ECG Assessment Research Articles

918 EARLY RECOGNITION OF SUBCLINICAL ATRIAL FIBRILLATION IN PATIENTS IMPLANTED WITH DIFFERENT DEVICES

Abstract Background Atrial fibrillation (AF) is the supra-ventricular tachyarrhythmia mostly encountered in the clinical practice.While appearing silent or with a constellation of symptoms, it confers a 5-fold risk of stroke. Early detection is mandatory to establish the diagnosis and recommend anticoagulation. Besides the arrhythmia recognition through several tools, such as Holter ECG and loop recorders, it has been underlined that cardiac implantable electronic devices with an atrial lead can help in recognizing asymptomatic AF periods, also known as atrial high-rate episodes (AHREs). Materials and Methods 48 patients with AHRE detection at device telemetry checks were enrolled; implanted device were pacemakers (n=31, 64.8%); implantable cardioverter/defibrillators (ICD, n=8, 16.6%); cardiac resynchronization therapy devices with defibrillators (CRT-D, n=9, 18.5%). Male gender was predominant (40 vs. 8), age was > 65years, and mean CHA2DS2VASc was 4.2±2.8. Patients underwent ECG assessment in 6-month intervals (at baseline and during follow-up), MOntreal Cognitive Assessment test, and device interrogation for AHRE of duration >5 minutes and rate >175 beats per minute. Randomization to a direct oral anticoagulant (DOAC) or usual care (aspirin when needed or placebo) was provided in a blind fashion and maintained for the entire study observation until occurrence of overt AF, followed by exclusion from the study. Results We found that 13%-16% of patients with device-detected AHRE developed AF over a mean follow-up of 2.5 year (range 4.6±2.0). These cases were given oral anticoagulation since change of indication according to current guidelines. Most important comorbidities were coronary artery disease (n=18 patients, 36.73%); systemic hypertension (n=41, 83.67%); diabetes (n=13, 26.53%); dyslipidemia (n=23, 46.8%); heart failure (n=17, 35.4%). 30 patients were treated with beta-blockers(62.5%). 2 patients died for gastrointestinal bleeding. One patient was excluded for major bleeding after one month from the enrollment. Total AHREs duration was significantly lower in patients with pacemaker (14 hrs) compared to patients with CRT-D (17 hrs) and ICD (20 hrs, p<0.05). Conclusions The impact of AHREs was higher in patients affected by cardiac dysfunction and concomitant diseases; none of the patients enrolled in the study developed ischemic stroke; major bleedings were observed in both arms. Further studies are warranted for considering oral anticoagulation based on the sole device interrogation in the context of subclinical atrial fibrillation.

Pregnancy in Women with Arrhythmogenic Left Ventricular Cardiomyopathy.

In the last few years, a phenotypic variant of arrhythmogenic cardiomyopathy (ACM) labeled arrhythmogenic left ventricular cardiomyopathy (ALVC) has been defined and researched. This type of cardiomyopathy is characterized by a predominant left ventricular (LV) involvement with no or minor right ventricular (RV) abnormalities. Data on the specific risk and management of pregnancy in women affected by ALVC are, thus far, not available. We have sought to characterize pregnancy course and outcomes in women affected by ALVC through the evaluation of a series of childbearing patients. A series of consecutive female ALVC patients were analyzed in a cross-sectional, retrospective study. Study protocol included 12-lead ECG assessments, 24-h Holter ECG evaluations, 2D-echocardiogram tests, cardiac magnetic resonance assessments, and genetic analysis. Furthermore, the long-term disease course of childbearing patients was compared with a group of nulliparous ALVC women. A total of 35 patients (mean age 45 ± 9 years, 51% probands) were analyzed. Sixteen women (46%) reported a pregnancy, for a total of 27 singleton viable pregnancies (mean age at first childbirth 30 ± 9 years). Before pregnancy, all patients were in the NYHA class I and none of the patients reported a previous heart failure (HF) episode. No significant differences were found between childbearing and nulliparous women regarding ECG features, LV dimensions, function, and extent of late enhancement. Overall, 7 patients (20%, 4 belonging to the childbearing group) experienced a sustained ventricular tachycardia and 2 (6%)-one for each group-showed heart failure (HF) episodes. The analysis of arrhythmia-free survival patients did not show significant differences between childbearing and nulliparous women. In a cohort of ALVC patients without previous episodes of HF, pregnancy was well tolerated, with no significant influence on disease progression and degree of electrical instability. Further studies on a larger cohort of women with different degrees of disease extent and genetic background are needed in order to achieve a more comprehensive knowledge regarding the outcome of pregnancy in ALVC patients.

Ultra-high-frequency ECG assessment of QRS fragmentation predicts sudden cardiac death risk in inherited arrhythmia syndromes

Abstract Background Fragmentation of the QRS complex, as a surrogate for scar or functionally disrupted ventricular activation, has been postulated as a risk factor for malignant ventricular arrhythmias across a range of cardiac diagnoses including cardiomyopathies, channelopathies and myocardial infarction. Fragmentation is subtle on the conventionally filtered 12-lead ECG and can easily be missed or over-diagnosed. Isolation of high-frequency (HF) QRS components could overcome this to demonstrate easily identifiable fragmentation but this has previously been limited by technological constraints resulting in a limited range of measured frequencies (150–300Hz). Ultra-high-frequency ECG (UHF-ECG) is a novel technology that utilises amplification and signal-averaging techniques to reliably measure frequencies up to 1000Hz. Purpose We explored the use of UHF-ECG in arrhythmia risk stratification. Methods We recruited 60 participants to undergo UHF-ECG recordings, including 23 healthy volunteers and 37 patients with inherited arrhythmia syndromes: 25 hypertrophic cardiomyopathy (HCM), 5 Brugada syndrome, 4 arrhythmogenic cardiomyopathy, 3 idiopathic ventricular fibrillation, 2 long QT syndrome and 1 non-ischaemic dilated cardiomyopathy. The arrhythmia risk status of patients with inherited disease was classified, by two independent researchers, into high or low risk based on their history of cardiac arrest, sustained ventricular arrhythmia, appropriate therapy, syncope and programmed ventricular stimulation result. A third researcher adjudicated disagreement. Two further researchers, blinded to aforementioned risk status, independently assessed the UHF-ECG recordings of all participants. Results 40 patients were classified as low risk, and 20 as high. Healthy volunteer UHF-ECGs showed uniform ventricular activation with single HF peaks in each lead. High-risk patients' UHF-ECGs showed multiple HF peaks, representing QRS fragmentation. The maximum number of HF peaks in any lead was used to measure severity of fragmentation. Example UHF-ECGs are shown in Figure 1. Fragmentation severity (number of peaks) correlated with arrhythmia risk status (chi-square statistic = 8.95, p-value = 0.03) across all participants (Figure 2) and when comparing high to low risk patients with inherited disease. UHF-ECG fragmentation could be observed even when the 12-lead ECG did not show any observable fragmentation. Among patients with inherited disease, patients with HCM showed the largest difference in UHF-ECG fragmentation between high and low risk. UHF-ECG fragmentation analysis showed excellent reproducibility with no difference in number of peaks identified between two independent assessors. Conclusion We demonstrate proof-of-concept that a novel ultra-high-frequency tool for measuring a broad range of high frequency QRS components can be used for sudden death risk stratification in patients with inherited cardiac conditions. Funding Acknowledgement Type of funding sources: None.

Effect of dronedarone versus placebo on atrial fibrillation progression: a post-hoc analysis from ATHENA trial

Abstract Background Atrial fibrillation (AF) may progress over time, leading to greater AF burden. Data suggest that patients receiving rhythm control drugs are less likely to progress to more severe forms of AF vs those receiving a rate control strategy only. ATHENA (NCT00174785) demonstrated that dronedarone significantly decreased cardiovascular (CV) hospitalization and death [1], but it is unclear whether dronedarone affects progression of AF and atrial flutter (AFL). Purpose This post hoc analysis of ATHENA assessed (1) the effect of dronedarone on estimated AF/AFL burden, and (2) AF progression to presumed permanent AF/AFL or AF regression to sinus rhythm (SR). Methods AF/AFL burden was estimated using a modified Rosendaal method [2] based on status of all ECG assessments at each visit. Cumulative incidence of presumed permanent AF/AFL (defined as ≥6 months of AF/AFL until end of study) or preserved SR (≥6 months of SR until end of study) were calculated using the complement of Kaplan-Meier estimates. Log-rank test was used to assess statistical significance. Results Demographic characteristics in 2231 patients on placebo and 2208 on dronedarone were well balanced between groups. Overall, 304 (13.8%) dronedarone-treated patients progressed to presumed permanent AF/AFL compared with 455 (20.4%) treated with placebo. Patients progressing to presumed permanent AF/AFL tended to have larger left atrial diameters and lower left ventricular ejection fractions irrespective of treatment group. The cumulative incidence of presumed permanent AF/AFL was significantly lower in dronedarone-treated patients over time (log-rank p<0.0001; Figure 1). Estimated AF/AFL burden was lower in dronedarone-treated patients over time (Figure 2). Overall, 1149 (52.0%) dronedarone-treated patients had preserved SR compared with 1021 (45.8%) placebo-treated patients, and cumulative incidence of preserved SR was significantly higher in the dronedarone arm compared with the placebo arm (log-rank p<0.0001). Treatment-emergent adverse events were consistent with the findings in the main ATHENA analysis. Conclusions Dronedarone use was associated with fewer patients progressing to presumed permanent AF/AFL, more patients with AF/AFL regressing to preserved SR, and a lower estimated AF/AFL burden, suggesting a protective benefit against AF disease progression. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Sanofi

Electrocardiography Interpretation Proficiency Among Medical Doctors of Different Grades in the United Kingdom.

Electrocardiography interpretation is a core clinical skill for all doctors participating in emergency medical services. Given the majority ofECGsinitially performed in hospital on admission are reviewed by junior doctors, and the need for life-threatening pathology to be diagnosed or excluded, further understanding of the level of competency in interpretation and factors associated with this are needed. This was a cross-sectional, descriptive, analytical study. The data were collected using a structured questionnaire. This was comprised of two sections; the first section contained questions related to confidence, previous ECG learning and factors thought to be associated with ECG interpretation competence. The second section was an ECG quiz of 10 12-lead ECGs of varying complexity for interpretation assessment. Descriptive and inferential statistics were utilized for data analysis. Sixty-twodoctors from foundation year 1 to registrar level working in acute medicine across three hospitals participated. The mean overall percentage score for the ECG quiz was 45%. No association was found between junior doctor training grade and overall score on the ECG assessment. Undergraduate and postgraduate teaching strategies also did not impact competence. Only 9.7% reported themselves as "confident" interpreting ECGs. There was a trend towards higher levels of competency among those who felt they had undergone sufficient ECG teaching and those who sought regular feedback from other clinicians. This study demonstrated low overall levels of ECG interpretation competency among junior doctors in a large acute teaching NHS trust regardless of grade. Factors associated with competency remain unclear.

ECG T-Wave Morphologic Variations Predict Ventricular Arrhythmic Risk in Low- and Moderate-Risk Populations.

BackgroundEarly identification of individuals at risk of sudden cardiac death (SCD) remains a major challenge. The ECG is a simple, common test, with potential for large‐scale application. We developed and tested the predictive value of a novel index quantifying T‐wave morphologic variations with respect to a normal reference (TMV), which only requires one beat and a single‐lead ECG.Methods and ResultsWe obtained reference T‐wave morphologies from 23 962 participants in the UK Biobank study. With Cox models, we determined the association between TMV and life‐threatening ventricular arrhythmia in an independent data set from UK Biobank study without a history of cardiovascular events (N=51 794; median follow‐up of 122 months) and SCD in patients with coronary artery disease from ARTEMIS (N=1872; median follow‐up of 60 months). In UK Biobank study, 220 (0.4%) individuals developed life‐threatening ventricular arrhythmias. TMV was significantly associated with life‐threatening ventricular arrhythmias (hazard ratio [HR] of 1.13 per SD increase [95% CI, 1.03–1.24]; P=0.009). In ARTEMIS, 34 (1.8%) individuals reached the primary end point. Patients with TMV ≥5 had an HR for SCD of 2.86 (95% CI, 1.40–5.84; P=0.004) with respect to those with TMV <5, independently from QRS duration, corrected QT interval, and left ventricular ejection fraction. TMV was not significantly associated with death from a cause other than SCD.ConclusionsTMV identifies individuals at life‐threatening ventricular arrhythmia and SCD risk using a single‐beat single‐lead ECG, enabling inexpensive, quick, and safe risk assessment in large populations.

Assessment of the pre-test probability of ischemic heart disease according to the data of dispersion mapping of an electrocardiogram and analysis of heart rate variability

February 2022 est., there were several validated ischemic heart disease (IND) pretest probability scales presented in the clinical guidelines of various cardiology communities (G.A. Diamond and J.S. Forrester, Duke, ESC 2019 scales). Despite their diversity, they lacked clear quantitative criteria and were based on a subjective assessment of the pain syndrome described by a patient, their gender and age. The purpose of this study was to investigate the possibilities of heart rate variability and ECG dispersion mapping for pre-test assessment of the probability of coronary artery disease. We studied 81 patients (mean age 61.48 ± 13.00 years) with suspected CAD. All patients underwent a five-minute ECG recording with the construction of ECG dispersion mapping and assessment of heart rate variability. Each subject underwent coronary angiography (within 12 months before or after the stress test) to verify the damage to the coronary bed. When analyzing the comparison of the results of coronary angiography and dispersion ECG mapping, 3 groups of patients were formed and studied: group A (coronary artery stenosis more than 50%, n = 18), B (coronary artery stenosis less than 50%, n = 16) and C (without coronary artery disease, n = 21). It was noted that the more pronounced the stenosis of the coronary arteries, the higher the index of microalternations “Myocardium” and T-alternation of the myocardium, and the lower the functional reserve of the myocardium. Considering that a short (thirty second) high-resolution ECG recording is required to perform dispersion ECG mapping, this method can be used as a screening for the selection of patients at high risk of coronary heart disease and exercise testing. We suggest that patients should be referred for exercise testing if two of the three criteria are present: BMI ≥ 22%, Functional reserve ≤ 70%, T-alternation ≥ 18% (AUC ROC is 0.718). The sensitivity and specificity of the presented method can be increased by adding indicators from the analysis of heart rate variability (heart rate, HF, LF) and patient’s age (AUC ROC is 0.929) to the formula.

Evaluating Completeness of Admissions Clerking Procedure for Patients Admitted to an Acute Psychiatric Inpatient Unit

AimsThere is a well-known bidirectional relationship between mental and physical health. A thorough mental and physical health assessment of new inpatients on admission is crucial to assess possible organic causes of psychiatric presentations and enable appropriate treatment to be commenced in a timely manner. We noted a pattern of incomplete clerking, leading to delays in commencing treatment and increased workload pressure on the ward medical team. Our audit aims to assess how thoroughly and in what time frame patients' admission assessments are being completed on an acute psychiatric inpatient unit.MethodsA sample of 20 patients was used for each cycle. Eight components were identified from the Trust clerking procedure. These were a full psychiatric history, capacity assessment, prescription chart, physical health systems review, physical examination, blood tests, ECG and VTE assessment. The expected standard was completion of all of the above at the point of admission or, if applicable, adequate documentation of patient refusal with documented reattempt within 24 hours.Electronic patient records were retrospectively reviewed to identify whether each component was completed, the number of days from admission to completion and if completed by the clerking doctor. Evidence of documented patient refusals and the number of incomplete draft entries were noted.ResultsInitial results showed only 20% of patients (n = 4) had the full expected clerking procedure completed at admission. Physical health assessments (ECG, blood test, physical examination) had the lowest completion rates. When components were not completed by the clerking doctor, there was often a delay of several days from admission to completion of by the ward day team. For 50% of patients, some assessments were never completed (without adequate refusal documented). Eight patients did not have a completed VTE assessment by the point of discharge.ConclusionReasons were identified for the poor completion rates of clerking assessments. These included a lack of understanding by on-call doctors about the importance of completing all assessments, unfamiliarity with ward equipment, lack of adequate handover to the ward medical team and staffing pressures. A new handover checklist was introduced for clerking doctors to use and enable better communication with the ward team. Clerking procedure summaries were displayed in on-call rooms and additional teaching was organised.

Rhaponticum carthamoides improved energy metabolism and oxidative stress through the SIRT6/Nrf2 pathway to ameliorate myocardial injury

BackgroundRhaponticum carthamoides (Willd.) Iljin (Rha) is a member of the family Compositae that is widely used in folk medicine as a dietary supplement to treat cardiovascular diseases (CVDs), such as senile cardiac insufficiency, and to restore myocardial function after surgery. Sirtuin 6 (SIRT6), an NAD+-dependent class III histone deacetylase, plays a considerable role in the administration of CVDs. However, the specific effects and mechanism of Rha on myocardial injury remain unknown. PurposeThis study aimed to explore the therapeutic potential of Rha against myocardial injury as well as its underlying mechanisms in vivo and in vitro. MethodsA myocardial ischaemia model was established in male SD rats by subcutaneously injecting ISO. The rats were gavaged with Rha (40, 80, 160 mg/kg) or Rho (6 ml/kg) for 14 successive days and then injected subcutaneously with ISO or saline solution on the 13th and 14th days. The positive effects of Rha against myocardial injury in rats were evaluated by ECG assessment, BP measurements, H&E staining, and myocardial enzyme detection. Biochemical indicators of energy metabolism and oxidative stress, such as NAD+/NADH, ATP, and MDA, were analysed by assay kits to assess the effects of Rha. The protein and mRNA expression levels of SIRT6 and Nrf2 in the myocardium were determined by western blotting and real-time PCR. ResultsOur results showed that Rha ameliorated myocardial ischaemia and inhibited energy metabolism disorders (NAD+/NADH ratio, ATP, and LD) and oxidative stress (SOD, ROS, etc.) in rat myocardial tissue and H9c2 cells. In addition, Rha upregulated SIRT6 and Nrf2 expression in myocardial injury. Mechanistic studies then found that SIRT6 knockdown reduced the expression of Nrf2 as well as the effects of Rha on the levels of ATP, LD, and ROS, whereas activation of Nrf2 improved the effects of Rha in cells. In summary, Rha might exert its cardioprotective effects via the SIRT6-mediated Nrf2 signaling pathway. ConclusionThe results suggest that Rha regulates energy metabolism and oxidative stress through the SIRT6/Nrf2 signaling pathway to play a protective role in myocardial injury.

Novel cryo-balloon technology for a successful pulmonary vein isolation: acute outcome and follow-up from a large multicenter Italian clinical setting

Abstract Funding Acknowledgements Type of funding sources: None. Background Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). Recently, a new cryoablation system (POLARx) with unique features has been made available for clinical use. To date, limited data exist on acute and follow-up outcome of this system in a multicentric clinical practice. Purpose We reported the preliminary experience of this novel technology in a multicenter Italian registry. Methods Consecutive patients (pts) undergoing AF ablation from the CHARISMA registry at 6 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred &amp;gt;60 sec or when time to isolation (TTI) was not available. The ablation endpoint was PV isolation as assessed by entrance and exit block. Rhythm monitoring during the follow-up examinations was performed via the clinical assessment of AF recurrence, ECG and Holter monitoring, according to the clinical practice of each center. All patients were followed-up for at least 6 months after the procedure. Arrhythmia recurrences within the first 3 months (blanking period) were classified as early recurrences and were not considered procedural failures Results Six-hundred twenty-four cryoapplications from 112 pts (439 PVs) were analyzed (n=89, 79.5% paroxysmal AF, n=23, 20.5% persistent AF, mean age 61.5±9 years, 76% male, 22% with an history of AT, mean LVEF 49±10%). PVI was achieved in all pts using only cryoablation. The mean number of freeze applications per pt was 5.6±2.1 (1.4±1.2 for LSPV, 1.5±1.1 for LIPV, 1.3±0.8 for RSPV and 1.3±0.8 for RIPV), with 318 (72.4%) PVs treated with a single cryoablation (92, 21% with 2 cryoablation; 29, 6.6% with more than 2 cryoablations). Fourty-four (39.3%) pts were treated with a single application to each of the PVs. Over a median of 296[245 to 382] days of follow-up, five (4.5%) patients experienced an early recurrence of AF/AT during the 90-day blanking period. Overall, 12 patients (10.7%) suffered an AF/AT recurrence after the 90-day blanking period (median time to recurrence 200[124 to 297] days). Specifically, 8 (7.1%) patients had AF recurrence only, 3 (2.7%) had AT recurrence only and 1 (0.9%) experienced both events. One (0.9%) patient underwent a repeated ablation procedure. The proportion of patients exhibiting AF/AT recurrences was similar between AF types (10 out 89, 11.2% for paroxysmal AF vs 2 out 23, 8.7% for persistent AF, p=1.00) with a hazard ratio of 0.9 (95%CI: 0.2 to 3.9, log-rank p=0.8894). One transient phrenic nerve palsy was observed, with full recovery in the 48-h post procedure; no major procedure-related adverse events were reported. Conclusion In this first multicentric experience, the novel cryo-balloon system proved to be safe and effective and resulted in a very low rate of AF/AT recurrence during follow-up.

Study of Detection of Left Atrial Enlargement by Echocardiography and ECG Correlation in Cardiac and Non-Cardiac Diseases

Evidences highlight the importance of enlarged left atrium (LA) as a barometer of diastolic burden. Detection of left atrial enlargement or its progression is frequently important in clinical medicine. It is well established that LAE has close relationship with atrial fibrillation, systemic thromboembolism events and heart failure4. ECG assessment of left atrial enlargement is a non-invasive and universally available method12. ECG analysis for left atrial enlargement includes configuration, amplitude and duration of ‘P’ wave55. Echocardiographic LA dimension is the best non – invasive test of left atrial size25. This prospective study was carried out in Ramakrishna care hospital Raipur for 24 months to study the detection of left atrial enlargement by echocardiography with ECG correlation in cardiac and non-cardiac diseases. Rheumatic mitral and aortic valve disease was the most common cause of left atrial enlargement accounting for 26.67% in this study. Next in this order were atrial fibrillation 20%, Hypertension 18.33%, IHD 13.34%, isolated aortic valve diseases 10%, cardiomyopathies 05%. MVP and Thyrotoxicosis each accounting for 3.33%. Echo was simple, non invasive technique to detect LAE from mild to severe grade and help for therapeutic purpose, prevent complications. So, echo was found to be more specific in detection of LAE than ECG. Keywords: LA-Left atrium, LV-Left ventricle, AF-Atrial fibrillation.

Arrhythmia prevalence and sudden death risk in adults with the m.3243A>G mitochondrial disorder

AimsTo define the prevalence of non-sustained tachyarrhythmias and bradyarrhythmias in patients with the m.3243A>G mitochondrial genotype and a previously defined, profile, associated with ‘high sudden-death risk’.Methods and resultsPatients at high...

Ventricular Dyssynchrony and Pacing-induced Cardiomyopathy in Patients with Pacemakers, the Utility of Ultra-high-frequency ECG and Other Dyssynchrony Assessment Tools.

The majority of patients tolerate right ventricular pacing well; however, some patients manifest signs of heart failure after pacemaker implantation and develop pacing-induced cardiomyopathy. This is a consequence of non-physiological ventricular activation bypassing the conduction system. Ventricular dyssynchrony was identified as one of the main factors responsible for pacing-induced cardiomyopathy development. Currently, methods that would allow rapid and reliable ventricular dyssynchrony assessment, ideally during the implant procedure, are lacking. Paced QRS duration is an imperfect marker of dyssynchrony, and methods based on body surface mapping, electrocardiographic imaging or echocardiography are laborious and time-consuming, and can be difficult to use during the implantation procedure. However, the ventricular activation sequence can be readily displayed from the chest leads using an ultra-high-frequency ECG. It can be performed during the implantation procedure to visualise ventricular depolarisation and resultant ventricular dyssynchrony during pacing. This information can assist the electrophysiologist in selecting a pacing location that avoids dyssynchronous ventricular activation.

Pericardial Involvement in Patients Hospitalized With COVID-19: Prevalence, Associates, and Clinical Implications.

BackgroundThe scope of pericardial involvement in COVID‐19 infection is unknown. We aimed to evaluate the prevalence, associates, and clinical impact of pericardial involvement in hospitalized patients with COVID‐19.Methods and ResultsConsecutive patients with COVID‐19 underwent clinical and echocardiographic examination, irrespective of clinical indication, within 48 hours as part of a prospective predefined protocol. Protocol included clinical symptoms and signs suggestive of pericarditis, calculation of modified early warning score, ECG and echocardiographic assessment for pericardial effusion, left and right ventricular systolic and diastolic function, and hemodynamics. We identified predictors of mortality and assessed the adjunctive value of pericardial effusion on top of clinical and echocardiographic parameters. The study included 530 patients. Pericardial effusion was found in 75 (14%), but only 17 patients (3.2%) fulfilled the criteria for acute pericarditis. Pericardial effusion was independently associated with modified early warning score, brain natriuretic peptide, and right ventricular function. It was associated with excess mortality (hazard ratio [HR], 2.44; P=0.0005) in nonadjusted analysis. In multivariate analysis adjusted for modified early warning score and echocardiographic and hemodynamic parameters, it was marginally associated with mortality (HR, 1.86; P=0.06) and improvement in the model fit (P=0.07). Combined assessment for pericardial effusion with modified early warning score, left ventricular ejection fraction, and tricuspid annular plane systolic excursion was an independent predictor of outcome (HR, 1.86; P=0.02) and improved model fit (P=0.02).ConclusionsIn hospitalized patients with COVID‐19, pericardial effusion is prevalent, but rarely attributable to acute pericarditis. It is associated with myocardial dysfunction and mortality. A limited echocardiographic examination, including left ventricular ejection fraction, tricuspid annular plane systolic excursion, and assessment for pericardial effusion, can contribute to outcome prediction.

C-reactive protein and atrial fibrillation: Insights from epidemiological and Mendelian randomization studies

Background and aimsThis study aimed to investigate the role of C-reactive protein (CRP) in atrial fibrillation (AF) from epidemiological and genetic perspectives. Methods and resultsIndividual-level data from the Kailuan cohort recruited between 2006 and 2017 were included. Serum CRP levels were measured at baseline and at biennial follow-up visits, and incident AF was ascertained from biennial 12-lead ECG assessment and medical records. Cox proportional hazards models were used to assess the association between baseline CRP levels or cumulative exposure to CRP and incident AF. A meta-analysis including nine prospective cohort studies and our current study was also conducted. Mendelian randomization (MR) analysis was performed to evaluate the aetiological role of CRP in AF. In our observational study (n = 86,424), high baseline CRP levels (>3 mg/L), compared with low CRP (<1 mg/L), were not significantly associated with AF risk (HR: 1.18; 95% CI: 0.99–1.40). High cumulative exposure to CRP (HR: 1.49; 95%CI: 1.01–2.21) was significantly associated with an increased risk of AF. Our meta-analysis suggested a positive association between elevated CRP levels and incident AF (relative risk: 1.27; 95% CI: 1.14–1.42). However, no significant association between genetically determined CRP and AF risk was observed in the MR analysis. ConclusionEvidence from observational studies suggested that elevated serum CRP levels were positively associated with incident AF, while the causal effects of CRP on AF were not supported by the MR analysis. Clinical trial registrationURL: https://www.chictr.org.cn; Unique identifier: ChiCTR-TNRC-11001489.

Neural architecture search for real-time quality assessment of wearable multi-lead ECG on mobile devices

Users need to pay for the medical services of the wearable ECG signals. The complicated interferences of wearable ECG may cause invalid medical diagnosis. To save medical expenses and reduce the workload of cardiologists, unacceptable wearable ECG should be filtered out on mobile devices in real time. Therefore, a robust and lightweight quality assessment model is essential. Existing convolutional neural network models are more robust than hand-crafted features based models, but most are too cumbersome to run on mobile devices. In this study, we utilize neural architecture search algorithm to search a network with a few parameters and low latency automatically for real-time quality assessment of wearable ECG data. To reach this goal, we construct a searching space with lightweight network blocks and add the hardware latency loss. We also propose a novel and effective strategy, any-lead, to assess the quality of all leads using a single model. We evaluated our method on a large-scale (10,709 signals) wearable 12-lead ECG dataset and a public dataset named Physionet Cinc Challenge 2011. The parameters and FLOPs of the architecture we searched were about 66.76 K and 36.44 M. Our model achieved excellent performance on the aforementioned datasets, with AUC of 98.32% and 97.64%, F1 scores of 94.36% and 93.52%, MCC of 84.74% and 83.22%, respectively, and with the inference time on an Android emulator of about 78 ms. Extensive experimental results demonstrate the effectiveness of our method in assessing the quality of all leads of wearable ECG data on mobile devices in real time.

Аssessment of vegetative regulation of the heart rate in patients with pulmonary TB

SummaryAim. To evaluate features of vegetative regulation of the heart rate in patients with pulmonary TB. Methods. The authors analyzed examination results of 109 patients with different forms of pulmonary TB (the main group). The comparison group consisted of 63 individuals with-out TB or heart disease. To identify features of vegetative regulation of the heart rate, all patients underwent 3-lead 24-hour ECG monitoring and assessment of heart rate variability (HRV) indices using spectral and time-domain analyses. The results were processed using MS Excel 2016 for Windows and Statistica 10 software programmes; nonparametric methods were used. Results. According to our research data, pulmonary TB patients had signifi-cantly lower values of the time-domain analysis of HRV: SDNN in 28% of cases (р&lt;0.05); RMSSD in 22% of cases (р&lt;0.05). The spectral analysis data showed HF in 91% of cases (р&lt;0.05), LF in 61% of cases (р&lt;0.05), a rigid circa-dian rhythm of the heart rate in 55% of cases (p&lt;0.05), and the increased index of vagosympathetic balance in 93% of cases (р&lt;0.05). The sympathicotonic type of vegetative regulation was detected in 93% of cases, the balanced initial vegetative type of HRV — in 5% of cases, and the parasympathicotonic type — in 2% of cases. The authors established a direct strong correlation between indices of RMSSD and HF, r=0.81 (p&lt;0.05). The changes in HRV parameters were not linked with clinical forms of TB (р&gt;0.05). Conclusion. Initial sympathicotonia prevails in patients with pulmonary TB, which indicates intensive work of the cardiovascular system, which in its turn leads to the increased risk of adverse cardiac events. Patients with pulmonary TB should undergo dynamic 24-hour Holter monitoring for timely correction of vegetative re-gulation of the heart rate.

Predictors of Response to Cardiac Resynchronization Therapy

Introduction: Cardiac resynchronization therapy (CRT) has revolutionized the treatment of cardiac dyssynchrony in chronic heart failure (HF), yet, complications and failures are reported in some patients. We aim to determine the predictors of response to CRT through clinical, electrocardiographic ECG, and echocardiographic assessment of patients following CRT and recommend the best practices to achieve optimum results for patients. Methodology: We analyzed the history, clinical examination, brain natriuretic peptide (BNP) levels, ECG, and echocardiography findings of 35 patients before CRT and on day 7 and day 180 following CRT. Observations: 71.4% of patients responded to CRT and 28.6% were nonresponders. The responders had fewer hospitalizations for HF. They showed a significant improvement in the New York Heart Association (NYHA) class, mean 6 min walk distance (6MWD), BNP level, QRS duration, and echocardiographic parameters on day 7 and day 180. The duration of HF ≤3 years, NYHA class III–IV symptoms, baseline 6MWD ≥240 m, QRS duration ≥150 ms, LVEF ≥25%, septal to posterior wall motion delay ≥130 ms, and mean pulmonary arterial pressure &lt;50 mmHg were identified as the strong predictors of response to CRT. Recommendations: Patients with symptomatic HF should undergo early CRT to reduce recurrent hospitalizations and those with NYHA Class III–IV symptoms should be offered CRT before the duration of HF exceeds 3 years. BNP levels and echocardiography are invaluable tools to assess outcomes following therapy. A multiparametric, echocardiographic approach is helpful in selecting patients likely to undergo reverse remodeling after CRT and predicting outcomes.

A Study Protocol on Assessment of ECG and Echocardiography Changes in Stroke Patients

Background: Ischemic stroke is accountable for about 80% of the first episode of cerebrovascular accidents. Cerebrovascular accident due to intracerebral hemorrhage is described as an abrupt onset of clinical signs of central nervous system dysfunction resulting from focal collection of blood inside the ventricular system or brain parenchyma, which is not caused by trauma. Stroke is reported as the most common cause of mortality in developed countries after cardiovascular problems. In cerebrovascular accidents, ECG changes like ST-T changes, QT prolongation, abnormal U waves etc have been reported. Also 2D echocardiographic changes have been reported in stroke patients. This study aims to assess different changes in electrocardiograph and 2D echo patterns cerebrovascular accident cases and their prognostic importance.&#x0D; Objectives: To study variations in Electrocardiogram and 2D Echo in stroke patients in stroke patients and to rule out end organ insufficiency of vital organs.&#x0D; Methodology: This will be a Prospective Cross-Sectional study. About 200 patients of Cerebrovascular accidents reporting to Dept of Emergency Medicine at AVBRH will be included in this study. All patients will undergo 12-lead electrocardiography, at the time of arrival to the hospital. CT scan/MRI will be performed within half an hour of reporting to Emergency Department. After management of stroke, 2D ECHO will be performed. Data of all patients will be analysed with appropriate statistical packages.&#x0D; Expected outcome: A Significant correlation is expected between ECG changes and stroke.

Cardio‐autonomic control during exercise and risk for incident delirium

AbstractBackgroundDelirium is associated with increased risk for Alzheimer’s disease (AD) and mortality; it is characterized by acute confusion commonly after stressors of illness during hospitalization. Integration between the heart and brain via the autonomic nervous system, or cardio‐autonomic control (CAC) is thought to be potentially protective during such stressors. Related to CAC, heart rate (HR) fluctuations display fractal correlations (similar temporal autocorrelation across different time scales) that reflect a dynamic interplay between sympathetic and vagal outflows, where disruption is thought to contribute to neuronal damage. We hypothesized that fractal correlations in HR fluctuations can serve as a novel physiological biomarker for predicting incident delirium.MethodWe derived fractal correlations (α) using ECG data from 37,978 participants (mean age 57.4) free from delirium and AD within the UK Biobank who underwent a 7‐minute stationary bike stress test between 2009‐2010, and had ≥1 inpatient hospitalization episode through to August 2020. Cox proportional hazards models were used to examine the association between α and incident delirium. We adjusted for demographics, physical activity levels, BMI, smoking, alcohol, cholesterol, diabetes, hypertension, ischemic heart disease, stroke, as well as test‐specific peak exercise load and mean heart rate achieved.ResultIncident delirium was newly diagnosed in 247 cases (6.5/1,000) during a median follow‐up time of 8.1 years (SD: 2.0, range: 0.2‐10.2) following ECG assessment. α showed a normal distribution with mean of 1.27±0.3 (SD). Negative association between α and incident delirium was observed. The fully adjusted hazard ratio was 1.26 (95% confidence interval: 1.10‐1.45; p=0.001) for each 1‐SD decrease in α. Putting this into context, a subject with a lower α at the 10thpercentile (vs. 90th) showed a 59% increased risk of developing incident delirium, equivalent to the additional risk of being 5‐years older or a current smoker in this cohort.ConclusionFractal correlation of heartbeat fluctuations during an exercise ECG recording was independently associated with incident delirium, and may be a hidden measure of brain‐heart resilience. As this cohort ages, future work will be able to answer the crucial question of whether this is a shared marker of vulnerability between delirium and AD.