AssistMED project: Transforming cardiology cohort characterisation from electronic health records through natural language processing - Algorithm design, preliminary results, and field prospects

INTRODUCTION

Electronic health records (EHR) are of great value for clinical research. However, EHR consists primarily of unstructured text which must be analysed by a human and coded into a database before data analysis- a time-consuming and costly process limiting research efficiency. Natural language processing (NLP) can facilitate data retrieval from unstructured text. During AssistMED project, we developed a practical, NLP tool that automatically provides comprehensive clinical characteristics of patients from EHR, that is tailored to clinical researchers needs.

MATERIAL AND METHODS

AssistMED retrieves patient characteristics regarding clinical conditions, medications with dosage, and echocardiographic parameters with clinically oriented data structure and provides researcher-friendly database output. We validate the algorithm performance against manual data retrieval and provide critical quantitative and qualitative analysis.

RESULTS

AssistMED analysed the presence of 56 clinical conditions, medications from 16 drug groups with dosage and 15 numeric echocardiographic parameters in a sample of 400 patients hospitalized in the cardiology unit. No statistically significant differences between algorithm and human retrieval were noted. Qualitative analysis revealed that disagreements with manual annotation were primarily accounted to random algorithm errors, erroneous human annotation and lack of advanced context awareness of our tool.

CONCLUSIONS

Current NLP approaches are feasible to acquire accurate and detailed patient characteristics tailored to clinical researchers' needs from EHR. We present an in-depth description of an algorithm development and validation process, discuss obstacles and pinpoint potential solutions, including opportunities arising with recent advancements in the field of NLP, such as large language models.

Greater distance between ablation lines reduces the arrhythmia recurrence rate after pulmonary vein isolation

INTRODUCTION

Pulmonary vein isolation (PVI) is a recommended strategy for rhythm control in atrial fibrillation (AF), but its success rate remains unsatisfactory. Continuous research is being conducted to explore new technologies and modifications to the existing ablation workflow in order to reduce the arrhythmia recurrence rate.

OBJECTIVES

This study aimed to determine the influence of the distance between ablation lines (DBL) on AF recurrence rate in patients undergoing their first PVI; and thus to optimize the procedure outcomes.

PATIENTS AND METHODS

This is a retrospective cohort study conducted at a tertiary care center in Poland. A total of 146 patients (median age, 62 years; women, 34.3%) referred for a first PVI for either paroxysmal (n = 103) or persistent (n = 43) AF were evaluated. The procedures were performed with the use of a very‑high‑power, short‑duration catheter (QDot MicroTM, Biosense Webster, Inc., Irvine, California, United States) or a conventional, ablation index-guided ThermoCool Smarttouch SF catheter (Biosense Webster, Inc.). Freedom from AF recurrence was used as a primary end point. The impact of DBL on the outcome of PVI, accounting for conventional risk factors, was evaluated.

RESULTS

Greater distance between opposite circumferential PVI lines and its ratio to the transverse diameter of the left atrium (DLB/TD) were associated with a lower risk of AF recurrence (hazard ratio [HR], 0.966; 95% CI, 0.935-0.998 [per 1 mm]; P = 0.04 and HR, 0.968; 95% CI, 0.944-0.993 [per 1%]; P = 0.01, respectively). There was no correlation between DBL or DBL/TD ratio and the impedance level.

CONCLUSIONS

Close distance between PVI lines contributes to AF recurrence; thus, increasing the DBL and ensuring a higher DBL/TD ratio may be an advantageous ablation strategy.

Practical use case of natural language processing for observational clinical research data retrieval from electronic health records: AssistMED project

INTRODUCTION

Electronic health records (EHR) contain data valuable for clinical research but in textual format, requiring encoding to databases by a human- a lengthy and costly process. Natural language processing (NLP) is a computational technique that allows text analysis.

OBJECTIVES

To demonstrate a practical use case of NLP for a large retrospective study cohort characterization and compare it to a human retrieval.

PATIENTS AND METHODS

Anonymized discharge documentation of 10314 patients from the cardiology tertiary care department was analyzed for inclusion in the CRAFT registry (NCT02987062) of patients with atrial fibrillation (AF). Extensive clinical characteristics regarding concomitant diseases, medications, daily dosage and echocardiography were collected manually and through NLP.

RESULTS

There were 3030 and 3029 patients identified by human and NLP-based approaches, respectively, reflecting 99.93% accuracy of NLP in detecting AF. Comprehensive baseline patient characteristics by NLP was faster than human analysis (3 hours and 15 minutes vs 71 hours and 12 minutes). The calculated CHA2DS2VASc and HAS-BLED scores based on both methods did not differ (human vs NLP; median, IQR, P value): 3 (2-5) vs 3 (2-5) P = 0.74 and 1 (1-2) vs 1 (1-2) P = 0.63. For most data, an almost perfect agreement between NLP and human retrieved characteristics was found; daily dosage identification was the least accurate NLP feature. Similar conclusions on cohort characteristics would be made; however, daily dosage detection for some drug groups would require additional human validation in the NLP-based cohort.

CONCLUSIONS

NLP utilization on EHR may accelerate acquisition and provide accurate data for a retrospective study.

Hypoxia-Inducible Factor-1α (HIF-1α) as a Biomarker for Changes in Microcirculation in Individuals with Systemic Sclerosis

INTRODUCTION

Systemic sclerosis is an autoimmune disease characterized by tissue fibrosis and microangiopathy. Vascular changes such as a decrease in capillary density diminish blood flow and impair tissue oxygenation. Reliable ways to monitor disease activity and predict disease progression are desired in the process of patient selection for clinical trials and to optimize individual patient outcomes. Hypoxia-inducible factor-1 (HIF-1) is a dimeric protein complex that plays an integral role in the body's response to hypoxia. Our study aimed to investigate the potential abnormalities of HIF-1α plasma concentration and its possible association with disease activity and vascular abnormalities in patients with systemic sclerosis.

METHODS

Blood plasma levels of HIF-1α were measured in patients with systemic sclerosis (n = 50) and in healthy individuals (n = 30) using commercially available ELISA test kits.

RESULTS

The results showed a marked increase in HIF-1α levels in patients with systemic sclerosis (3.042 ng/ml [2.295-7.749]) compared to the control group (1.969 ng/ml [1.531-2.903] p < 0.01). Patients with diffuse cutaneous SSc (2.803 ng/ml, IQR 2.221-8.799) and limited cutaneous SSc (3.231 ng/ml, IQR 2.566-5.502) exhibited elevated serum HIF-1α levels compared to the control group (p < 0.01). We found a notable increase in HIF-1α plasma concentration in patients with an "active" pattern (6.625 ng/ml, IQR 2.488-11.480) compared to those with either an "early" pattern (2.739, IQR 2.165-3.282, p < 0.05) or a "late" pattern (2.983 ng/ml, IQR 2.229-3.386, p < 0.05). Patients with no history of digital ulcers had significantly higher levels of HIF-1α (4.367 ng/ml, IQR 2.488-9.462) compared to patients with either active digital ulcers (2.832 ng/ml, IQR 2.630-3.094, p < 0.05) or healed digital ulcers (2.668 ng/ml, IQR 2.074-2.983, p < 0.05).

CONCLUSIONS

Our results indicate that HIF-1α may serve as a biomarker in assessing microcirculatory changes in individuals with systemic sclerosis.

Copeptin as a Biomarker of Microcirculation Alterations in Systemic Sclerosis

Background

Systemic sclerosis is a connective tissue disease characterized by vasculopathy and progressive fibrosis, leading to multiorgan dysfunction. Given the complex and not fully elucidated pathogenesis, biomarkers of rapid disease progression and therapeutic response are lacking. Copeptin, which reflects vasopressin activity in serum, is used in diagnosing or prognosing different cardiometabolic conditions.

Objective

The aim of study was to investigate the concentration of copeptin in patients with systemic sclerosis and correlate it with specific clinical symptoms.

Patients and Methods

Serum copeptin was measured in patients with systemic sclerosis (34 women and 3 men; mean age 57.6 years) and in healthy individuals (n=30) using commercially available ELISA kits. According to the criteria of LeRoy our systemic sclerosis cohort consisted of 17 patients with limited cutaneous systemic sclerosis (45.9%) and 20 diffuse cutaneous systemic sclerosis patients (54.1%). According to the criteria of LeRoy our systemic sclerosis cohort consisted of 17 patients with limited cutaneous systemic sclerosis (45.9%) and 20 diffuse cutaneous systemic sclerosis patients (54.1%). The median duration of the disease was 10 [4-14] years.

Results

We found significantly higher copeptin concentration in patients with systemic sclerosis (4.21 pmol/L [3.04-5.42]) in comparison to control group (3.40 pmol/L [2.38-3.76], p<0.01). Copeptin significantly correlated with Raynaud's condition score (r=0.801, p<0.05). Patients with "late" capillaroscopic patterns had higher copeptin concentrations (5.37 pmol/L [4.29-8.06]) than patients with "early" (2.43 pmol/L [2.25-3.20], p<0.05) and "active" patterns (3.93 pmol/L [2.92-5.16], p<0.05]). Copeptin was found to be significantly higher in SSc patients with DUs (5.71 pmol/L [IQR 4.85-8.06]) when compared to SSc patients without DUs (3.31 pmol/L, [2.28-4.30], p<0.05). Additionally, copeptin concentration had good diagnostic accuracy in discriminating between patients with and without digital ulcers (AUC=0.863). Alprostadil decreased copeptin concentration from 4.96 [4.02-6.01] to 3.86 pmol/L [3.17-4.63] (p<0.01) after 4-6 cycles of administration.

Conclusion

Our findings suggest that copeptin may be a promising biomarker of microcirculation alterations in systemic sclerosis.

Photoplethysmography wave morphology in patients with atrial fibrillation

OBJECTIVE

Most current algorithms for detecting Atrial Fibrillation (AF) rely on Heart Rate Variability (HRV), and only a few studies analyse the variability of Photopletysmography (PPG) waveform. This study aimed to compare morphological features of the PPG curve in patients with AF to those presenting a normal sinus rhythm (NSR) and evaluate their usefulness in AF detection.&#xD;Approach: 10-minute PPG signals were obtained from patients with persistent/paroxysmal AF and NSR. Nine morphological parameters (1/ΔT, Pulse Width [PW], Augmentation Index [AI], b/a, e/a, [b-e]/a, Crest Time [CT], Inflection Point Area [IPA], Area and five HRV parameters (Heart rate [HR], Shannon entropy [ShE], root mean square of the successive differences [RMSSD], number of pairs of consecutive systolic peaks [R-R] that differ by more than 50 ms [NN50], standard deviation of the R-R intervals [SDNN]) were calculated.&#xD;Main Results: Eighty subjects, including 33 with AF and 47 with NSR were recruited. In univariate analysis five morphological features (1/ΔT, p<0.001; b/a, p<0.001; [b-e]/a, p<0.001; CT, p=0.011 and Area, p<0.001) and all HRV parameters (p=0.01 for HR and p<0.001 for others) were significantly different between the study groups. In the stepwise multivariate model (Area under the curve [AUC] = 0.988 [0.974-1.000]), three morphological parameters (PW, p<0.001; e/a, p=0.011; (b-e)/a, p<0.001) and three of HRV parameters (ShE, p=0.01; NN50, p<0.001, HR, p = 0.01) were significant. &#xD;Significance: There are significant differences between AF and NSR, PPG waveform, which are useful in AF detection algorithm. Moreover adding those features to HRV-based algorithms may improve their specificity and sensitivity.&#xD.

Flecainide in clinical practice

Flecainide, similar to encainide and propafenone, is IC class antiarrhythmic, inhibiting Nav1.5 sodium channels in heart muscle cells and modulates cardiac conduction. Despite its over 40-year presence in clinical practice, strong evidence and well-known safety profile, flecainide distribution in Europe has not always been equal. In Poland, the drug has been available in pharmacies only since October this year, and previously it had to be imported on request. Flecainide can be used successfully in both the acute and chronic treatment of cardiac arrhythmias. The main indication for flecainide is the treatment of paroxysmal supraventricular tachycardias, including atrial fibrillation, atrioventricular nodal re-entrant tachycardia, atrioventricular re-entrant tachycardia and ventricular arrhythmias in patients without structural heart disease. Beyond that, it may be used in some supraventricular tachycardia in children and for sustained fetal tachycardia. Many studies indicate its efficacy comparable to or better than previously used drugs such as propafenone and amiodarone, depending on the indication. This review aims to highlight the most important clinical uses of flecainide in the light of the latest scientific evidence and to provide an overview of the practical aspects of treatment, including indications, off-label use, contraindications, areas of use, monitoring of treatment and most common complications, taking into account special populations: children and pregnant women.

Safety and effectiveness of very-high-power, short-duration ablation in patients with atrial fibrillation: Preliminary results

BACKGROUND

Pulmonary vein isolation (PVI) is at the forefront of rhythm control strategies in patients with atrial fibrillation (AF). A very-high-power, short-duration (vHPSD) catheter, QDot MicroTM (Biosense Webster) was designed to improve the effectiveness of AF ablation within a shorter procedure time. The aim of this study was to compare the effectiveness and safety of PVI ablation between this vHPSD ablation mode and conventional ablation-index-guided ablation (ThermoCool Smarttouch SF catheter).

METHODS

This single-center, retrospective, observational study enrolled 108 patients with AF, referred for catheter ablation between December 16, 2019 and December 3, 2021. In 54 procedures (mean age: 58.0 ± 12.3; 66.67% male), a QDot MicroTM catheter was used (vHPSD-group), and 54 patients (mean age: 57.2 ± 11.8; 70.37% male) were treated with a ThermoCool SmarttouchTM SF catheter (AI-group). The primary endpoint was freedom from AF 3 months after ablation.

RESULTS

Atrial fibrillation was found to recur in 14.81% of patients in the vHPSD-group and in 31.48% of patients in the AI-group (p = 0.07). There was no difference in treatment-emergent adverse events between the two groups (6.3% vs. 0%; p = 0.10). One severe adverse event (a cerebral vascular accident) was observed in the vHPSD-group. The mean dose of remifentanil was reported to be lower during QDot MicroTM catheter-based PVI (p < 0.01). The vHPSD-based PVI was associated with shorter radiofrequency application time (p < 0.001), fluoroscopy time (p < 0.0001), and total procedure time (p < 0.0001).

CONCLUSIONS

This study suggests vHPSD ablation is safe, can reduce the dosage of analgesics during significantly shorter procedures and may enhance the success rate of catheter-based PVI.

Safety and effectiveness of very high-power short duration ablation in patients with atrial fibrillation: early results

Background

Pulmonary vein isolation (PVI) is at the forefront of treatment methods of rhythm control in patients with atrial fibrillation (AF) (1). The novel contact-force sensing catheter, QDot MicroTM (Biosense Webster) was designed to improve effectiveness of AF ablation and allow better time management due to shorter procedure time. It is a very high power-short duration (vHP-SD) catheter optimized for high density mapping and temperature control, which enables the application of high energy (up to 90W, 4s) (2).

Purpose

The aim of the study was to compare the QDot MicroTM catheter with the ThermoCool SmarttouchTM SF catheter with regard to the effectiveness and safety of PVI ablation.

Methods

It is a single center, cross-sectional, observational study enrolling 101 consecutive patients suffering from symptomatic paroxysmal or persistent AF, referred for first catheter ablation between 16 December 2019 and 03 December 2021. In 47 procedures (mean age 54 years; 70% male; 77% paroxysmal) the QDot Micro catheter was used (vHP-SD group; Qmode+ 90W, 4s), whereas the remaining 54 patients (mean age 57 years; 70% male; 67% paroxysmal) were treated with the ThermoCool SmarttouchTM SF catheter (control group, Ablation Index guided ablation). The primary endpoint was freedom from AF at 3-months after ablation. The secondary endpoints included the amount of opioids administered as well as the incidence of early-onset treatment-emergent adverse events (TEAEs).

Results

AF recurrence was documented in 14.9% patients in vHP-SD group and in 31.5% patients in control group (p=0.06). The mean dose of remifentanil was reported to be lower during Qmode+ catheter-based PVI (0.50 (0.40–0.60) vs. 0.70 (0.55–0.90) mg; p&lt;0.001). There was no statistically significant difference in TEAEs between both groups (6.3 vs. 0%; p=0.10). One severe adverse event (cerebral vascular incident 2 days after PVI – due to thrombus in the left ventricle) was observed in vHP-SD group.

Conclusions

This study suggests that the vHP-SD ablation is safe and enables sedative-analgesic medications demand reduction during procedure. vHP-SD mode may enhance the success rate of catheter-based PVI, however further research is needed to provide additional evidence of its superiority.

Funding Acknowledgement

Type of funding sources: None.

Administrative Data in Cardiovascular Research-A Comparison of Polish National Health Fund and CRAFT Registry Data

(1) Background: Administrative data allows for time- and cost-efficient acquisition of large volumes of individual patient data invaluable for evaluation of the prevalence of diseases and clinical outcomes. The aim of the study was to evaluate the accuracy of data collected from the Polish National Health Fund (NHF), from a researcher's perspective, in regard to a cohort of atrial fibrillation patients. (2) Methods: NHF data regarding atrial fibrillation and common cardiovascular comorbidities was compared with the data collected manually from the individual patients' health records (IHR) collected in the retrospective CRAFT registry (NCT02987062). (3) Results: Data from the NHF underestimated the proportion of patients with AF (NHF = 83% vs. IHR = 100%) while overestimating the proportion of patients with other cardiovascular comorbidities in the cohort. Significantly higher CHA2DS2VASc (Median, [Q1-Q3]) (NHF: 1, [0-2]; vs. IHR: 1, [0-1]; p < 0.001) and HAS-BLED (Median, [Q1-Q3]) (NHF: 4, [2-6] vs. IHR: 3, [2-5]; p < 0.001) scores were calculated according to NHF in comparison to IHR data, respectively. (4) Conclusions: Clinical researchers should be aware that significant differences between IHR and billing data in cardiovascular research can be observed which should be acknowledged while drawing conclusions from administrative data-based cohorts. Natural Language Processing of IHR could further increase administrative data quality in the future.

Heart rate control and its predictors in patients with heart failure and sinus rhythm. Data from the European Society of Cardiology Long-Term Registry

BACKGROUND

Higher resting heart rate (HR) in patients with heart failure (HF) and sinus rhythm (SR) is associated with increased mortality. In patients hospitalized for HF, the aim herein, was to assess the use and dosage of guideline-recommended HR lowering medications, HR control at discharge and predictors of HR control.

METHODS

In the present study, were Polish participants of the European Society of Cardiology HF Long-Term (ESC-HF-LT) Registry. Those selected were hospitalized for HF, with reduced ejection fraction (HFrEF) and SR at discharge (n = 236). The patients were divided in two groups ( < 70 and ≥ 70 bpm). Logistic regression was used to identify the predictors of HR ≥ 70 bpm.

RESULTS

Of patients with HFrEF and SR, 59% had HR ≥ 70 bpm at hospital discharge. At discharge, 96% and only 0.5% of the patients with HFrEF and SR received beta-blocker and ivabradine, respectively. In the HF groups < 70 and ≥ 70 bpm, only 11% and 4% of patients received beta-blocker target doses, respectively. There was no difference in the use of other guideline-recommended medications. Age, New York Heart Association class, HR on admission and lack of HR lowering medications were predictors of discharge HR ≥ 70 bpm.

CONCLUSIONS

Heart rate control after hospitalization for HFrEF is unsatisfactory, which may be attributed to suboptimal doses of beta-blockers, and negligence in use other HR lowering drugs (including ivabradine).

Raynaud's Phenomenon with Focus on Systemic Sclerosis

Raynaud’s phenomenon is a painful vascular condition in which abnormal vasoconstriction of the digital arteries causes blanching of the skin. The treatment approach can vary depending on the underlying cause of disease. Raynaud’s phenomenon can present as a primary symptom, in which there is no evidence of underlying disease, or secondary to a range of medical conditions or therapies. Systemic sclerosis is one of the most frequent causes of secondary Raynaud’s phenomenon; its appearance may occur long before other signs and symptoms. Timely, accurate identification of secondary Raynaud’s phenomenon may accelerate a final diagnosis and positively alter prognosis. Capillaroscopy is fundamental in the diagnosis and differentiation of primary and secondary Raynaud’s phenomenon. It is helpful in the very early stages of systemic sclerosis, along with its role in disease monitoring. An extensive range of pharmacotherapies with various routes of administration are available for Raynaud’s phenomenon but a standardized therapeutic plan is still lacking. This review provides insight into recent advances in the understanding of Raynaud’s phenomenon pathophysiology, diagnostic methods, and treatment approaches.

Is Increased Resting Heart Rate after Radiofrequency Pulmonary Vein Isolation a Predictor of Favorable Long-Term Outcome of the Procedure?

Background: Increased resting heart rate (RHR) after pulmonary vein isolation (PVI) for treatment of atrial fibrillation (AF) is a common observation, possibly resulting from ganglionated plexus modification during ablation. Previous trials have suggested that an increase in RHR after ablation might be related to higher efficacy of the procedure. The aim of this study was to determine whether or not higher increase in RHR after radiofrequency (RF) PVI might predict better long-term outcome of the procedure in a real-life cohort of patients in whom index ablation for paroxysmal AF was performed. Material and methods: The health records of patients who underwent index point-by-point or drag lesion RF PVI for paroxysmal AF in our department between January 2014 and November 2018 were analyzed. Resting heart rate (RHR) was determined from 12-lead ECG recorded prior to the ablation and before discharge to evaluate changes in RHR after PVI. Only patients in sinus rhythm before the procedure and at discharge were included in the analysis. Telephone follow-up was collected for evaluation of arrhythmia recurrence status. Results: A total of 146 patients who underwent PVI for paroxysmal AF were included. Mean follow-up time was 3.5 years. RHR increased from 64 [58.5−70], prior to procedure, to 72 [64.25−80] bpm at discharge (p < 0.001). Higher increase in RHR was not protective from arrhythmia recurrence in long-term observation in both univariable HR = 1.001 (CI 0.99−1.017, p = 0.857) and multivariable analyses HR = 1.001 (CI 0.99−1.02, p = 0.84). Conclusions: RHR after PVI increased in comparison to baseline in our cohort. However, we did not observe higher increase in RHR to be associated with more favorable long-term effectiveness of the procedure.

Sex differences in incidence, management, and outcomes in adult patients aged over 20 years with clinically diagnosed myocarditis in the last ten years: data from the MYO-PL nationwide database

INTRODUCTION

Comprehensive epidemiological data about the course of myocarditis and sex differences are lacking.

OBJECTIVES

To investigate the current differences in the incidence, clinical characteristics, management and outcomes of the males and females with a clinical diagnosis of myocarditis in Poland in the last ten years.  Patients and methods: The nationwide MYO-PL (the occurrence, trends, management, and outcomes of patients with myocarditis in Poland) database identified hospitalization records with a primary diagnosis of myocarditis following the International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), derived from the database of the national healthcare insurer. ClinicalTrials.gov identifier: NCT04827706.

RESULTS

A total of 16,319 patients (4,208 (25.8%) women and 12,111 (74.2%) men) aged over 20 years with a hospital-based clinical diagnosis of myocarditis were included in the study. The females were older than the males (median age 54 (36-70) and 35 (28-47) years, respectively). The incidence of myocarditis was age-, sex- and season-dependent. The incidence rate of myocarditis increased over time only in the males. Although the females were more symptomatic and demonstrated more comorbidities than the males, they were less likely to be admitted to a cardiology ward or undergo diagnostic tests. Regardless of age and sex, patients with myocarditis had a poorer prognosis than the general population. The females aged 21-40 years had a poorer prognosis than the males.

CONCLUSIONS

The incidence of myocarditis was age-, sex- and season-dependent. Significant improvement is required in the management of myocarditis, including the initial diagnostic process, as well as short- and long-term therapy, particularly in women.

A multicenter, randomized, double-blind, placebo-controlled study to evaluate the efficacy of immunosuppression in biopsy-proven virus-negative myocarditis or inflammatory cardiomyopathy (IMPROVE-MC)

BACKGROUND

Myocarditis is frequently associated with poor prognosis as there is no evidence-based treatment. Therefore, current international recommendations indicate that a well-designed prospective trial to confirm benefits from immunosuppressive therapy is highly warranted. The aim of the IMPROVE-MC study is to assess the efficacy and safety of immunosuppressive treatment compared with placebo on top of the guideline-recommended medical therapy in patients with biopsy-proven virus-negative myocarditis/inflammatory cardiomyopathy.

METHODS

The IMPROVE-MC (ClinicalTrials.gov: NCT04654988) is a prospective, randomized, double-blind, placebo-controlled, parallel-group, multicenter trial that will recruit 100 adults, with biopsy-proven myocarditis/inflammatory cardiomyopathy, with left ventricular ejection fraction (LVEF) ≤ 45% and ≥ 3-month history of symptoms. Patients will be randomized (1:1 ratio) to a group treated with prednisone and azathioprine vs. placebo. Patients will undergo 1-year double-blind therapy followed by a 1-year observation period to assess the long-term effects of the treatment. Apart from a routine clinical work-up, all patients will undergo cardiac magnetic resonance (CMR) and biopsy during screening and 1 year after applying the therapy. Primary endpoint is a change from baseline in LVEF at 12 months. Secondary endpoints are related to clinical evaluation (including New York Heart Association class, distance in 6-minute walk test, number of patients with the need for hospitalization), laboratory findings (biomarkers of fibrosis and myocardial necrosis, concentration of anti-heart auto-antibodies, heart tissue immunohistologic assessment), diagnostic tools (e.g., changes of echocardiographic, CMR and Holter-ECG parameters) and quality of life.

CONCLUSIONS

The IMPROVE-MC study will provide high-quality scientific data on the efficacy and safety of immunosuppressive therapy for patients with biopsy-proven myocarditis. Trial registration number and date of registration: ClinicalTrials.gov:NCT04654988; 04/12/2020.

The prevalence and association of major ECG abnormalities with clinical characteristics and the outcomes of real-life heart failure patients-Heart Failure Registries of the ESC

BACKGROUND

Electrocardiogram (ECG) abnormalities increase the likelihood of heart failure (HF) but have low specificity and their occurrence is multifactorial.

AIMS

This study aimed to investigate the prevalence and association of major ECG abnormalities with clinical characteristics and outcomes in a large cohort of real-life HF patients enrolled to HF Registries (Pilot and Long-Term) of the European Society of Cardiology.

METHODS

Standard 12-lead ECG containing at least one of the following simple parameters was considered a major abnormality: abnormal rhythm; > 100 b.p.m.; QRS ≥120 ms; QTc ≥450 ms; pathological Q-wave; left ventricle hypertrophy; left bundle branch block. A cox proportional hazards regression model was used to identify predictors of the primary (all-cause death) and secondary (all-cause death or hospitalization for worsening HF) endpoints.

RESULTS

Patients with abnormal ECG (1222/1460; 83.7%) were older; more frequently were male and had HF with reduced ejection fraction, valvular heart disease, comorbidities, higher New York Heart Association class or higher concentrations of natriuretic peptides than patients with normal ECG. In a one-year observation the primary and secondary endpoints occurred more frequently in patients with abnormal ECG compared to normal ECG (13.8% vs 8.4%; P = 0.021 and 33.0% vs 24.7%; P = 0.016; respectively). Abnormal rhythm, tachycardia, QRS ≥120 ms and QTc ≥450 ms were significant in univariable (both endpoints) analyses but only tachycardia remained an independent predictor of the primary endpoint.

CONCLUSIONS

HF patients with the major ECG abnormalities were characterized by worse clinical status and one-year outcomes. Only tachycardia was an independent predictor of all-cause death.

District versus academic hospital - clinical outcomes of patients with atrial fibrillation. MultiCenter expeRience in Atrial Fibrillation Patients Treated With Oral Anticoagulants (CRAFT) study

INTRODUCTION

Atrial fibrillation(AF) is associated with increased hospitalization.

OBJECTIVES

We aimed to compare long-term outcomes in patients with AF hospitalized in the academic and the district hospital.

PATIENTS AND METHODS

This retrospective observational study included data from MultiCenter expeRience in AFib Patients Treated With OAC (CRAFT;NCT02987062) which encompassed AF patients hospitalized between 2011-2016 in the academic and the district hospitals. Primary endpoint was major adverse events(MAEs) defined as all-cause death, thromboembolic and haemorrhagic events during median 4-year follow up period.

RESULTS

We analysed 2983 AF patients: 2271(76%) patients from the academic and 712(24%) from the district hospitals. Patients treated at the district hospital experienced more often MAEs(53% vs 37%, P<0.001), all-cause death(40% vs 24%, P<0.001) and thromboembolic events(13% vs 7.8%),P<0.001), with similar rate of haemorrhagic events(15% vs 15.0%, P=1.00) as compared to patients treated at the academic hospital. In multivariable logistic regression, in the academic hospital, female sex, coronary artery disease, smoking and antiplatelet drug therapy were identified as significantly associated with a higher likelihood of thromboembolic events. Heart failure, renal failure and vitamin K antagonist (in academic), and coronary artery disease (in district hospital) were significantly associated with a higher likelihood of haemorrhagic events. District (vs academic) conditions were associated with higher risk of MAEs and all-cause death in male patients and those with low bleeding risk, and with higher incidence of thromboembolic events in females, elderly patients and those with high bleeding risk and diabetes.

CONCLUSIONS

AF patients treated at the district hospital have worse long-term outcomes than those treated in academic conditions.

Intestinal barrier integrity in patients with plaque psoriasis

Psoriasis is a chronic inflammatory systemic disease. Growing evidence suggests that human homeostasis depends on a mutualistic relationship with gut bacteria that produce a number of biologically active compounds. Therefore, enteric microbiota dysbiosis with gut barrier disruption may be an important factor in the development of chronic inflammatory diseases. The aim of our study was to assess non-invasive markers of intestinal barrier integrity in patients with moderate to severe psoriasis. Concentrations of claudin-3 (intestinal epithelial tight junction structure) and intestinal fatty acid binding protein (I-FABP; marker of enterocyte damage) were determined in the blood of patients with chronic plaque psoriasis (n = 20) and healthy individuals (n = 20) using commercially available enzyme-linked immunoassay test kits. Claudin-3 concentration was higher in patients with psoriasis compared with healthy control (median, 54.07 vs 42.36 ng/mL; P < 0.001). Patients with psoriasis also had elevated concentration of plasma I-FABP (median, 708.8 vs 147.1 pg/mL; P < 0.05). Our results support the hypothesis that dysfunction of the intestinal barrier in psoriasis disturbs the homeostatic equilibrium between the microbiota and immune system. Further studies are needed in order to develop new therapeutic interventions based on modulation of intestinal permeability.

[Parietal calcifications of the kidney pelvis in Corynebacterium urealyticum urinary infection]

Linear renal pelvis calcifications in a native kidney due to Corynebacterium urealyticum are described. These micro-organisms have an opportunistic behaviour and can be responsible for nosocomial urinary tract infection. Alkaline incrusted cystitis with linear vesical calcifications are considered as the most typical pattern. Renal pelvis may also be concerned, with parietal calcifications.

The WAIS as a lateralizing and localizing diagnostic instrument: a study of 656 patients with unilateral cerebral lesions

A retrospective study of 656 patients with unilateral cerebral lesions is reported. Their performance on a shortened version of the WAIS was assessed in relation to laterality of lesion and to localization of lesion within a hemisphere. The Verbal IQ measure was impaired in all the left-hemisphere localization subgroups compared with the corresponding right-hemisphere localization subgroups. The converse was not the case, the Performance IQ measure was only significantly impaired in two localization groups, the group with lesions restricted to the right parietal lobe and the larger group consisting of all patients with right parietal involvement. With the exception of a selective impairment on the Block Design and Picture Arrangement in the group consisting of all patients with right parietal involvement, there was no evidence of distinctive patterns of impairment associated with any localization subgroup. A right-and left-hemisphere index based on the major laterality impairments were computed for each patient. These indices were used to assess the relationship between aetiology of lesion and sex and patterns of impairment. Although overall hemisphere differences and laterality index differences were obtained, there was only a minor interaction with aetiology and there was no evidence of differential patterns of impairment associated with sex.

Etudes stereochimiques. VIII. Sur la serie exo-maleopimarique

not available