Ambulatory Monitoring Research Articles

Discrepancies between home blood pressure and ambulatory blood pressure monitoring in apparent treatment-resistant hypertension: analysis from the Korean resistant hypertension cohort.

This study aimed to investigate the characteristics of out-of-office blood pressure (BP) measurements in patients with apparent treatment-resistant hypertension (aRH) enrolled from 15 tertiary care centers in South Korea. aRH was defined as having uncontrolled office BP ≥ 130/80 mmHg despite receiving three classes of antihypertensive medication or any level of BP despite receiving ≥4 classes of antihypertensive medication. Patients with complete data for office BP, 24-h ambulatory BP monitoring (ABPM), and home BP measurements at baseline were included. BP control status between ABPM and home BP measurements was compared. Out of 1457 patients, 823 meeting the enrollment criteria were included (mean age: 59.9 ± 13.6 years; 57.5% male patients). Among them, 7.2% had controlled BP, 8.7% had whitecoat uncontrolled hypertension, 15.1% had masked uncontrolled hypertension, and 69% had sustained hypertension, as measured through baseline ABPM. Additionally, 43% of patients with controlled BP based on home BP measurement had nocturnal hypertension. Relying solely on home BP measurement may result in misclassifying 70% of patients as having either controlled BP or whitecoat uncontrolled BP. This study reaffirms the circadian pattern of resistant hypertension, characterized by a higher prevalence of non-dipping and rising patterns, even in patients with BP controlled based on ABPM. Considering the persistent difference between home BP measurement and ABPM, even at a lower home BP threshold, integrating both measurements into the management of aRH is advisable.

Abstract 4134668: Title: Mandibular advancement device versus CPAP on cardiovascular health and quality of life in OSA a pre-specified 12 months follow up of outcomes

Background: Obstructive sleep apnoea (OSA) is a significant cause of hypertension. ACC/AHA Guidelines recommended screening and treatment of OSA in patients with hypertension; however, evidence comparing mandibular advancement devices (MAD) to continuous positive airway pressure (CPAP) on cardiovascular health is lacking. We present the complete 12 months follow-up data on the comparative effectiveness of MAD versus CPAP in ambulatory BP reduction, QoL, cardiac arrhythmia, and myocardial remodelling. Method: In a randomized, non-inferiority trial (margin 1.5 mmHg), 321 participants, aged over 40, with hypertension and high cardiovascular risk were recruited. Of these, 220 participants with OSA (apnoea–hypopnea index ≥15 events/h) were randomized to either MAD or CPAP (1:1). Pre-specified secondary outcomes include: ambulatory BP, quality of life (QoL) (sleep-specific: ESS, SAQLI, FOSQ; non-sleep-specific: SF-36, EQ-5D), ambulatory ECG monitoring, and cardiac MRI. Results: A total of 89 (80.9% of 110) participants from MAD, and 91 (82.7% of 110) participants from CPAP completed 12 months follow-up. The median daily usage was 5.5 hours for MAD and 4.9 hours for CPAP. The between-group difference in 24h mean BP from baseline to 12 months was - 0.57 mmHg (95% confidence interval: (-2.53 to 1.39, non-inferiority P < 0.001). Compared with the CPAP group, MAD group demonstrated a larger reduction in all the 24h with the most pronounced differences observed in the asleep BP parameters (Table 1). Both the MAD and CPAP improved QoL (Table 2). CPAP had greater improvement in FOSQ from sleep-specific questionnaires (P=0.038), and social QoL in SF-36 from non-sleep-specificl questionnaires (P=0.013). The ambulatory ECG monitoring (MAD: 2.8 ± 1.0 days, CPAP: 2.3 ± 1.1 days) showed no between-group differences in % atrial fibrillation(P=0.209), % ventricular ectopic isolated count (P=0.790) and % supraventricular ectopic isolated count (P= 0.333). The cardiac MRI sub-study (101 participants : MAD= 45, CPAP= 56) showed CPAP had greater improvement in right ventricular stroke volume (P=0.023) and MAD had greater improvement in circumferential strain favours the MAD group (P=0.015) (Table 3). Conclusion: At 12 months , MAD was non-inferior to CPAP for reducing 24h mean arterial BP. MAD showed greater reduction in 24h BPs, especially during asleep. While both the MAD and CPAP are effective in improving QoL, CPAP is more effective in improving FOSQ and social QoL (SF-36).

Abstract 4135923: Predictive Value of Supraventricular Tachycardia on Ambulatory ECG Monitoring for Recurrent Atrial Fibrillation Post-Catheter Ablation

Introduction: Established predictors of recurrent atrial fibrillation (AF) following catheter ablation (CA) have not incorporated findings on post-CA ambulatory ECG monitoring (AECG). Aims: This study examined the predictive value of supraventricular tachycardia (SVT) detected on 7–14-day AECG for recurrent AF within one year post-CA. Methods: This single-center retrospective study included a select subset of patients who underwent CA for AF between 2015 and 2023 and had AECG monitoring within the first year post-CA. SVT presence and characteristics on AECG were analyzed.Data on demographics, AF risk factors, and AF recurrences were extracted from electronic health records. ROC curves determined SVT episode thresholds. A multivariable regression model included established risk factors and SVT thresholds, and best subsets regression identified predictors of AF recurrence. Results: Of 7,481 patients undergoing CA for AF, 1,245 were monitored within one year post-CA. Among this subset, 439 (35.26 %) had recurrent AF during the first year post- CA. Of the 439 patients with recurrent AF, 99 had AECG monitoring before recurrence. These 99 patients were compared with the 672 patients with no AF recurrence. Average duration of AECG monitoring for the entire cohort was 11±2.7 days. Mean SVT episodes per day ≥4.6 and total number of SVT episodes ≥14.5 were significantly associated with recurrent AF (OR =1.99, P =0.030, and OR =2.77, P =0.019, respectively). Significant predictors of AF recurrence were female gender, heart failure, confirmed SVT, cardioversion before ablation, mean SVT episodes per day, and total SVT episodes on AECG. Conclusion: High burden of SVT on AECG monitoring (defined in this study to be ≥4.6 episode per day or ≥14.5 total episodes per monitoring period) was significantly associated with AF recurrence. Longitudinal studies in larger unselected populations are needed to confirm these results.

Abstract 4117085: Frequency and Patterns of Paroxysmal Supraventricular Tachycardia Episodes Among Patients Opting For Acute Drug Treatment: Analysis of the NODE-303 Open-Label Etripamil Trial

Background: Etripamil nasal spray (NS) is a fast acting, self-administered calcium channel blocker in development for the termination of AV-nodal-dependent supraventricular tachycardia (SVT). Prior randomized, placebo-controlled and open-label studies have demonstrated favorable safety and efficacy of etripamil in converting paroxysmal supraventricular tachycardia (PSVT) to sinus rhythm (SR) self-administered without direct medical supervision. Research Question/Hypothesis: To assess patterns and annualized PSVT episode frequency among patients opting to self-administer acute treatment with etripamil. Methods: NODE-303 was an event-driven, multi-center, open-label Phase 3 study, conducted in North and South America to evaluate the safety and efficacy of etripamil in patients with documented PSVT over multiple episodes. Test dosing was not performed prior to at-home use. Enrolled patients, upon perceiving symptoms of PSVT: applied an ambulatory ECG monitor, performed a previously trained vagal maneuver and, if symptoms persisted, self-administered etripamil NS 70 mg. During the study, the protocol was amended to allow a repeat dose (70 mg) if symptoms persisted 10 min after the first dose. Each patient could self-treat up to 4 episodes. Results: Of 1,116 enrolled patients, 503 (45.1%) treated ≥1 perceived PSVT episode (safety population). Etripamil achieved conversion to SR in 60% of patients by 30 minutes and 70% by 60 minutes. A total of 220, 118, 62, and 103 patients completed the study with 1, 2, 3, and 4 etripamil-treated perceived episodes of PSVT, respectively, with an average time on study of 440 days. Among these patients, the average number of annualized etripamil-treated PSVT episodes was 3.2 (standard deviation 3.8). Annualized use: etripamil was self-administered for 0-2 PSVT episodes per year, 2-6 episodes, 6-12 episodes, and >12 episodes, in 54%, 32%, 10%, and 4% of patients, respectively (Figure). Conclusions: This analysis aimed to assess the annualized use of etripamil NS in a real-world setting, by analyzing how often patients would self-administer the drug for PSVT episodes. Of patients that self-administered etripamil (n=503), the majority treated >1 episode and the annualized frequency of episodes treated with etripamil was 3.2 episodes/yr.

Abstract 4136869: Time Course and Predictors of PVC Recurrence After Acutely Successful Catheter Ablation

Introduction: In prior studies, predictors of long-term success following acutely successful radiofrequency (RF) ablation have included female-sex, single-PVC morphology and EGM-QRS > 24ms. Time course and predictors of PVC recurrence following acutely successful ablation has been less well documented. Use of extended ambulatory monitoring in the immediate post-procedural period can help to identify those with early recurrence. Goals: To define time to recurrence and predictors of recurrence of PVCs after RF ablation following acutely successful ablation. Methods: Consecutive patients from January 1 st , 2016 through December 31 st , 2023 undergoing PVC ablation with available post-ablation extended ambulatory monitoring (Zio, iRhythm, San Francisco, CA) were retrospectively analyzed. Recurrence was defined as an increase in PVC burden to >5% during monitoring after acute success or failure to have sustained reduction in PVC burden of >80%. Acute success was defined as elimination of the targeted PVC after the last ablation lesion. Long-term succes was defined as absence of targeted PVC's during all follow-up visits and PVC-burden < 5% on follow-up monitoring. Results: Among 121 patients who underwent successful PVC ablation, 101 (83.4%) had long-term success and 20 (17%) had recurrence. Patients with recurrence were older (62.4 ± 12 vs 55 ± 13., p = 0.019), had a higher incidence of CAD (13 (13%) vs 9 (45%), p = 0.001) and CHF (40 (40%) vs 15 (75%), p = 0.004). At time of ablation, the recurrence group was also more likely to have >1 PVC morphology (6 (6%) vs 8 (40%), p = <0.001). Location and earliest activation time of the predominant PVC were not assocated with likelihood of recurrence. Within the recurrence group, 13 (65%) had recurrence in the immediate 2 week post-procedural period with an average time to recurrence of 3.9 days. Conclusion: Recurrence occured in slightly less than 20% of cases with a relatively high proportion of those occuring within the immediate 2 week post-procedural period during extended ambulatory monitoring. The presence of greater than 1 PVC morphology at time of ablation is a risk factor for recurrence suggesting a higher likelihood of acute suppression without durable resolution in those instances.

Blood Pressure Regulation in Post-COVID POTS: Beyond Sinus Tachycardia.

Postural orthostatic tachycardia syndrome (POTS) is a frequently diagnosed cardiovascular disorder after COVID-19 infection. POTS is characterized by the presence of excessive sinus tachycardia on standing without a fall in blood pressure (BP). We investigated the BP profile using 24-hour ambulatory BP monitoring in patients with new-onset POTS after COVID-19 compared with prepandemic population-based controls. We performed a case-control study in 100 patients (mean age, 40.0±12.9 years; 85% women) with verified post-COVID-19 new-onset POTS diagnosed by a positive head-up tilt testing versus 100 controls from a population-based cohort with a negative active standing test, no history of syncope, POTS, or endocrine disease (mean age, 42.3±14.0 years; 78% women). Twenty-four-hour BP profile was assessed for circadian BP variation including hypotensive systolic BP (SBP) episodes (<80, <90, and <100 mm Hg). Patients with post-COVID-19 POTS had significantly higher nighttime SBP, but not daytime SBP, and more daytime SBP hypotensive episodes compared with controls. Nondipping (34% versus 19%; P<0.001) and reverse dipping patterns (9% versus 0%; P<0.001) were more frequent in post-COVID-19 POTS. In the logistic regression, patients with post-COVID-19 POTS had significantly higher mean 24-hour SBP (odds ratio, 1.08 [95% CI, 1.04-1.11]; P<0.001) and nighttime SBP (odds ratio, 1.07 [95% CI, 1.04-1.10]; P<0.001), independent of age and sex. Patients with post-COVID-19 POTS demonstrate higher mean 24-hour and nighttime SBP and show disruptions of circadian BP rhythm regulation compared with population-based controls, as well as more daytime hypotensive episodes. Future studies are needed to test whether patients with post-COVID-19 POTS may benefit from tailored BP therapy.

Diagnostic and therapeutic challenges in implementing hypertension management after kidney transplantation.

Evidence for blood pressure (BP) measurement and hypertension management in kidney transplant recipients (KTR) remains lacking. Accurate BP measurement technique is a critical component of hypertension management, and 24-h ambulatory BP monitoring remains the gold standard for diagnosis of hypertension in KTR. BP target at different periods posttransplant is uncertain, but likely higher than that in nontransplant patients given factors related to long-standing uremic milieu and kidney transplantation such as vascular calcification altering transplant renal hemodynamic and allograft perfusion and immunosuppression. Dividing BP target into immediate, early, and late posttransplant periods can guide differential diagnoses of hypertension and BP control with a target SBP less than 160 mmHg in general and BP 115-135/65-85 mmHg for adult KTR receiving pediatric kidneys during the immediate posttransplant period, 130/80 mmHg during early and late posttransplant periods. Calcium channel blockers were shown to have favorable graft outcomes. Novel antihypertensive medications for resistant and refractory hypertension and device-based therapies are limited due to KTR's ineligibility for participating in clinical trials. In KTR, BP measurement and monitoring practice should follow the standard clinical practice guideline for nontransplant patients by considering posttransplant factors and immunosuppressive state. Novel treatment options required further studies.

Efficacy of Olmesartan/Amlodipine Single-Pill Combination on 24-h Mean Systolic Blood Pressure Measured by Ambulatory Monitoring in Non-Responders to Valsartan or Candesartan Monotherapy.

The aim of this study was to evaluate the efficacy of olmesartan/amlodipine (OLM/AML) single-pill combination (SPC) therapy using ambulatory blood pressure monitoring (ABPM) in non-responders to valsartan or candesartan monotherapy. Isolated systolic hypertension (ISH) is the most prevalent form of hypertension in middle-aged and elderly individuals. Patients aged over 55 years who did not achieve the target systolic blood pressure (SBP < 140mmHg) with valsartan 80mg or candesartan 8mg for at least 4 weeks were included. Doses were escalated from 20/5mg to 40/5mg and finally to 40/10mg of OLM/AML SPC until patients reached the target SBP. Efficacy was assessed via ABPM by comparing baseline values with those in the 12th week. Office blood pressure (OBP) and brachial-ankle pulse wave velocity (baPWV) were assessed at baseline, weeks 4, 8, and 12. Fifty-four patients (average age 64 ± 6 years; 33 males) participated. The 24-h mean BPs decreased significantly from an average of 146.2 ± 12.7/93.3 ± 9.2mmHg to 129.7 ± 14.3/83.4 ± 10.7mmHg (p < 0.001), and pulse pressures (PPs) from ABPM were reduced (p < 0.001). Additionally, significant reductions in night-time SBP standard deviations (SDs) (14.7 ± 4.7vs. 12.5 ± 3.9, p = 0.029) were observed at 12 weeks compared to baseline. OBPs significantly dropped from 151.1 ± 9.7/89.3 ± 8.3mmHg to 125.5 ± 13.8/77.8 ± 8.8mmHg after 12 weeks of SPC therapy (p < 0.001). Reductions in PPs of OBP and baPWVs were also observed. OLM/AML SPC therapy effectively reduced the 24-h mean BP, as measured by ABPM, in hypertensive patients over 55 years old who failed to achieve a target SBP (< 140mmHg) with angiotensin receptor blocker (ARB) monotherapy using valsartan 80mg or candesartan 8mg. Trial Registration: ClinicalTrials.gov identifier: NCT01713920.

Prognosis of patients with wild-type transthyretin cardiac amyloidosis and non-sustained ventricular tachycardia.

Little is known regarding the prevalence and prognostic implications of non-sustained ventricular tachycardia (NSVT) in patients with wild-type transthyretin cardiac amyloidosis (ATTRwt-CA). We aimed to investigate the prevalence of NSVT in patients with ATTRwr-CA, and the association of NSVT with sustained ventricular arrhythmias (VA) and all-cause mortality. In a cohort of ATTRwt-CA patients from 2011 to 2022 without prior sustained VA, we ascertained the presence and characteristics of NSVT during clinically indicated ambulatory Holter monitoring. Patients were stratified based on the presence of NSVT at baseline. The primary and secondary endpoints of sustained VA and all-cause mortality, respectively, were assessed during follow-up. The cohort included 217 patients with ATTRwt-CA (95% males, median age 75 years; median NYHA class 2). Baseline Holter monitoring demonstrated NSVT in 116 (53%) patients. During a median follow-up of 27 months (IQR 16-45) after the index Holter monitor, 11 (5.1%) patients reached the primary endpoint of sustained VA (incidence 1.8 per 100 person-years, all monomorphic VT), and 46 (21%) patients died. In univariable Cox proportional hazard model, NYHA class 3 or 4 heart failure (p = .048), the presence of NSVT (p = .04), the duration of longest NSVT run (p = .029), and the percentage of ventricular ectopy (p < .001) were associated with the primary outcome. When adjusting for age and NYHA class 3 or 4 heart failure, the presence of NSVT remained associated with the primary outcome (p = .03). All-cause mortality was not significantly different between patients with and without NSVT. A cutoff for ventricular ectopy burden of 0.5%, the median for all patients in this study, was associated with increased risk in sustained VA (log-rank p = .004) and mortality (log-rank p = .02). NSVT is highly prevalent among ATTRwt-CA patients undergoing clinically indicated Holter monitoring and may confer an increased risk of incident sustained VA.

Association of longitudinal changes in 24-h blood pressure level and variability with cognitive decline.

A high office blood pressure (BP) is associated with cognitive decline. However, evidence of 24-h ambulatory BP monitoring is limited, and no studies have investigated whether longitudinal changes in 24-h BP are associated with cognitive decline. We aimed to test whether higher longitudinal changes in 24-h ambulatory BP measurements are associated with cognitive decline. We included 437 dementia-free participants from the Maracaibo Aging Study with prospective data on 24-h ambulatory BP monitoring and cognitive function, which was assessed using the selective reminding test (SRT) and the Mini-Mental State Examination (MMSE). Using multivariate linear mixed regression models, we analyzed the association between longitudinal changes in measures of 24-h ambulatory BP levels and variability with cognitive decline. Over a median follow-up of 4 years (interquartile range, 2-5 years), longitudinal changes in 24-h BP level were not associated with cognitive function ( P ≥ 0.09). Higher longitudinal changes in 24-h and daytime BP variability were related to a decline in SRT-delayed recall score; the adjusted scores lowered from -0.10 points [95% confidence interval (CI), -0.16 to -0.04) to -0.07 points (95% CI, -0.13 to -0.02). We observed that a higher nighttime BP variability during follow-up was associated with a decline in the MMSE score (adjusted score lowered from -0.08 to -0.06 points). Higher 24-h BP variability, but not BP level, was associated with cognitive decline. Prior to or in the early stages of cognitive decline, 24-h ambulatory BP monitoring might guide strategies to reduce the risk of major dementia-related disorders including Alzheimer's disease.

Assessment of appropriate utilization of out-of-office diagnostic tools for the diagnosis of hypertension

ABSTRACT Background: Out-of-office blood pressure (BP) measurement devices, such as ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM), enhance the accuracy and reliability of BP readings, detecting white-coat and masked hypertension. The American Heart Association (AHA) advises confirming hypertension diagnoses with ABPM to prevent overdiagnosis, emphasizing the importance of precise out-of-office diagnostic tools. This study aimed to 1) explore the prevalence of ABPM and HBPM use prior to hypertension diagnosis; 2) assess the adherence to AHA recommendations regarding ABPM utilization; and 3) investigate the association between patient characteristics and out-of-office BP monitoring practices. Methods: A retrospective cross-sectional study analyzed a random sample of adult patients newly diagnosed with essential hypertension at a tertiary hospital primary care center in Riyadh, Saudi Arabia, between 2016 and 2022. Results: This study evaluated the use of ABPM and HBPM in a sample of 268 newly diagnosed hypertensive patients, with a mean age of 49.17 ± 12.69 years. Although ABPM orders were placed for 57.8% of patients, only 48.5% completed the procedure. Notably, 42.2% of hypertension diagnoses were solely based on ABPM, while 7.1% and 1.1% utilized HBPM alone or in combination with ABPM, respectively. This analysis revealed a lower utilization of ABPM among older adults, individuals with diabetes or chronic kidney disease, and married patients (P &lt; 0.05). However, this association with marital status, diabetes, and chronic kidney disease was no longer statistically significant in a fully adjusted model (P &gt; 0.05). Conclusion: Out-of-office BP monitoring, particularly ABPM, was underutilized in newly diagnosed hypertensive patients, especially in older age groups and patients with specific comorbidities, who may benefit the most from this method. These results underscore the need for increasing physician knowledge and compliance with the existing guidelines.

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&amp;lt;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 (&amp;gt;10 seconds), Ventricular Tachycardia (&amp;gt;100 BPM for &amp;gt;3 beats), Severe Tachycardia (&amp;gt;170 BPM for ≥30 seconds), Pause/Asystole (≥3 seconds), Severe Bradycardia (&amp;lt;35 BPM), and 2nd Degree or Higher AV Block. Emergent criteria were defined as VT (&amp;gt;100 BPM for ≥30 beats), Severe Tachycardia (≥220 BPM for ≥30 seconds), Pause/Asystole (≥10 seconds), and Severe Bradycardia (&amp;lt;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&amp;lt;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&amp;lt;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&amp;lt;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&amp;lt;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 &amp;lt;30 s and a rate &amp;gt;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 &amp;lt;140/&amp;lt;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&amp;lt;.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&amp;lt;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) &amp;lt; 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, &amp;lt;130/80mmHg (intensive) and &amp;lt;140/90 mmHg (conventional) were investigated. Results Controlled ambulatory BP (aBP; &amp;lt;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 (&amp;lt;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 (&amp;lt;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 (&amp;lt;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 &amp;lt; 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 &amp;gt;210mmHg in men and &amp;gt;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=&amp;lt;0.0001). Those with HRE had higher 24hSBP (124vs121mmHg, p=0.009), Night SBP (117vs111mmHg, p&amp;lt;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=&amp;lt;0.0001), MSNA levels (36vs28 bursts, p=&amp;lt;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.