Ambulatory Monitoring Research Articles

Predicting 1-year atrial fibrillation risk from a patch-based ambulatory ECG monitoring without atrial fibrillation

Abstract Introduction Early identification of atrial fibrillation (AF) can enable interventions that reduce cardiovascular events. However, AF remains undiagnosed in about 10-20% of affected individuals, and paroxysmal AF often remains undetected despite the use of in-clinic ECGs, consumer smartwatch ECGs, or ambulatory ECG monitoring. We therefore investigated whether ambulatory ECG patch-based monitoring without AF can predict AF in the subsequent 1-year post monitoring. Purpose This study aims to validate a machine-learning model for AF prediction within 1-year post-wear, based on the observation of non-AF single-lead ECG recordings. Methods We considered a clinically monitored cohort of 67,296 individuals wearing multiple single-lead ECG multi-day ambulatory monitoring patches as part of real-world care. For all selected individuals, the first patch recorded no occurrences of AF and was worn for a minimum of 6.5 days. We assess the risk of future AF based on the raw ECG, heartrate variability, frequency of ectopic beats, age and gender (ECG model), which is then compared with the risk assessment by a model based on age and gender (Baseline model). We then observe AF incidence on subsequent patches worn within one year from the first patch. We evaluated the model's accuracy by observing the number of AF cases identified (or missed) among the individuals with highest risk according to the model. Results In the clinically monitored cohort, a total of 3463 individuals experienced AF within the next year (incidence 5.1%) after a first AF-free monitoring period of a minimum 6.5 days. The receiver operating characteristic (ROC) curve shows an area under the curve (AUC) for the ECG model of 0.75 (95% CI: [0.74, 0.76]), and for the Baseline model of 0.66 (CI: [0.65, 0.67]). When selecting the top 20% (13,459) participants with the highest risk and verifying who developed AF in the following 1-year, we obtain positive prediction value (PPV) or precision of 12% and sensitivity (recall) of 46% for the ECG model (which correctly identifies 1,594 individuals with incident AF), and of 8% and 29%, respectively, for the Baseline model (p-value<0.001). (Figure) Conclusion A machine learning model using as input an AF-free single-lead ECG can quantify the risk of observing AF in a population including individuals with low burdens of paroxysmal or new onset of AF within 1 year. Further research and validation are needed to enhance the interpretability and clinical applicability of the model, while prediction may be further improved with clinical AF diagnoses ascertained from other data sources. The findings of this study have important implications for the early detection and management of AF, potentially enabling earlier intervention and improved outcomes in individuals with undiagnosed AF.

Diagnostic yield of actionable arrhythmias in patients referred with syncope and collapse using ePatch extended holter

Abstract Background/Introduction Cardiac syncope commonly points to a potentially lethal disease process and carries one-year mortality up to 30%. Current guidelines on management of syncope suggest choosing ambulatory monitoring modality based upon the likelihood of symptoms during the monitoring period and is frequently undertaken with short duration (0-2 days) or extended wear Holter (EWH) monitoring (3-14 days). Purpose Determine the diagnostic yield (DY) of actionable arrhythmias (AA) in patients referred for syncope and collapse prescribed short or extended ambulatory monitoring. Methods A retrospective analysis was conducted for patients wearing the Philips ePatch between July 1st, 2022, and June 30th, 2023, with ICD-10 referral code R55 (Syncope and Collapse). Monitoring duration was grouped by 0-2, 3-7, and 8-14 days of wear time. Wear time was defined as number of hours with analysable ECG data. Arrhythmia detection was defined as either non-AA (did not meet urgent or emergent criteria) or AA (met urgent and/or emergent criteria). Urgent criteria were defined as Atrial Fibrillation/Flutter (>10 seconds), Ventricular Tachycardia (>100 BPM for >3 beats), Severe Tachycardia (>170 BPM for ≥30 seconds), Pause/Asystole (≥3 seconds), Severe Bradycardia (<35 BPM), and 2nd Degree or Higher AV Block. Emergent criteria were defined as VT (>100 BPM for ≥30 beats), Severe Tachycardia (≥220 BPM for ≥30 seconds), Pause/Asystole (≥10 seconds), and Severe Bradycardia (<20 BPM). Results The DY for any urgent and/or emergent AA was 6.8%, 11.0%, and 20.4% at 0-2, 3-7 and 8-14 days of wear time, respectively (p<0.00001 for all). For urgent AA, DY increased 1.6X at 3-7 vs 0-2 days, 1.9X at 8-14 vs 3-7 days and 3X at 8-14 vs 0-2 days of wear time (p<0.05 for all); for emergent AA, the DY increased 5X at 3-7 vs 0-2 days, 1.6X at 8-14 vs 3-7 days, and 8.2X at 8-14 vs 0-2 days of wear time (p<0.05 for all) (Graph 1). When examining tachyarrhythmias vs bradyarrhythmias, similar multiplicative yields in AA were noted between short, intermediate, and extended duration monitoring; statistical significance was noted for all arrhythmia subtypes (p<0.01), except for Severe Tachycardia and Bradycardia which were not significant between 0-2 and 3-7 days of wear time (Graph 2). Conclusion(s) In patients referred for ambulatory monitoring with syncope and collapse, urgent and emergent actionable arrhythmias increase significantly when extending from short to intermediate to long duration monitoring, with both tachyarrhythmias and bradyarrhythmias demonstrating similar increases in occurrence. Accordingly, EWH monitoring in patients referred with syncope and collapse has greater potential to identify arrhythmic aetiologies than use of standard duration Holter.

Prediction of nonsustained ventricular tachycardia development by the analysis of premature ventricular complex-related intervals on 24-hour rhythm monitoring and testing a novel index

Abstract Introduction Ventricular tachycardia (VT) and ventricular fibrillation (VF) are life- threatening arrhythmias, with non-sustained ventricular tachycardia (NSVT) serving as a potential precursor. Identifying individuals at risk of NSVT is crucial for effective management and prevention of sudden cardiac death in high-risk patients. In daily clinical practice, premature ventricular complex (PVC) and sometimes NSVT are frequently detected on 24-hour ambulatory rhythm monitoring. Purpose In this study, we aimed to predict the development of NSVT by analyzing PVC morphology and intervals in 24- hour ambulatory rhythm monitorings. Methods A retrospective analysis of 24-hour ambulatory rhythm monitoring recordings from 2018 to 2023 was conducted. Inclusion criteria required clear measurement of PVC intervals, at least 100 PVC in the recording, and two preceding normal QRS beats. NSVT diagnosis was based on four consecutive PVC lasting <30 s and a rate >100/min. Various PVC-related parameters were analyzed, and new variables were derived. Statistical analysis included Mann-Whitney U tests and ROC analysis. Results The study included 202 patients, revealing significant differences in several VES temporal variables between groups with only PVC (Group I) and PVC with NSVT (Group II). Notably, Age-Adjusted Sum of Intervals Index (AASI Index-(100 x [(Tp-to- QRSvpa)+(coupling time)+(Qtc1)]/age), long coupling times, extended Tp-to-QRSvpaintervals, and prolonged Tpe-vpa intervals were associated with NSVT development. Age played a pivotal role in predicting NSVT when integrated into a specific variable AASI index. The optimal cut-off value was 4.21, with 84% sensitivity and specificity. Conclusion The study suggests that ventricular arrhythmias may be predicted using temporal parameters of PVC, especially when age is included as a modifier. The AASI index calculated on a PVC and preceeding two normal beats on 24-hour ambulatory rhythm monitoring seems to be promising parameter. These findings hold potential for future development of artificial intelligence-based algorithms for use in any PVC to identify at-risk patient groups, provided larger datasets are utilized to refine predictive models.Variables included in the analysis for cDefinitions of variables and ROC curve

Antihypertensive treatment of masked hypertension guided by ambulatory blood pressure monitoring: a double-blind, placebo-controlled trial

Abstract Background Masked hypertension, office normotension combined with out-of-office hypertension, is associated with target organ damage (TOD), but whether antihypertensive treatment guided by out-of-office blood pressure (BP) would reduce TOD is unproven. Purpose To assess TOD change on antihypertensive treatment guided by ambulatory BP monitoring. Methods We conducted a double-blind, placebo-controlled randomized trial at 15 Chinese hospitals. Enrolment started on February 14, 2017 and follow-up ended on October 31, 2021. Patients of either sex, aged 30-70 years, not on antihypertensive drugs were eligible, if at two screening visits 1-week apart office BP was <140/<90 mm Hg and the 24 hour, daytime or nighttime ambulatory BP was ≥130/≥80, ≥135/≥85, or ≥120/≥70 mm Hg, respectively. Patients had ≥1 sign of TOD: ECG left ventricular hypertrophy (LVH), brachial-ankle pulse wave velocity (baPWV) ≥1400 cm/s, or urinary albumin-to-creatinine ratio (ACR) ≥3.5 mg/mmol in women and ≥2.5 mg/mmol in men. Active antihypertensive treatment consisted of allisartan starting at 80 mg/day to be increased to 160 mg/day at month 2 and to be combined with amlodipine 2.5 mg/day at month 4, if the ambulatory BP remained uncontrolled. Matching placebos were used likewise in the control group. The primary endpoint included normalization of baPWV, ACR or LVH or ≥20% reduction in baPWV or ACR. Results Of 320 patients (43.1% women; mean age 54 years), 153 were randomized to active antihypertensive treatment and 167 to placebo. At baseline, office BP averaged 130/81 mm Hg and the 24 hour BP 136/84 mm Hg. The prevalence of elevated baPWV, ACR and LVH was 97.5%, 12.5%, and 7.8%. The 24-hour systolic/diastolic decreased by 9.0/5.6 mm Hg (95% CI: 7.5-10.5/4.8-6.5 mm Hg) on active treatment and by 1.4/1.0 mm Hg (-0.1-2.8/0.2-1.8 mm Hg) on placebo. Regression of TOD, the primary outcome, occurred more frequently in patients randomized to active treatment than in those assigned to placebo with 1 year rate of 45.8% (95% CI: 37.9-53.7%) and 25.8% (19.1-32.4%), respectively (P<.001 for between-group differences in BP and TOD). Per-protocol and subgroup analyses were confirmatory. Conclusions Masked hypertensive patients require antihypertensive treatment guided by out-of-office BP monitoring before subclinical TOD progresses to major cardiovascular complications.

Adverse Myocardial and vascular side effects of Immune Checkpoint Inhibitors: a prospective multimodal cardiovascular assessment (AMICI study)

Abstract Background Immune checkpoint inhibitors (ICIs) are transformative treatments in oncology, yet they are also associated with a range of cardiovascular (CV) events. Purpose To identify the incidence of CV events (including subclinical) in patients receiving ICIs for solid cancer, either alone or in association with other cancer therapies (e.g., chemotherapies, target therapies). Objectives and methods The Adverse Myocardial and vascular side effects of Immune Checkpoint Inhibitors(AMICI) study prospectively assessed the incidence of CV changes by means of a thorough multimodal assessment. This included repeated CV imaging (transthoracic echocardiograms (TTE), cardiac magnetic resonance imaging (CMR)), serum biomarkers (troponin, brain natriuretic peptides in a single laboratory), and ambulatory ECG monitoring, before and during (at 6 weeks and at 6 months) ICI therapy (Figure). Cardiovascular events included myocarditis, pericarditis, acute coronary syndrome, heart failure (HF), high degree conduction abnormalities (defined as new grade 2 or 3 atrioventricular block) or sustained ventricular arrhythmias (defined as 3 or more ventricular beats at a rate ≥ 120/min), CV death as a composite endpoint, validated by an independent expert panel Results Out of 130 solid cancer patients considered for ICI therapy, 49 patients (38 (77.6%) male; mean age 64.3 (­SD 11.0) years old) were included (June 2020 -December 2021). 22 (55.1%) suffered from kidney or bladder cancer; 7 (14.3%) had CV disease prior to cancer diagnosis; 4 (8.2%) received PD1 and CTLA4 inhibitors. Early CV events were observed in 9 (18.4%) patients at mean 40.1 (SD 5.9) days, with heart failure (HF) in 5 (10.2%), ventricular arrhythmias or new conduction disorders in 4 (8.2%) patients. History of AF (HR 4.49 (CI 1.11-18.14), P=0.035) predicted early CV events at 6 weeks (Table). At 6 months follow-up, 18 CV events were observed in 15/49 (31%) patients, with 6 (12.2%) HF events, 5 (10.2%) significant ventricular arrhythmias or conduction disorders and 4 (8.2%) AF. There was a significant decline in LVEF (P<0.001) in patients even in the absence of CV event (P=0.003) or HF (P=0.003). Higher creatinine at inclusion (HR 0.99 [0.98-1.00], P=0.006) predicted HF. Conclusions Cardiovascular complications arising during cancer treatment with ICIs are primarily due to the exacerbation of pre-existing HF or the onset of non-inflammatory heart rhythm disorders. The majority of these CV changes manifest shortly after starting ICIs and do not need hospital admission. Our results suggest that more close follow-up may be needed in patients with underlying CV conditions when starting ICI therapy, by means of CMR and ambulatory ECG holter monitoring.

Quality of life measures with etripamil self-administration for acute episodes of paroxysmal supraventricular tachycardia in a medically unsupervised setting: patient-reported outcomes from NODE-303

Abstract Background Etripamil nasal spray (NS) is a fast-acting, self-administered calcium-channel blocker in development for the conversion of AV-nodal dependent paroxysmal supraventricular tachycardia (PSVT) in a medically unsupervised setting. Prior studies show favorable safety and efficacy in converting single episodes of PSVT to sinus rhythm (SR). Purpose In NODE-303, patient-reported outcome (PRO) instruments assessed quality of life (QoL) over multiple etripamil-treated episodes of PSVT. Methods NODE-303 was an event-driven, multi-center, open-label Phase 3 study in North and South American patients with documented PSVT that evaluated the safety and efficacy of etripamil in PSVT termination, over multiple episodes and without the need for prior test dosing. Enrolled patients who perceived PSVT symptoms applied an ambulatory ECG cardiac monitoring system (CMS), performed a pre-trained vagal maneuver and, if symptoms persisted, self-administered etripamil NS 70 mg. A study amendment allowed a repeat dose (etripamil NS, 70 mg) if symptoms persisted 10 min after the first dose. Each patient could self-treat up to 4 episodes. Safety was assessed through adverse events, clinical data, and ECG CMS recordings. The Treatment Satisfaction Questionnaire for Medication (TSQM; validated for acute episodic assessments) and other PROs were administered, and healthcare utilization data were acquired. Patients completed PROs at baseline (BL), monthly, and per PSVT episode, which collected information on symptoms, episode characteristics, rescue medications, and emergency room visits. Additional PROs were the Brief Illness Perception Questionnaire (BIPQ), Cardiac Anxiety Questionnaire (CAQ), and 36-Item Short Form Health Survey (SF-36). Results There were higher proportions of patients reporting mild, minimal or no disease severity, every 6 months, than at BL; extremely severe, severe, and moderate disease severity was reported by smaller proportions of patients than at BL, though incomplete surveys at later visits may limit this analysis. Anxiety and stress about future PSVT episodes were consistently reduced from BL. Measures of treatment satisfaction, effectiveness, and convenience were consistent across multiple episodes, and were at levels considered favorable for the TSQM instrument (Table 1). Rates of emergency-room visits and hospital admissions across multiple, treated PSVT episodes were similar to those observed in trials assessing single episodes (Table 2). The BIPQ, CAQ or SF-36 had no notable changes from BL. Conclusions Etripamil self-administration was associated with patient-reported improvements in degree of disease severity, decreased anxiety and stress over future PSVT episodes, and levels of treatment satisfaction, effectiveness, and convenience considered favorable for respective PRO instrument. Using a symptom-prompted, self-administered treatment for PSVT could potentially improve QoL measures and reduce healthcare resource utilization.

Differential impact of clinic BP target on the prevalence and predictors of the masked uncontrolled hypertension and white-coat uncontrolled hypertension

Abstract Background Although intensive blood pressure (BP) control have been advocated, major clinical practices guidelines still recommend clinic BP (cBP) < 149/90 mmHg as the target for antihypertensive therapy. But, cBP targets could influence the prevalence and predictors of any hypertension phenotype. We investigated how different cBP targets impacted on the prevalence and predictors of masked uncontrolled hypertension (MUCH) and white-coat uncontrolled hypertension (WUCH) using the Korean Ambulatory Blood Pressure (KorABP) registry. Methods A multicenter prospective longitudinal cohort study was performed in outpatients with hypertension. Among 5,965 patients enrolled in the KorABP registry, 1,601 patients on antihypertensive medications with a valid ambulatory BP monitoring record were included in this study. Two different cBP targets, <130/80mmHg (intensive) and <140/90 mmHg (conventional) were investigated. Results Controlled ambulatory BP (aBP; <130/80 mmHg) was observed in 472 patients (29.5%). Controlled cBP was shown in 348 patients (21.7%) with the intensive cBP target and in 697 patients (43.5%) with the conventional cBP target. Controlled hypertension, WUCH, MUCH and uncontrolled hypertension were found in 294, 174, 54, and 1,075 patients with the intensive target and in 378, 94, 319 and 810 patients with the conventional target, respectively. Among the patients with controlled cBP, the prevalence of MUCH markedly decreased with the intensive target (15.5%), compared to the conventional target (45.8%). In contrast, among the patients with uncontrolled cBP, the prevalence of WUCH had only 3.8% increase with the intensive target (10.4%), compared to the conventional target (14.2%) (Figure 1). With the conventional target, 75.9% of patients with MUCH had cBP between 130/80 mmHg and 139/89 mmHg. The concordance between the controlled aBP and controlled cBP was higher with the intensive target than with the conventional target (Cohen’s κ 0.62 [0.58-0.67] vs. 0.46 [0.41-0.50]). The logistic models for MUCH included the left ventricular mass index and underuse of antihypertensive drugs (<2 types of drugs) as the common predictors of the both targets. With the conventional target, clinic systolic BP and diastolic BP were the strongest predictors of MUCH, but the cBP was not a predictor of MUCH with the intensive target. The logistic models for WUCH included beta-blocker use, increased heart rate and lower waist circumference and clinic systolic BP as the common predictors of WUCH with the both target. The logistic model for MUCH performed better with the conventional target, whereas the logistic model for WUCH performed better with the intensive target (Figure 2). Conclusion The use of the intensive cBP target (<130/80 mmHg) could reduce the prevalence of MUCH with minimal increase in the prevalence of WUCH and would provide the better assessment for the BP control status than the use of the conventional cBP target (<140/90 mmHg).Figure 1Figure 2

Identification of the optimal method for measuring left atrium volume as a marker of undetected atrial fibrillation in patients with cryptogenic stroke and high prevalence of overweight

Abstract Introduction Paroxysmal atrial fibrillation (AF) is detected in approximately one-third of patients diagnosed with cryptogenic stroke undergoing prolonged ECG monitoring. Several risk factors for AF have been described, including left atrium (LA) enlargement, LA deformation, age, cardiovascular risk factors, and biomarkers as N-pro-BNP and troponin. Specifically, LA enlargement is a direct marker of atrial cardiopathy, which predisposes to AF. However, the methods to calculate LA enlargement vary. While LA biplane volume indexed to body surface area (BSA) remains the standardized method of choice according to current guidelines, it may underestimate the degree of enlargement in overweight patients. Additionally, overweight produces a systemic inflammatory state which is also associated with AF. Purpose The primary objective of the study was to define the best parameter among LA end systolic volume (LAESV), LAESV indexed to BSA (LAESV/BSA), and LAESV indexed to ideal BSA for identifying patients admitted for cryptogenic stroke with undetected paroxysmal AF. The secondary objective was to assess the accuracy of these parameters in both normal-weight and overweight patients. Methods Consecutive patients over 65 years-old diagnosed with cryptogenic stroke in our tertiary hospital were enrolled. All patients underwent 15-days ambulatory ECG monitoring to screen for undetected paroxysmal AF. Clinical, echocardiographic and laboratory data were prospectively collected. Ideal BSA was calculated using the Devine method. The accuracy of LA volume parameters in classifying patients with undetected paroxysmal AF was assessed using the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. The analysis was stratified for overweight status (BMI < 25 or BMI ≥ 25). Results A total of 66 patients (Mean age 78.4 ± 7.6 years; 48% male) were included. Of them, 39 (59%) had hypertension, 16 (24%) had diabetes and 39 (59%) were overweight. AF was present in 21 (32%) patients. The mean LAESV, LAESV/BSA, LAESV/ideal BSA were 56.2 ± 23.0 ml, 34.2 ± 12.6 ml/m2, and 34.7 ± 14.1 ml/m2, respectively. Figure 1 illustrates the ROC curves for LA volume parameters in the main cohort and stratified by overweight status. Overall, no relevant differences in AUC were observed among LAESV, LAESV/BSA, LAESV/ideal BSA in each scenario. However, BMI significantly altered the discrimination performance of LA volume measures, which resulted optimal in normal-weight patients (AUC from 0.838 to 0.886) and absent in overweight patients (AUC from 0.838 to 0.521 to 0.564). Conclusions LAESV, LAESV/BSA, LAESV/ideal BSA show similar discrimination performance in identifying undetected AF in patients with cryptogenic stroke. However, the presence of overweight considerably impacts on the predictive value of LA volume parameters in this clinical scenario.ROC curves

Treadmill exercise test as a screening tool in the development of hypertension

Abstract Background Guidelines promote screening people with high normal BP for the presence of end-organ damage because their presence is associated with a 2- to 3-fold increase in the risk of CVD. Purpose Office blood pressure measurements may be unable to detect early subclinical cardiac damage of adverse prognostic significance in subjects with high normal blood pressure. Methods 100 consecutive subjects with high normal BP [systolic BP=130-139mmHg and/or diastolic BP=85-89mmHg] were examined for early signs of hypertension-mediated organ damage (HMOD). They underwent an echocardiographic study, a negative for ischemia treadmill exercise test (Bruce protocol) where the index SBP/MET-slope [(peak SBP—resting SBP)/(peakMET-1)] was used. Arterial stiffness was evaluated based on carotid-femoral pulse wave velocity (PWV). The sympathetic drive was assessed by MSNA. Follow-up was scheduled every 6 months for 3 consecutive years, where BP measurements were assessed in the office and with ambulatory BP monitoring (ABPM). All participants offered lifestyle advice to lower their BP. The endpoint was the development of HTN either with Office BP or ABPM. Results Of 100 subjects (54±8 years, 42 males, baseline office BP: 132/82 mmHg, 24-hour BP: 122/76 mmHg), 40 developed HTN in 3 years. 34 subjects developed Hypertensive Response to Exercise (HRE) (BP >210mmHg in men and >190mmHg in women) and all of them developed HTN. The SBP/MET-slope in future hypertensives was increased in all stages till peak exercise independently of sex type (stage1: 6.7vs4.9 p=0.049, stage2: 8.4vs4.8 p=0.001, peak: 6.7vs4.9, p=0.001). Their exercise capacity was reduced (10vs11.3METs, p=0.002) as well as their maximum exercise heart rate (156vs164, p=<0.0001). Those with HRE had higher 24hSBP (124vs121mmHg, p=0.009), Night SBP (117vs111mmHg, p<0.001), Day SBP (127vs124mmHg, p=0.012) Office Pulse Pressure (51vs47mmHg, p=0.01). Additionally, they had increased PWV (8.3vs7.5m/sec, p=<0.0001), MSNA levels (36vs28 bursts, p=<0.0001), LVMI (38vs34 gr/m2.7, p=0.02), and a statistically significant deterioration of 2021 CKD-EPI eGFR (90 vs 97 mL/min/1.73 m², p=0.02). All of them correlated with development of hypertension (p=0.002), while they did not differ regarding their metabolic profile at the follow-up. Conclusion Detecting exaggerated blood pressure response and specifically an increased SBP/MET-slope in the end of second stage of Bruce protocol at treadmill exercise test is associated with increased systemic vascular resistance and early subclinical HMOD which may upgrade an individual’s cardiovascular disease (CVD) risk as they progress to HTN indicating a need for instituting a BP-lowering strategy.

The effect of spironolactone versus eplerenone on blood pressure targets in resistant hypertension patients

Abstract Objective to evaluate different effects on blood pressure (BP) control in two treatment options spironolactone (SPIR) versus eplerenone (EPL) as an add-on therapy in resistant hypertensive (RAH) patients. Design and methods: We studied 208 patients with true RAH confirmed by the office and ambulatory BP monitoring (ABPM) despite the use of 3 antihypertensive medications including a calcium channel blocker, a blocker of the renin-angiotensin system, and a thiazide diuretic with maximally tolerated doses for at least 3 months. Patients were randomized into 2 groups throughout 12 weeks of once-daily treatment with SPIR (25–50 mg) or EPL (25-50 mg) in addition to their baseline triple-combination and then rotated with drugs. BP was measured in the office and by ABPM. Changes in laboratory tests were also studied. The predictive values of plasma aldosterone, active renin concentration (ARC), aldosterone-renin ratio (ARR), and serum potassium were analyzed to determine the antihypertensive response. Results There were no significant differences in the reduction of average office BP, average systolic 24-h, daytime, and nighttime BP by SPIR and EPL. SPIR reduced average diastolic 24-h BP by 7.3 mm Hg, diastolic daytime BP by 7.2 mm Hg, and diastolic nighttime BP by 7.5 mm Hg compared with a reduction of 5.6 mm Hg (P = 0.01), 5.6 mm Hg (P = 0.03) and 4.2 mm Hg (P = 0.0001) with EPL, respectively. Overall, 40.7 % RAH patients achieved targets of clinical BP and 24-h ABPM levels on SPIR and 33.3 % on EPL (Р = 0.002). After 12 weeks of treatment mean plasma potassium concentrations increased by 7.1 (P = 0.0001) on SPIR and by 5.0 % (Р = 0.0001) on EPL, but eGFR did not significantly change on the two drugs. Plasma aldosterone (β = 0.498, Р = 0.02) and ARC (β= -0.374, Р = 0.04) were predictors of the BP-lowering effect of SPIR and plasma aldosterone (β = 0.453, Р = 0.04) was a predictor of reduction BP for EPL in multivariate modeling. Breast pain or tenderness, changes in sex drive, and irregular menstrual cycles or spotting were more often by SPIR than by EPL (5.2 % vs 1.9 %, respectively, P = 0.04). Conclusions The greater antihypertensive effect of SPIR is related to aldosterone status, ARS level in resistant hypertension. EPL may be recommended for RAH patients who have high serum potassium levels that cannot tolerate spironolactone and for people with systolic resistant hypertension.

Prevalance and impact of concomitant atrial fibrillation in patients undergoing percutaneous coronary intervention for acute myocardial infarction

Abstract Introduction Atrial fibrillation (AF) is a common cardiac arrhythmia associated with coronary artery disease (CAD) and myocardial infarction (MI). The prevalence of AF in patients following acute MI varies, with conflicting evidence on its impact on outcomes. Concomitant atrial fibrillation is associated with an adverse prognosis in patients with acute myocardial infarction (MI). However, it remains unclear whether this is due to a causal effect of AF, or whether AF acts as a surrogate marker for comorbidities in this population Also, there are limited data on whether coronary artery disease distribution impacts the risk of developing AF. Purpose This large cohort study aims to determine the prevalence of AF in acute MI patients treated with PCI, assess its independent prognostic value for MACCE, investigate the association of AF with CAD distribution patterns, and provide insights into the long-term outcomes of AF in this patient population. Methods A cohort of 1000 consecutive MI patients treated with PCI was retrospectively analyzed. Data on demographics, medical history, presentation, treatment, and outcomes was collected. Propensity score matching was used to adjust for baseline differences between AF and non-AF groups. CAD distribution, major adverse events, and MACCE were assessed using statistical analyses. Results Amongst the studied population, 6.5% people had AF (65/1000) and it was noted that those with AF had a worse outcome. However, on statistical analyses (both on multivariable cox and propensity matching) accounting for risk factors, outcomes were not significantly different between those with and without AF. Hence, this negated key baseline differences between AF and non-AF groups, with no significant differences in demographics or presentation. Patients with AF had a higher prevalence of severe CAD in the left main stem (LMS) and left circumflex artery (LCx). The association of AF with MACCE was not significant in the matched groups. Long-term follow-up revealed similar rates of MACCE between AF and non-AF groups. Discussion AF in acute MI patients undergoing PCI is associated with a higher prevalence of severe CAD in the LMS and LCx. AF appears to be a surrogate marker of other risk factors, rather than an independent risk factor for MACCE. The study highlights the need for tailored aggressive treatment for risk factor modification in AF patients with MI. Conclusions AF is associated with an increased risk of MACCE in acute MI patients undergoing PCI. However, this association is primarily driven by the burden of comorbidities associated with AF, emphasizing the importance of tailored treatment strategies for AF patients. Prospective studies with routine ambulatory monitoring are recommended to validate these findings and guide future practice.

Prognostic value of hypoxaemic burden from overnight oximetry in heart failure with preserved ejection fraction.

Nocturnal hypoxaemic burden, quantified as time spent with oxygen saturation below 90% (T90), is an established independent predictor of mortality in heart failure (HF) with reduced ejection fraction. The prognostic value of T90 in HF with preserved ejection fraction (HFpEF) is unknown. This study aims to determine the association of T90 with adverse outcomes in HFpEF. One hundred twenty-six patients prospectively included from our specialised HFpEF outpatient clinic underwent ambulatory home sleep monitoring to obtain oximetry data, including T90. We investigated the association between T90 and a composite endpoint of HF hospitalisations or all-cause mortality. Nocturnal hypoxaemic burden in this HFpEF population was high, with a median T90 of 13.7min. In only 10 patients (7.9%), oxygen saturation was at no time point below 90%. After median 34months [IQR 18.4-52.0] of follow-up, 32 patients (25%) reached the composite endpoint. T90 was significantly associated with the composite endpoint, also after adjusting for potential confounders (HR 1.004 (95% CI 1.001-1.007, P=0.019) per 1min T90 increase or HR 1.265 (95% CI 1.061-1.488) per 1h T90 increase). Patients with HFpEF in the highest T90 tertile (T90≥31.4min) had a significantly higher event rate compared to patients in the lowest two T90 tertiles, with 19 (45%) versus 13 (15%) events, respectively (P<0.001). Nocturnal hypoxaemic burden is an independent prognostic marker for the composite of HF hospitalisations or all-cause mortality in HFpEF. Whether reduction of T90 improves the prognosis of patients with HFpEF warrants further research.

Real-Time Ambulatory ECG Does Not Expedite Care.

Ambulatory ECG (AECG) monitoring is pivotal to the diagnosis of arrhythmias and can be performed with near "real-time" notification of abnormalities. There are limited data on the relative benefit of real-time monitoring compared with traditional Holter monitoring. This is a retrospective observational analysis of University of Utah Health patients who underwent ambulatory ECG studies from 2010 to 2022. The study cohort was stratified by patients with an ambulatory ECG that provides real-time event notification (non-Holter) versus those who do not (Holter). The outcomes were cardiac implantable electronic device procedure, ablation procedure, emergency department/hospitalization visit, and initiation of anticoagulation out to 6 months. We identified 20 259 patients, 16 650 with non-Holter studies and 3609 with Holter studies. Holter patients were younger (mean 52 versus 55, P<0.001), more often women (60.2% versus 57%, P<0.001), and had lower mean CHADS2-VA2Sc scores (1.7 versus 2.1, P<0.001). The median time to ablation procedure was 74 versus 72 (P=0.5), for Holter versus non-Holter, respectively. Median days to new cardiac implantable electronic device implantation was 54 days versus 52 (P=0.6); initiation of anticoagulation among patients not already treated was 42 versus 31 days (P=0.03). Time to first emergency department visit or hospitalization was 63 versus 57 (P=0.6). In multivariable models, there were no significant differences in time to intervention between Holter and non-Holter for each outcome. Real-time monitoring demonstrates mixed results in terms of reducing time to intervention, with the significant benefit limited to oral anticoagulation initiation. It is time to revisit clinical scenarios where real-time ambulatory monitoring may not improve health care efficiency.

Expanding Insights on Ambulatory Reflux Monitoring: Future Directions and Clinical Integration.

Expanding Insights on Ambulatory Reflux Monitoring: Future Directions and Clinical Integration.

Comparison of daytime and nighttime supine gastroesophageal reflux by pH monitoring of individuals with clinical suspicion of gastroesophageal reflux disease.

This study aims to compare pHmetric characteristics of diurnal and nocturnal supine reflux. We studied 500 consecutive individuals with clinical suspicion of gastroesophageal reflux disease (GERD) who underwent esophageal high-resolution manometry and prolonged ambulatory pH monitoring. Patients were classified with supine GERD pattern when the percentage of acid reflux time in the supine position was equal to or greater than 2.2%. Data on acid reflux in the supine position during daytime and nighttime recumbency were: (i) acid exposure time, (ii) number of reflux episodes, (iii) longest reflux episode, (iv) interval between the last meal and the supine position, (v) interval between the supine position and the first acid reflux episode, and (vi) reported symptoms. Of the 500 evaluated patients, 238 (48%) had GERD. Among these, supine pattern was observed in 134 (56%) patients, bipositional in 53 (23%), and orthostatic in 51 (21%). In patients with daytime recumbency, 112 (51% of 217) were pathological refluxers, with a mean DeMeester score of 45 ± 26. Total acid exposure time (P = 0.8) and reported Symptom Index (P = 0.2) did not differ depending on the period, whether diurnal or nocturnal. All other pHmetric parameters were lower during daytime recumbency. In conclusion, diurnal supine reflux has similar acid exposure time and temporal correlation between symptoms and reflux episodes as nocturnal supine reflux. Other pHmetric parameters are lower for diurnal supine reflux.

Update Motility Disorders: Gastro-Oesophageal Reflux Disease – Diagnostic and Conservative Approach

Background: Gastro-oesophageal reflux disease (GORD) is extremely common, with at least 1 in 10 people in the general population reporting heartburn and acid regurgitation on a weekly basis. GORD can also be associated with a variety of atypical symptoms, including chest pain, chronic cough, and laryngopharyngeal symptoms. The causes of GORD are multifactorial, and the severity of symptoms is influenced by peripheral and central factors, including psychosocial stress and anxiety. Therefore, for a variety of reasons, no single investigation provides a definitive diagnosis, and standard treatment with acid suppressants is not always effective. Summary: This review introduces the Lyon Consensus, now in its second iteration, a classification system that provides a “conclusive” positive or negative diagnosis of GORD by integrating the results of endoscopy, ambulatory reflux monitoring, and high-resolution manometry. Different algorithms are applied to patients with high and low pre-test probability of a causal relationship between reflux episodes and patient symptoms. The results of these studies identify patients with “actionable” results that require escalation, revision, or discontinuation of GORD treatment. Guidance is provided on the range of conservative treatments available for GORD, including dietary and lifestyle advice, antacids and alginates, and drugs that suppress acid secretion. Key Messages: GORD is a common disorder; however, the causes of reflux and symptoms can be complex. As a result, the diagnosis can be missed, and management is sometimes challenging, especially for patients with atypical symptoms. The Lyon classification establishes a conclusive diagnosis of GORD, based on results of endoscopic and physiological investigation. Typical symptoms usually respond to empiric use of alginate-antacid preparations and acid suppression; however, the management of treatment refractory symptoms is tailored to the individual.

Cardiac involvement in a female patient with Beçhet’s disease Newer diagnostic and therapeutic approaches: a case report

Abstract Background Behçet’s disease (BD) is a multisystemic chronic inflammatory disorder. Cardiac manifestations in BD are extremely rare. There have been no reports of cardiac involvement of BD and especially endomyocardial fibrosis in left ventricle. Case summary A 50-year-old woman presented at the emergency department experiencing palpitations and fatigue, accompanied by elevated levels of B-type natriuretic peptide. Her medical history included mucocutaneous involvement of BD. Vital signs were within normal ranges and electrocardiography showed a normal sinus rhythm. Physical examination did not reveal any pathological findings. The 24-hour ambulatory electrocardiogram monitoring indicated sinus rhythm with premature ventricular contractions. Transthoracic echocardiography demonstrated a reduced left ventricle ejection fraction. Further investigation with cardiac magnetic resonance imaging reported diffused areas of subendocardial enhancement, indicative of fibrosis likely due to vasculitis probably associated with BD. The patient was administered tartrate metoprolol, eplerenone, dapagliflozin in addition to the ongoing medical treatment for BD, which included methylprednisolone, colchicine and apremilast. This treatment approach resulted in an improvement in the patient’s clinical condition. Discussion This case highlights that diffuse subendocardial fibrosis of the left ventricle (LV) may be associated with the underlying BD.

Blood Pressure on Ambulatory Monitoring and Risk for Cardiovascular Disease and All-cause Mortality: Ecological Validity or Measurement Reliability?

The association with cardiovascular disease (CVD) is stronger for mean systolic blood pressure (SBP) estimated using ambulatory blood pressure monitoring (ABPM) versus office measurements. Determining whether this is due to ABPM providing more measurement reliability or greater ecological validity can inform its use. We estimated the association of mean SBP based on 2 office measurements and 2, 5, 10, and 20 measurements on ABPM with incident CVD in the Jackson Heart Study (n=773). Hazard ratios (HRs) for CVD were estimated per standard deviation higher mean SBP. CVD events were defined by incident fatal or non-fatal stroke, non-fatal myocardial infarction, or fatal coronary heart disease. There were 80 CVD events over a median 15 years. The adjusted HRs for incident CVD were 1.03 (95%CI: 0.90-1.19) for mean office SBP and 1.30 (95%CI: 1.12-1.50), 1.34 (95%CI: 1.15-1.56), 1.36 (95%CI: 1.17-1.59), and 1.38 (95%CI: 1.17-1.63) for mean SBP using the first 2, 5, 10 and 20 ABPM readings. The difference in the HRs for incident CVD ranged from 0.26 (95%CI: 0.07-0.46) to 0.35 (95%CI: 0.15-0.54) when comparing mean office SBP versus 2, 5, 10, or 20 sequential ABPM readings. The association with incident CVD was also stronger for mean SBP based on 2, 5, 10, and 20 randomly-selected ABPM readings versus 2 office readings. Mean SBP based on two ABPM readings versus two office measurements had a stronger association with CVD events. The increase in the strength of the association with more ABPM readings was small.

Electrocardiographic Clues for Early Diagnosis of Ventricular Pre-Excitation and Non-Invasive Risk Stratification in Athletes: A Practical Guide for Sports Cardiologists.

Ventricular pre-excitation (VP) is a cardiac disorder characterized by the presence of an accessory pathway (AP) that bypasses the atrioventricular node (AVN), which, although often asymptomatic, exposes individuals to an increased risk of re-entrant supraventricular tachycardias and sudden cardiac death (SCD) due to rapid atrial fibrillation (AF) conduction. This condition is particularly significant in sports cardiology, where preparticipation ECG screening is routinely performed on athletes. Professional athletes, given their elevated risk of developing malignant arrhythmias, require careful assessment. Early identification of VP and proper risk stratification are crucial for determining the most appropriate management strategy and ensuring the safety of these individuals during competitive sports. Non-invasive tools, such as resting electrocardiograms (ECGs), ambulatory ECG monitoring, and exercise stress tests, are commonly employed, although their interpretation can sometimes be challenging. This review aims to provide practical tips and electrocardiographic clues for detecting VP beyond the classical triad (short PR interval, delta wave, and prolonged QRS interval) and offers guidance on non-invasive risk stratification. Although the diagnostic gold standard remains invasive electrophysiological study, appropriate interpretation of the ECG can help limit unnecessary referrals for young, often asymptomatic, athletes.

Cardiopulmonary Fitness and Personalized Exercise Prescription in Patients With Hypertrophic Cardiomyopathy.

Patients with hypertrophic cardiomyopathy (HCM) are generally restricted regarding participation in competitive sports based on the potential risk of sudden cardiac death and malignant arrhythmias. As a result, they are often inactive and experience the negative consequences of a sedentary lifestyle. Hence, the need arises to strike the right balance between these 2 extremes through personalized exercise prescription. The aims of this study were (1) to assess the characteristics of patients with HCM practicing regular aerobic physical activity compared with sedentary patients; (2) to perform a personalized moderate-intensity exercise prescription and evaluate its effects. Patients with HCM were evaluated through clinical assessment, ECG, ambulatory ECG monitoring, echocardiography, and cardiopulmonary testing. A personalized moderate-intensity exercise prescription was performed, and the same investigations were repeated. Physically active patients with HCM demonstrated better cardiopulmonary functional capacity than sedentary patients (oxygen consumptionpeak/kg 32.9±7.4 versus 25.2±7.4 mL/min per kg P≤0.0001, ventilation/carbon dioxide production slope 26.7±4.3 versus 29.9±5.2 P=0.004), with similar prevalence of ventricular arrhythmias (P=0.43). Sedentary subjects showed a borderline higher prevalence of obesity (P=0.07) than physically active subjects. Moderate-intensity exercise prescription led to improved cardiopulmonary fitness without occurrence of adverse events. Patients with HCM practicing regular aerobic exercise have a better functional capacity in the absence of relevant events than sedentary patients. Conversely, a sedentary lifestyle led to a deterioration of cardiopulmonary functional capacity and fitness. The tailored moderate-intensity personalized exercise prescription appears to be a feasible approach in carefully selected patients with HCM to counterbalance the negative effects of sedentary behavior without significant major events.