants with no known CVD who underwent ECG and CAC computed tomography. The ECG risk score was the sum of five ECG abnormalities: heart rate of >80 beats, QRS of >110 ms, left ventricular hypertrophy, T-wave inversion, and prolonged QTc. A multinomial regression model was used to estimate the prevalence ratios (PRs) and their 95% confidence intervals (CIs) for prevalent CAC. The prevalence of CAC progressively increased as the ECG risk score increased. After adjustment for conventional CVD risk factors and other confounders, the multivariable-adjusted PRs (95% CI) for a CAC of 1−100 in the 1, 2, and ≥3 ECG risk score groups were 1.06 (1.02−1.10), 1.12 (1.03−1.22), and 1.19 (1.00−1.42), respectively, while the corresponding PRs for a CAC of >100 were 1.03 (0.95−1.12), 1.44 (1.25−1.66), and 1.75 (1.33−2.29), respectively. Integrative ECG scoring may help identify individuals requiring lipid-lowering medications, even in young and asymptomatic populations.

Literature Review of the Association Between Prenatal Education and Rates of Cesarean Birth Among Women at Low Risk

A review of the literature was performed to explore the association between prenatal education and rates of primary cesarean birth for women at low risk for cesarean birth. Most women who are nulliparous with a singleton fetus of term gestational age and in the vertex position are considered to be at low risk and favorable for a vaginal birth, yet the cesarean birth rate for women at low risk was 25.6% in 2019. It has been suggested that the rise in the cesarean birth rate among low-risk women may not be due to medical indications but, rather, to nonmedical factors, such as a provider's or woman's preference or lack of prenatal education. Evidence from this literature review supports the premise that prenatal education classes should be routinely incorporated into maternity care in an effort to reduce cesarean birth rates for the low-risk population.

Transcatheter aortic valve replacement: potential use in lower-risk aortic stenosis

INTRODUCTION

The widespread use of transcatheter aortic valve implantation (TAVI) is expanding to low-risk patients. Nevertheless, a low clinical risk does not always correspond to a low procedural risk for the percutaneous approach.

AREAS COVERED

The initial trials on TAVI in low-risk populations had encouraging results, showing non-inferiority in comparison to surgical aortic valve replacement (SAVR). However, the low-risk definition is based on risk score calculators developed for the surgical setting and not including other specific features that are more relevant to TAVI and can affect procedural outcomes. For example, the presence of bicuspid aortic valves, high calcific burden, low coronary height or conduction disturbances is all potentially associated with suboptimal results or even procedural complications. In addition, the lack of longer follow-up prevents us to draw conclusions about long-term outcomes, including data about valve durability and coronary re-access.

EXPERT OPINION

Although current evidence suggest similar results for TAVI and SAVR in low-risk populations, there are some technical and procedural limitations that still need to be addressed in order to close the gap between TAVI and surgery. Optimal, lasting results with a low rate of procedural complications are highly expected in low-risk, otherwise healthy subjects, with potential for longevity.

Maternal age trends support uptake of non-invasive prenatal testing (NIPT) in the low-risk population

Purpose: To examine trends in patients submitting samples for cell-free DNA screening to determine whether they reflect a shift towards NIPT use in the low-risk population. Methods: A review of demographic information was performed for all specimens submitted to the Ariosa Diagnostics clinical laboratory for the Harmony^® prenatal test between January 1, 2014 and December 30, 2017. The proportions of specimens for patients under 35 years and 35 years and older were compared. Results: There was a significant increase in the proportion of specimens submitted by patients under 35, from 47.3% in 2014 to 60.3% in 2017 (Chi-square test, p < .001). Conclusions: The proportion of samples submitted to our laboratory by patients under 35 years has significantly increased in the 4-year subset, which represents the demographics of a diverse group of patients from across the globe. This suggests an increase in uptake of NIPT in the low-risk population.

Unconditional reference values for the amniotic fluid index measurement between 26w0d and 41w6d of gestation in low-risk pregnancies

OBJECTIVE

To establish reference values for the amniotic fluid index (AFI) measurement between 26w0d and 41w6d of gestation in a Brazilian population.

METHODS

We performed a cross-sectional study with 1984 low-risk singleton pregnant women between 26w0d and 41w6d of gestation. AFI was measured according to the technique proposed by Phelan et al. Maternal abdomen was divided into four quadrants using the umbilicus and linea nigra as landmarks. Single vertical pocket in each quadrant was measured and the AFI was generated by the sum of these four values without umbilical cord or fetal parts. All ultrasound exams were performed by only two experienced examiners. AFI was expressed as median, interquartile range, mean and ranges in each gestational age (GA) interval. Polynomial regressions were performed to obtain the best fit with adjustment by the determination coefficient (R(2)).

RESULTS

Mean of AFI ranged from 14.0 ± 4.1 cm (range, 9.7-14.0) at 26w0d to 8.3 ± 4.7 cm (range, 1.9-16.5) at 41w6d, respectively. The best polynomial regression fit curve was a first-degree: AFI = 16.29-0.125*GA (R(2) = 0.01). According the scatterplot, AFI values practically did not vary with advancing GA.

CONCLUSION

Reference values for the AFI measurement between 26w0d and 41w6d of gestation in a low-risk Brazilian population were established.

The capacity of mid-pregnancy cervical length to predict preterm birth in low-risk women: a national cohort study

INTRODUCTION

We investigated the predictive capacity of mid-trimester cervical length (CL) measurement for spontaneous and iatrogenic preterm birth.

MATERIAL AND METHODS

We performed a prospective observational cohort study in nulliparous women and low-risk multiparous women with a singleton pregnancy between 16(+0) and 21(+6) weeks of gestation. We assessed the prognostic capacity of transvaginally measured mid-trimester CL for spontaneous and iatrogenic preterm birth (<37 weeks) using likelihood ratios (LR) and receiver-operating-characteristic analysis. We calculated numbers needed to screen to prevent one preterm birth assuming different treatment effects. Main outcome measures were preterm birth <32, <34 and <37 weeks.

RESULTS

We studied 11,943 women, of whom 666 (5.6%) delivered preterm: 464 (3.9%) spontaneous and 202 (1.7%) iatrogenic. Mean CL was 44.1 mm (SD 7.8 mm). In nulliparous women, the LRs for spontaneous preterm birth varied between 27 (95% CI 7.7-95) for a CL ≤ 20 mm, and 2.0 (95% CI 1.6-2.5) for a CL between 30 and 35 mm. For low-risk multiparous women, these LRs were 37 (95% CI 7.5-182) and 1.5 (95% CI 0.97-2.2), respectively. Using a cut-off for CL ≤ 30 mm, 28 (6.0%) of 464 women with spontaneous preterm birth were identified. The number needed to screen to prevent one case of preterm birth was 618 in nulliparous women and 1417 for low-risk multiparous women (40% treatment effect, cut-off 30 mm).

CONCLUSION

In women at low risk of preterm birth, CL predicts spontaneous preterm birth. However, its isolated use as a screening tool has limited value due to low sensitivity.

Non-invasive prenatal testing for trisomies 21, 18 and 13: clinical experience from 146,958 pregnancies

OBJECTIVES

To report the clinical performance of massively parallel sequencing-based non-invasive prenatal testing (NIPT) in detecting trisomies 21, 18 and 13 in over 140,000 clinical samples and to compare its performance in low-risk and high-risk pregnancies.

METHODS

Between 1 January 2012 and 31 August 2013, 147,314 NIPT requests to screen for fetal trisomies 21, 18 and 13 using low-coverage whole-genome sequencing of plasma cell-free DNA were received. The results were validated by karyotyping or follow-up of clinical outcomes.

RESULTS

NIPT was performed and results obtained in 146,958 samples, for which outcome data were available in 112,669 (76.7%). Repeat blood sampling was required in 3213 cases and 145 had test failure. Aneuploidy was confirmed in 720/781 cases positive for trisomy 21, 167/218 cases positive for trisomy 18 and 22/67 cases positive for trisomy 13 on NIPT. Nine false negatives were identified, including six cases of trisomy 21 and three of trisomy 18. The overall sensitivity of NIPT was 99.17%, 98.24% and 100% for trisomies 21, 18 and 13, respectively, and specificity was 99.95%, 99.95% and 99.96% for trisomies 21, 18 and 13, respectively. There was no significant difference in test performance between the 72,382 high-risk and 40,287 low-risk subjects (sensitivity, 99.21% vs. 98.97% (P = 0.82); specificity, 99.95% vs. 99.95% (P = 0.98)). The major factors contributing to false-positive and false-negative NIPT results were maternal copy number variant and fetal/placental mosaicism, but fetal fraction had no effect.

CONCLUSIONS

Using a stringent protocol, the good performance of NIPT shown by early validation studies can be maintained in large clinical samples. This technique can provide equally high sensitivity and specificity in screening for trisomy 21 in a low-risk, as compared to high-risk, population.

Maternal age and emergency operative deliveries at term: a population-based registry study among low-risk primiparous women

OBJECTIVE

To study the association between maternal age and emergency operative delivery. The roles of in-labour indications, and birthweight ≥ 4000 g, gestational age ≥ 42 weeks, induction of labour, and epidural use, according to maternal age were explored.

DESIGN

Population-based study.

SETTING

Medical Birth Registry of Norway and Statistics Norway.

POPULATION

We studied 169 583 low-risk primiparous mothers with singleton, cephalic labours, at ≥37 weeks of gestation, from 1999 to 2009.

METHODS

The associations between maternal age and mode of delivery were analysed using multinomial regression analyses, adjusting for sociodemographic factors.

MAIN OUTCOME MEASURES

Emergency caesarean section and operative vaginal delivery.

RESULTS

Of women aged ≥40 years, 22% had emergency caesarean sections and 24% had operative vaginal deliveries, giving adjusted relative risk ratios (RRRs) of 6.60 (95% confidence interval, 95% CI 5.53-7.87) and 3.30 (95% CI 2.79-3.90), respectively, when compared with women aged 20-24 years. Adjustments for sociodemographic factors only slightly changed the estimates. Dystocia was the main indication, followed by fetal distress. All of the listed factors increased the level of emergency operative deliveries, mainly because of an increase in dystocia. The increase in risk for emergency caesarean section by all factors, and for operative vaginal deliveries by epidural, were greater in older than in younger women, but were significant for epidural only.

CONCLUSIONS

We found a close association between maternal age and emergency operative delivery in low-risk primiparas. Contributory factors increased the risk for both emergency operative delivery and epidural more in older than in younger women.