Cardiac Patients Research Articles

Spline Estimator in Nonparametric Ordinal Logistic Regression Model for Predicting Heart Attack Risk

In Indonesia, one of the main causes of death for both young and elderly people is heart attacks, and the main cause of heart attacks is non-communicable diseases such as hypertension. Deaths due to heart attacks caused by non-communicable diseases, namely hypertension, rank first in Indonesia. Therefore, predictions of the risk of having a heart attack caused by hypertension need serious attention. Further, for determining whether a patient is experiencing a heart attack, an effective method of prediction is required. One efficient approach is to use statistical models. This study discusses predicting risk of heart attack via modeling and classifying hypertension risk based on factors that influence it, namely, age, cholesterol levels, and triglyceride levels by using the spline estimator of the Nonparametric Ordinal Logistic Regression (NOLR) model. In this study, we assume an ordinal scale response variable with q categories to have an asymmetric distribution, namely, a multinomial distribution. The data used in this study are secondary data from medical records of cardiac poly patients at the Haji General Hospital in Surabaya, Indonesia. The results show that the proposed model approach has the greatest classification accuracy and sensitivity values compared to NOLR model approach using GAM, and the classical model approach, namely the Parametric Ordinal Logistic Regression (POLR) model. This means that the NOLR model approach is suitable for predicting hypertension and heart attack risks. Also, the NOLR model estimated using the LS-Spline estimator obtained is valid for predicting the risk of heart attack with accuracy value of 85% and sensitivity value of 100%.

Patient perspectives on health care models in cardiac surgery: a qualitative evaluation

BackgroundThe implementation of ERAS represents a promising solution to improve treatment efficiency and facilitate patient involvement. This innovative care model aims to optimize recovery processes following surgeries by adopting a holistic, interprofessional approach. At our hospital, ERAS was implemented in minimally invasive heart valve surgery, offering two distinct ERAS models. Additionally, there is also the standard of care without ERAS. The objective of the study is to gain insight into patient satisfaction and perceived differences across these various care models.MethodsPatients were interviewed using semi-structured interviews approximately two to three months after undergoing surgery. The data were analysed using qualitative content analysis in accordance with the methodology proposed by Kuckartz. Four main categories were established: Preoperative care, postoperative care and communication, patient participation and involvement, and rehabilitation and post-clinical course.ResultsComprehensive preoperative education and seamless communication throughout the perioperative care journey were identified as fundamental to patient satisfaction and optimal care processes. Patients in the ERAS + model reported higher overall satisfaction with their care compared to patients in the standard of care and ERAS groups.ConclusionPreoperative education establishes the foundation for patients’ subsequent behaviours and expectations regarding their treatment. Physical activity, nutrition, and mental health are significant aspects. The active involvement and participation of patients and their families in the treatment process facilitated superior postoperative care, intensive physiotherapy, mental support, and faster recovery. A functional flow of information throughout the entire care process is vital. Moreover, having a dedicated point of contact had a beneficial impact on patients´ well-being. The integration of innovative ERAS concepts, which encompass interprofessional preoperative patient education and psychosomatic support, represents a promising approach from a patient perspective, offering benefits to a broad spectrum of cardiac surgical patients.

Assessing the Nursing Workload in the Cardiothoracic Intensive Care Unit: Comparative Study.

This study aimed to assess nursing workload in Cardiac Intensive Care Unit (CICU) after three cardiothoracic surgery procedures during first four postoperative days using Nursing Activities Score (NAS) and Nine Equivalents of Nursing Manpower Use Score (NEMS) systems, to compare their performance for that purpose and to investigate association between nursing workload and type of surgery. A comparative study. The research environment includes CICU of the University Hospital for Cardiovascular Diseases in Serbia. A total of 808 patients who underwent coronary, valvular, or combined surgery, resulting in 2282 filled NAS and NEMS pairs chart. Statistical analysis was performed using SPSS-19. The correlation between NAS and NEMS was tested by Spearman's correlation coefficient. Differences were considered statistically significant at p < 0.05. The lowest median of cumulative NAS 176 (175-257) and NEMS 76 (64-91) had coronary surgery patients, the highest NAS 224.5 (178-334.5) and NEMS 83 (69-121) had those with combined surgery; this difference was statistically significant (p < 0.001). The median of both scores decreased after surgery, with the following values from the first to the fourth postoperative day: NAS from 104 (102-105) to 81 (74-85) and NEMS from 46 (42-46) to 30 (30-37). The difference in mean values of both scores between the first and the fourth postoperative day was statistically significant (p < 0.001). NAS and NEMS were in a positive, strong correlation (r = 0.913; p < 0.005). Both scores can be used to measure nursing workload, identify the required number of nurses in CICU, and support task allocation. NAS may have an advantage because it better describes extensive postoperative monitoring and care needed for cardiac surgery patients. Nursing workload is associated with type of surgery, with the highest workload measured in patients who underwent combined surgery procedure and on the first postoperative day.

Characteristics and correlated factors of preoperative sleep disorders in cardiac surgical patients

Objective: To investigate the clinical characteristics and correlated factors of preoperative sleep disorders in patients undergoing various types of cardiac surgery. Methods: The data of patients at the Structural Heart Surgery Center of Beijing Anzhen Hospital, Capital Medical University, from April 2023 to February 2024 were retrospectively collected. Patients were categorized into five groups based on cardiac surgical diagnosis: coronary heart disease, valvular disease, large vessel disease, congenital heart disease, and others. Each group was further subdivided into normal sleep (NS) and sleep disorder (SD) groups based on the Pittsburgh Sleep Quality Index (PSQI) scores. Demographic information, cognitive function, psychiatric symptoms, and other relevant data were collected. Clinical characteristics were compared between groups, and factors associated with preoperative sleep disorders were analyzed using multivariate logistic regression. Results: A total of 1 016 patients aged (58.6±12.7) years were included in the study, including 701 males and 315 females. The incidence of SD was 45.6% (463/1 016). Multivariate logistic regression analysis showed that aging was a risk factor for sleep disorders in patients with coronary heart disease (OR=1.050, 95%CI: 1.026-1.077) and valvular disease (OR=1.033, 95%CI: 1.013-1.053). High Self-rating Depression Scale (SDS) score was a risk factor for sleep disorders in patients with valvular disease (OR=1.050, 95%CI: 1.013-1.091). High score on the Montreal Cognitive Assessment (MoCA) subitem-abstraction ability was a protective factor for sleep disorders in patients with coronary heart disease (OR=0.695, 95%CI: 0.490-0.981). Conclusions: The risk factors of preoperative sleep disorders in cardiac surgery patients vary based on the type of cardiac disease. Aging, depression and abstraction ability correlate with sleep disorders in cardiac surgical patients.

The identification, referral and management of patients with cardiac-related distress: a new model to support psychological recovery after a cardiac event

Abstract Background Identification, referral and management of patients with psychological distress is an important component of cardiac rehabilitation (CR). We developed a protocol to identify patients in hospital, CR and primary care settings, and refer them to a specialist psychocardiology clinic. Using the newly developed Cardiac Distress Inventory (CDI), we demonstrated that counselling resulted in reduced rates of cardiac-related distress. This study demonstrates the importance of having a clear pathway from screening to referral to intervention to support cardiac patients in their recovery. Purpose The team identified a dearth of high-quality research on distress in cardiac patients, including a lack of data on the resolution of cardiac-related distress after psychotherapeutic intervention. This was due to the lack of appropriate measurement of cardiac distress, and the absence of clear pathways for identification, referral and management of cardiac distress. Methods The Cardiac Emotions Study is a multi-site, multi-component study of cardiac-related distress. The team first developed the 55-item Cardiac Distress Inventory (CDI), a comprehensive clinical assessment tool. A brief screening version, the 12-item Cardiac Distress Inventory Short Form (CDI-SF), was then developed. Patients referred to the specialist psychocardiology clinic over a 6-month period (N=113) were administered the CDI-SF, together with the Generalised Anxiety Disorder 7 (GAD7) and the Patient Health Questionnaire (PHQ9), with all measures re-administered at discharge. Results More than half the clients presented to the Clinic within the first 3 months post-event (58%), while 84% presented within the first year. At presentation, over half the clients were anxious (GAD7&amp;gt;10; 53%), depressed (PHQ9&amp;gt;10; 57%), or distressed (CDI-SF&amp;gt;13; 56.4%). Levels of particular aspects of cardiac distress are shown in the Figure. On completion of counselling, distress had resolved for the majority of clients, with the distress rate of 18.6% at discharge equivalent to that seen in a normative sample of cardiac patients. Rates of anxiety and depression also significantly decreased after counselling. Conclusion This study demonstrated that distressed cardiac patients could be appropriately identified in settings such as hospital, CR and primary care and referred for counselling, and that counselling resulted in significant reductions in rates of cardiac distress, anxiety and depression. Undergoing counselling through a specialist psychocardiology clinic assisted clients in obtaining normative rates of post-cardiac event distress. The analysis showed the necessity of having a clear clinical pathway from screening to psychological treatment, and the utility of having a validated measure of cardiac distress that is sensitive to change after intervention.

Generalizability of SELECT to a contemporary cohort of cardiac surgical patients: analysis of the TRICS III Randomized Trial

Abstract Background The SELECT trial reported a significant reduction in cardiovascular (CV) outcomes with semaglutide amongst patients without diabetes who had pre-existing CV disease and a body-mass index (BMI) of 27 or greater. Patients undergoing cardiac surgery represent a high-risk subset of those with established CV disease, and may benefit from treatment with semaglutide. Purpose This study evaluated the generalizability of SELECT to a contemporary international cohort of cardiac surgical patients, and assessed whether differences between SELECT-eligible and non-eligible patients translated to altered risks of CV outcomes. Methods Present data was gathered from the TRICS III trial, a multicentre, randomized trial of restrictive versus liberal red-cell transfusion thresholds amongst 5243 cardiac surgical patients with a EuroSCORE I of ≥6. The proportion of cardiac surgical patients eligible for SELECT was determined by applying its selection criteria to the TRICS III cohort. Finally, baseline characteristics and outcomes stratified by SELECT eligibility were compared. Results A total of 4887 patients from the TRICS III cohort had available data for analysis, of which 452 (9.2%) were deemed to have been eligible for the SELECT trial. A comparison of baseline characteristics between SELECT-eligible and non-eligible patients are presented in Table 1; while SELECT-eligible patients were more likely to have preserved left ventricular function (71.7% vs. 61.0%), EuroSCORE I values were comparable between the two groups (7.8±2.1 vs. 7.9±1.9). The rate of a 3-point MACCE of Death, MI or stroke in the present cohort of SELECT-eligible patients undergoing cardiac surgery (16.6%) was numerically higher than those enrolled in SELECT receiving semaglutide (8.1%) or placebo (10.0%), despite the shorter follow-up (6 months vs. 39.8 months). Six month outcomes following cardiac surgery were similar regardless of SELECT eligibility (Figure 1); no difference in risk of outcomes was documented for the 3-point MACCE [SELECT Eligible vs. Non-eligible – 16.6% vs. 14.5%; OR 1.17 (0.9-1.53); P=0.24] and the TRICS III primary composite of Death, MI, Stroke, or New-Onset Renal Failure with Dialysis [17.0% vs. 17.0%; OR 1.0 (0.77-1.29); P=0.98]. There was a trend towards higher rates of MI at 6 months amongst SELECT-eligible patients, but this difference failed to reach statistical significance [8.5% vs. 6.3%; OR 2.0 (0.96-1.39); P=0.08). Conclusions In this large international cohort of contemporary cardiac surgical patients, nearly 10% would have met eligibility for SELECT. SELECT-eligible patients undergoing cardiac surgery in TRICS III had a numerically higher rate of MACCE than those enrolled in SELECT, highlighting the high risk nature of this patient subgroup. However, amongst SELECT-eligible and non-eligible patients undergoing cardiac surgery, no significant difference in CV outcomes was uncovered.

Development of the compliance with mechanical ventilator scale in: A validity and reliability study.

Mechanical ventilation is a widely used treatment modality in cardiac surgery intensive care units (ICUs), especially for patients requiring respiratory support during postoperative management. The aim of this study was to define the process of developing a scale to assess adherence to mechanical ventilation in cardiac surgery patients and to assess the validity and reliability of the scale. This is a scale development and scale validation study. The study was conducted with 222 patients between April and September 2023. In the first stage, face-to-face interviews were conducted with seven nurses. Based on the literature review and content analysis of the interviews, the researchers created an item pool. In the second stage, the validity and reliability of the Mechanical Ventilator Compliance Scale in cardiac surgery patients were assessed. The scale was developed to be used by nurses working in cardiac surgery ICUs. The first 36-item scale was subjected to content validity assessment by 14 experts. It was revised according to the experts' feedback and a content validity criterion of 0.83 was obtained. Confirmatory factor analysis showed good fit values for the scale (χ2/SD = 3.09, GFI = 0.90, AGFI = 0.90, CFI = 0.91, RMSEA = 0.06, and RMR = 0.07). Test-retest analysis to assess the reliability of the scale showed good agreement between responses over time (ICC: 0.932; p < .001). Cronbach's alpha values for the scale and its subscales, behavioural and physical responses were 0.956, 0.949 and 0.912, respectively. The study findings indicate that the scale is a reliable and valid tool for assessing mechanical ventilator compliance in cardiac surgery patients. This study provides nurses in cardiac surgery intensive care units with a measurement tool to objectively assess patients' compliance with mechanical ventilation therapy. The scale provides more reliable results by preventing subjective judgement and estimation in patient assessment.

A prehabilitation programme is feasible and acceptable for mild-to-moderately frail patients undergoing cardiac surgeries

Abstract Background Preoperative frailty is a strong prognostication in cardiac surgical patients to predict poorer health outcomes. Intervening at the preoperative stage through prehabilitation is gaining increasing research attention. Previous studies tested a single frailty-reversing strategy, either nutritional or exercise, the exercise protocols were mainly aerobic-focused, which deviates from the exercise prescription principles suggested for frailty management, rendering an effective prehabilitation intervention is yet to be developed in cardiac surgical patients. Purpose This study aimed to examine the preliminary effects and explore the feasibility of a multi-component frailty-specific prehabilitation programme for mild-to-moderately frail patients undergoing cardiac surgeries/procedures. We hypothesised that compared with patients who receive usual care, patients awaiting cardiac surgeries who participate in the prehabilitation programme would have improved functional capacity, frailty status, quality of life and psychological outcomes, increased serum albumin and reduced C-reactive protein. Methods This study adopted a mixed-method design comprising a pilot randomised controlled trial and a qualitative study. Adult patients with a Clinical Frailty Scale score between 4 and 6, waiting for coronary artery bypass grafting surgery and/or valve repair/replacement, with at least 5 weeks of procedural waiting time and without contraindications for exercise were recruited. They were randomized in a 1:1 ratio to receive the prehabilitation programme or usual care. The programme comprised a structured preoperative education, nutritional optimization, stress management; and a multi-component exercise training with 3 sessions/week and 60 minutes/session. The exercise training lasted at least 4 weeks and maintained throughout the preoperative period. Results Twenty participants were randomized into the intervention (n = 11) or control (n = 9) group. The programme was feasible, acceptable and no severe adverse events were recorded. The lost to follow-up rate was 7.9%, and the overall attendance was 96%. The intervention group showed significantly greater improvement in functional capacity, frailty status and psychological outcomes than the control group at post-intervention. Participants gave positive comments about the programme and its delivery mode. They expressed that the one-on-one home-based practice enabled them greater confidence to overcome kinesiophobia. Two participants voiced out the preference for exclusive home-based training, rather than having hospital-based training in the first two weeks. Conclusion(s) The prehabilitation programme is feasible and acceptable for patients waiting for cardiac surgeries. It improves the functional performance, frailty status and psychological outcomes in these patients. A full-scale randomised controlled trial is warranted to investigate its longer-term and clinical effects.

Personalized cardiac rehabilitation in older geriatric patients: an analysis of age, heart failure subtypes, and physical metrics

Abstract Background While cardiac rehabilitation (CR) is recognized for enhancing physical fitness, psychological well-being, and overall quality of life in cardiac patients, its universal application often overlooks the heterogeneity within the geriatric population. This study delves into the effectiveness of CR among older geriatric patients, aiming to uncover the disparities in response across various demographics, heart failure subtypes, and angina classifications, thereby underscoring the imperative for personalized CR programs. Methods We retrospectively analyzed 438 CR participants from December 2020 to December 2023, stratifying them by age (median: 65.14 years, IQR: 57.23-72.64), sex (23.74% female), heart failure subtype, and CCS angina class to identify distinct response patterns to CR. The analysis included a comprehensive assessment of physical metrics pre- and post-12-week CR program following cardiac surgeries, transcatheter procedures, coronary events, and/or interventions. We employed the Wilcoxon Rank Sum test for statistical analysis, focusing on identifying non-responders and quantifying effect sizes (r) to determine the magnitude of change across various physical metrics. Results Notable improvements were observed in metabolic equivalents (METs) (+1.82), oxygen uptake (VO2 peak) (+6.36 mL/kg/min), Duke Activity Status Index (DASI) score (+14.79), moderate to vigorous physical activity (MVPA) (+131.28 minutes/week), sitting time (-1.21 hours/day), total activity (+145.65 minutes/week) and sit-to-stand repetitions (+2.65). The greatest effect sizes were observed in DASI score (r=0.750) and sit-to-stand (r=SIS) repetitions (r=0.610), consistent across demographics, heart failure, and CCS categories. Other metrics noted variable changes, with handgrip strength showing no consistent trend. Sensitivity analyses revealed that older geriatric patients (≥ 80 years) with HFpEF experienced significant improvements in DASI score (r=0.638), MVPA (r=0.636), and SIS (r=0.504), while those with HFrEF and HFmrEF showed no significant improvements in any physical metrics. CCS angina classification, common comorbidities, and initial referral events did not significantly influence outcomes. Conclusion This study reaffirms the efficacy of CR but crucially identifies the gaps in its universal application, particularly among older geriatric patients with diverse heart failure subtypes. Our analysis advocates for developing personalized CR programs tailored to patients' individual profiles to enhance effectiveness of rehabilitation. By addressing these specific needs, we can ensure more inclusive and optimized patient care, ultimately supporting the expansion of CR indications to foster a more holistic approach to cardiac health in the geriatric population.

Fear of recurrence and its association with mental health outcomes after spontaneous coronary artery dissection (SCAD)

Abstract Background Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction, predominantly affecting younger women with few traditional cardiac risk factors. The condition is characterised by relatively high rates of recurrence. Recent qualitative studies demonstrate that SCAD survivors often experience fears about the future, particularly relating to SCAD recurrence and death. Research in psycho-oncology demonstrates that experiencing fear of cancer recurrence predicts worse outcomes for mental health and quality of life, an association that is also likely in cardiac patients. To date, no quantitative research has investigated fear of recurrence and its association with mental health in SCAD survivors. Purpose The aim of this study was to investigate the prevalence of fears relating to SCAD recurrence and the association of fear of recurrence with mental health outcomes. Methods 293 SCAD survivors completed an online questionnaire assessing the psychosocial impacts of SCAD. Participants rated whether they experienced these impacts ‘not at all’, ‘a small amount, ‘a moderate amount’ or ‘a large amount’ within the first six months of their SCAD. Items related to fears about the future, recurrence, and death were extracted for analysis. Participants also completed measures of anxiety (Generalised Anxiety Disorder-7), depression (Patient Health Questionnaire-9), distress (Cardiac Distress Inventory - Short Form), and mental health related quality of life (Short Form 12, mental health component). Results In the six months following their SCAD, 97.6% of survivors experienced some level of worry about having another SCAD, 95.6% were concerned about triggering another SCAD, 95.6% experienced fear of the future, and 82.6% experienced fear of dying. Reports of experiencing ‘a large amount’ of fear in these areas were 54.6%, 45.1%, 42.7%, and 30.4% respectively. The amount of worry reported about having another SCAD was significantly associated with increased levels of anxiety, depression, and cardiac distress, and reduced mental health quality of life. Conclusions Almost all SCAD survivors reported fears, worries, and concerns related to recurrence. Worry about SCAD recurrence was significantly associated with important mental health outcomes. Cardiac health professionals should monitor fears of recurrence in their patients, as a large amount of worry may be indicative of poor mental health, and referral to psychology services may be appropriate.Rates of fears of SCAD recurrence

Evaluating an integrated clinical pharmacy service model in an ambulatory cardiac clinic- a single centre study

Abstract Background Evidence suggests that multidisciplinary cardiology clinics improve patient outcomes. Currently, there is limited data on the type of pharmacist-led interventions occurring in cardiac ambulatory clinics in the Australian setting. Purpose The primary aim of this pilot audit is to examine the frequency and type of pharmacist-led interventions in the ambulatory clinics of this specialist hospital. The secondary aim is to assess factors associated with hospital readmissions within 30 days of Pharmacists' reviews. Methods A retrospective pilot audit was conducted for patients who attended an integrated multidisciplinary Heart Failure (HF) and Hypertension (HTN) clinic from April 2023 to February 2024. Patients’ demographics, Charlson comorbidity index (CCI), and the number and types of pharmacist interventions and readmission data 30 days post clinic review were recorded. Descriptive statistics were used to evaluate patient characteristics and logistic regression for hospital readmissions. Results A total of 398 patients were reviewed by pharmacists, with 300 (75%) from the HF clinics and 98 (25%) from the HTN clinics. Patients’ median age was 63± 14.8 years and median CCI was 4± 3.7. Pharmacists documented medication histories for all patients (100%) and provided 355 recommendations, of which 213 (60%) were actioned by the cardiologist. Pharmacists had a face-to-face consultation and provided education and counselling to 175 (44%) patients. The most common types of interventions were related to guideline-directed prescribing and deprescribing (68, 39%), followed by up-titration of current therapies (61, 35%). Pharmacists also provided education on medication adherence and lifestyle modifications (28, 16%) as well as optimizing medications related to other comorbidities (18, 10%). A total of 8 patients (2%) were re-admitted l within 30 days of clinic review from either heart failure exacerbation or hypertensive crisis. Patients who had a face-to-face consultation and education with a pharmacist were less likely to be readmitted within 30 days (P=0.048). However, none of the other predictors tested for readmission such as age (P= 0.572), gender (0.296), history of non-compliance (0.834), CCI (0.984) or a diagnosis of HF or HTN (0.473) were predictors for readmission within 30 days of clinic review. Conclusion Pharmacists play an integral role in the cardiac ambulatory setting by providing expert medication advice and patient education to optimize patients’ outcomes. This study demonstrates that the activities performed by pharmacists working in Australian cardiac clinics are consistent with other international ambulatory clinics. The study also identified opportunities to develop a similar service for other ambulatory clinics at this hospital such as lipid and atrial fibrillation clinics. Additionally, further research is required to assess long term benefit of pharmacist led interventions on cardiac patients.

Machine learning methods for diagnostic disease prediction and treatment decisions in parvovirus B19 positive viral cardiomyopathy

Abstract Background Parvovirus B19 (B19V) is the most common type of virus found in endomyocardial biopsies (EMB) from patients with inflammatory heart disease. However, the detection of genomic B19V-DNA appears to have little clinical significance and is often considered an incidental finding. Recent analyses of a large cohort of B19V-positive patients revealed that the detection of RNA transcripts rather than DNA is of clinical importance, as B19V-RNA-positive patients have a significantly worse cardiovascular outcome. Here, we applied machine learning (ML) methods to assess the impact of B19V transcriptional activity on cardiac inflammation and patient clinical outcome. Methods and results A total of 305 patients with a known clinical course and a positive endomyocardial B19V-DNA test were included in this study. Follow-up measurements of the B19V-specific transcripts VP1/2 and NS1 revealed significantly worse clinical courses than in patients without B19V-RNA detection (P=0.019, hazard ratio (95% CI)=1.62 (1.10-2.57)). LVEF at follow-up was significantly lower in patients with detected B19V-RNA (P=0.007), and adverse events such as worsening LV function (P=0.003) or stable systolic dysfunction (P=0.013) were more frequent in this group. Importantly, analysis of inflammatory markers in EMB showed no difference in patients with and without RNA detection (P=0.432), suggesting that the deterioration in clinical outcome was related to B19V transcriptional activity rather than an increase in inflammation. The analysis of area under the receiver operating characteristic curve (AUROC) of B19V-RNA-negative patients revealed that the macrophage marker MAC-1 (AUROC=0.66, P=0.002) was the single most prognostically relevant parameter, while the T cell marker CD3 (AUROC=0.73, P&amp;lt;0.001) was identified as the most prognostically relevant marker in B19V-RNA-positive patients. The linear combination of several inflammatory markers increased the AUROC value to 0.67 in B19V-RNA-negative patients and to 0.74 in B19V-RNA-positive patients. To further increase prognostic accuracy, we trained ML models on features derived from EMB inflammatory markers. For the prediction of major adverse cardiac events within 60 months, the best ML-models achieved an AUROC of 0.87 in B19V-RNA-positive and of 0.86 in B19V-RNA-negative patients, while models that neglect the differentiation of patients with regard to the presence of B19V RNA transcripts only achieved an AUROC of up to 0.76. Conclusions These results show that B19V transcriptional activity is an independent risk marker for adverse cardiac events in patients with viral cardiomyopathy and thus confirm the clinical-therapeutic importance of myocardial biopsy. Furthermore, we present an ML-based algorithm that accurately indicates disease progression in B19V-positive cardiomyopathy patients and is thus helpful for appropriate therapy recommendation.

The role of digital health intervention in improving physical activity in cardiac rehabilitation center: a randomised controlled trial

Abstract Background Physical activity plays a crucial role in cardiac rehabilitation for secondary prevention. Despite its importance, participation rates in cardiac rehabilitation programs remain low. Telemedicine, particularly telerehabilitation, presents a viable solution by offering remote access to cardiac rehabilitation services. This innovative approach has the potential to significantly enhance patient outcomes. Purpose This study aimed to assess the effectiveness of digital health intervention in improving physical activity in cardiac rehabilitation center. Methods A prospective randomised controlled trial was conducted, enrolling 80 eligible cardiac rehabilitation patients. Participants were 1:1 randomised into two groups: a 12-week center-based cardiac rehabilitation program (control group), and a 12-week center-based cardiac rehabilitation program combined with a digital health intervention (intervention group). This digital health intervention consists of smartphone, web, and tablet applications to monitor physical activity outside of rehabilitation sessions and motivate patients to engage in more physical activities. Results Of the initial 80 patients, 70 completed the study, and the results are presented in Table 1. In the intervention group, there was a statistically significant improvement in peak rate of oxygen consumption (VO2 peak) (p &amp;lt; 0.01) and peak power output (W peak) (p &amp;lt; 0.01), as measured by cardiopulmonary exercise testing between the end and the beginning of the study at the significance level of 0.05. Similar improvements were also observed in the control group (p = 0.0002 for VO2 peak and p &amp;lt; 0.01 for W peak). After 12 weeks of intervention, significant between-group differences were found: We observe a greater improvement in VO2 peak, on average 1.39 (95% CI: 0.23-2.54) ml/kg, and in W peak, on average, 12.29 (95% CI: 4.12-20.45), higher in the intervention group compared to the control group. Regarding physical activity, the intervention group showed a significant improvement in step count (P = 0.002), measured by an accelerometer, whereas no significant improvement was observed in the control group (P = 0.9714). There is a statistically significant difference in the change of step count between the intervention and control group at the significance level of 0.05. We observe a greater improvement, on average 14 788 steps (95% CI: 4 246 – 25 331), in the intervention group compared to the control group. Conclusion This study shows that a combination of a digital health intervention based telerehabilitation with a center-based cardiac rehabilitation is more effective in increasing patient’s exercise capacity and physical activity compared with a center-based cardiac rehabilitation.Table 1:results

Improving early mortality risk detection in light-chain cardiac amyloidosis patients with routine echocardiographic indicators and mayo staging

Abstract Background Light-chain cardiac amyloidosis (AL-CA) is a fatal cardiomyopathy caused by the deposition of monoclonal immunoglobulin light-chain in the cardiac fibers, conduction system, valves, and other parts of the heart. The Mayo 2004 staging system is widely used to assess the prognosis of AL-CA. Those in the highest-risk categories, Mayo 2004 stage IIIb, exhibit extremely poor responses to conventional treatment regimens, resulting in high early mortality rates. However, within the same stage, prognostic outcomes among patients can still vary significantly. Hence, a more detailed stratification of high-risk patients is crucial for pinpointing those at extreme risk. Objective To investigate whether conventional echocardiographic measurements can enhance the identification of high-risk patients with early mortality in AL-CA on the basis of existing risk stratification. Methods Continuous enrollment of patients diagnosed with AL-CA at our center from May 2020 to December 2022. Clinical data, echocardiography, and follow-up results of the patients were collected. Logistic regression analyses were used to identify risk factors for early mortality, with risk factor thresholds calculated using Receiver Operating Characteristic (ROC) curves. Kaplan-Meier survival analysis was employed to assess endpoint events. The diagnostic efficacy of the model was evaluated using the area under the ROC curve and the Integrated Discrimination Improvement (IDI). Results A total of 76 patients were included with an average age of 59±10 years. Among them, 51 were male (67.1%). The median follow-up duration was 10 months (ranging from 5 to 20 months). Early mortality, defined as death within 6 months, occurred in 20 patients (26.3%). Twenty-three patients were categorized under the Mayo 2004 stage IIIb (30.3%). The 6-month mortality rate for patients in the Mayo 2004 stage IIIb was 56.5%. The sensitivity of early diastolic transmitral flow velocity to early diastolic mitral annular tissue velocity ratio divided left ventricular ejection fraction [(E/e’) /LVEF] in predicting early mortality in patients with AL-CA is 63%, and the specificity is 92%.When compared to the Mayo 2004 stage IIIb alone, (E/e')/LVEF≥0.5 combined with the Mayo 2004 stage IIIb had an area under the curve of 0.731 and 0.824, respectively, in the ROC curve. The IDI was 0.113 (95% CI: 0.013-0.213, P=0.026), representing an 11.3% enhancement in the predictive value of early mortality in AL-CA patients. Conclusion Routine echocardiography derived E/e' to LVEF ratio offered added prognostic value for early mortality beyond Mayo staging.Kaplan-Meier survival curve

Health literacy in adult cardiac surgery patients; a multi-site Australian study

Abstract Background Almost 60% of Australians report low levels of health literacy (HL). International evidence indicates limited comprehension of the risks and benefits of cardiac surgery, in addition to understanding the basic elements of informed consent. Purpose The aim of this study was to explore HL in adult cardiac surgical candidates. Methods We recruited consecutive English speaking adult patients from a major public (Site 1), major private (Site 2) and regional hospital (Site 3) in Victoria, Australia. Prior to discharge, a Registered Nurse conducted a semi-structured interview using the Health Literacy Questionnaire (HLQ). The HLQ is a multidimensional validated instrument comprised of 9 independent scales. Data were analysed using descriptive statistics, t-tests and ANOVA. Results We recruited 164 (29.5%) eligible participants from; Site 1 (63, 32.1%), Site 2 (49, 19.3%) and Site 3 (52, 49.5%) respectively. Average age was 64.6 (SD 11.8), most participants were male (n = 134, 81.7%), few lived alone (n = 28, 17.1%), 122 (74.4%) identified as being Australian 5 (4.1%) of whom were indigenous and 9 (5.5%) spoke a language other than English at home. The majority of participants highest level of education was aligned with a trade certificate (n = 48, 29.3%) or not completing high school (44, 26.8%) and most were retired (n = 68, 41.5%), working full time (n = 51, 31.1%) or part time (n = 24, 14.6%). Less than half had private insurance (n = 72, 43.9%), more than half had presented to emergency (n = 87, 53.0%) in the previous 12 months and a history of cardiac complaints (n = 137, 83.5%) was as expected. In this study participants felt understood and supported by healthcare providers (Scale 1 M 3.32, SD 0.26), had sufficient information to manage their health (Scale 2 M 3.13, SD 0.35), proactively managed their health (Scale 3 M 2.98, SD 0.39), had strong social supports (Scale 4 M 3.31, SD 0.36), could appraise health information (Scale 5 M 2.88, SD 0.49) and were proactively engaged (Scale 6 M 4.00, SD 0.50). More challenging was their ability to advocate on their own behalf (Scale 7 M 3.80, SD 0.60), to explore information (Scale 8 M 3.70, SD 0.60) and to understand all written information (Scale 9 M 3.90, SD 0.60). Site 2 participants were highly educated, less likely to live alone, more likely to have private insurance, had fewer emergency presentations and higher scores on scales 6 to 9 (p &amp;lt; 0.05) that measure health care interactions, than those from Site 1 or 3. Conclusions There was a high level of HL in this cohort and findings indicate patient strengths in relation to HL differed according to site. In measuring individual skills and experience of participants interacting with services, systems and the health care environment this study provides valuable insight into HL levels in cardiac surgery candidates.

Soluble transferrin receptor is associated with red blood cell transfusion in infant cardiac surgery

Abstract Background Iron deficiency (ID) is linked to an increased need for perioperative red blood cell (RBC) transfusion in cardiac surgery. The soluble transferrin receptor (sTfR), an inflammation-independent marker of ID, has emerged as a potential marker for evaluating iron status. However, the relationship between sTfR level and the need for a high-volume of RBC transfusion in pediatric cardiac surgery patients has not been explored. Purpose The objective of this study was to explore the distribution of sTfRs and their association with high-volume RBC transfusion in infants during cardiac surgery. Methods From August 2021 to July 2022, 236 low-weight infants (≤10 kg) who underwent cardiac surgery were included in this study. Preoperative sTfR levels and the volume of RBCs perioperatively transfused were recorded. Receiver operating characteristic curve analysis and multivariable logistic model were used to explore the association between sTfR levels and the need for a high-volume of RBC transfusion in this study. Results In our study, 29 (12.2%) patients received more than 2 units during the perioperative period. sTfR level was the most accurate marker for predicting the need for RBC transfusion (AUC=0.643, cutoff=17.53 nmol/L, sensitivity=58.6%, specificity=73.9%). Moreover, in both the continuous and categorical variable-adjusted models, a high sTfR level was associated with a greater need for RBC transfusion (P=0.006; P&amp;lt;0.001). Conclusions RBC transfusion is common for low-weight infants undergoing cardiac surgery. Furthermore, a high preoperative sTfR level is associated with the need for a high-volume perioperative RBC transfusion.

Characterisation of plasma proteins and circulating microRNAs in out-of-hospital cardiac arrest patients - approaches for predicting outcome

Abstract Rationale: Early prognostication after out-of-hospital cardiac arrest (OHCA) is an unmet clinical need. There is limited data on serial release kinetics of cardiac, brain and systemic biomarkers such as Neuron Specific Enolase (NSE) and S-100B. miRNAs are sensitive biomarker candidates in acute myocardial infarction (MI). Objective The objective was to characterise circulating biomolecules in the early release kinetics after OHCA, compared with a STEMI control group and assessed with clinical outcome. Methods and Results Serial blood samples of patients with OHCA with STEMI (n=20) and STEMI control (n=20) were collected at baseline and at 6, 12, 24 and 48h after admission. Untargeted plasma proteomics were performed using data-independent acquisition–mass spectrometry (DIA–MS). Candidate proteins and miRNAs were quantified. Proteomics returned n=156 proteins with significantly different kinetics between OHCA and STEMI. Six clusters, depicting distinct biological pathways, with characteristic differences between OHCA and STEMI were identified. The most distinct and significant differences between OHCA and STEMI patients were seen for acute phase reactants LBP, AACT, CRP and the lipid metabolite A2GL as well as endothelial and platelet miR-126 and cardiomyocyte-apoptosis/ischemia-reperfusion related miR-320a. Cardiogenic shock was best characterised by differential kinetics of coagulation and complement related proteins FA9, HRG, FHR1 and inflammation related miR-146. The primary endpoint was poor neurological recovery at 30-days. Individuals with good outcome showed distinct differences in adaptive immune response, complement and coagulation cascades and hemostasis. Circulating plasma levels of hypoxia-associated miR-101, miR-210 and S-100B protein were significantly elevated at baseline in OHCA patients. These molecules further showed higher baseline values in patients with poor outcome. For current prognosis marker NSE, this difference only develops after 48h. Cardiac/muscle miRNAs followed an early release-pattern similar to high-sensitivity cardiac troponin-T (hs-cTnT). Machine learning models were used to calculate the AUC for the prediction of poor neurological outcome at baseline. This was highest for hypoxia-induced miR-210 (AUC: 0.854), which performed significantly better than the protein biomarkers NSE (AUC: 0.646) and S-100B (AUC:0.656). Conclusions Untargeted mass spectrometry reveals distinct biological pathways and candidate biomolecules affected in patients suffering from OHCA compared with STEMI controls, in patients developing cardiogenic shock and in those with adverse versus good neurological outcome. Platelet-, inflammation and hypoxia associated miRNAs are associated with OHCA, cardiogenic shock and prognostication of adverse neurological outcome. Pronounced differences in early release kinetics of RNA and protein biomarkers may improve identification of OHCA patients at risk of poor outcome.

A randomized controlled trial of an eight-week cardiac rehabilitation home verse hospital exercise programme for post coronary cardiac bypass patients

Abstract Background The prevalence and morbidity and mortality rates of coronary heart disease (CHD) continue to increase towards epidemic proportions in the Kingdom of Saudi Arabia (KSA). Despite the advances in Cardiac surgery, currently there are no established out-patient phase program of Cardiac Rehabilitation (CR) for CHD participants in KSA. Aim of the study To evaluate the effectiveness of a home-based CR (Home CR) program using individualized exercise (Physiotools-R) and out-patient phase of CR (Hospital CR) program compared to standard care of home instructions on physical function, physiological and psychological status, body composition and the quality of life of the CHD participants post Coronary Artery Bypass Graft (CABG) surgery. Methods 73 participants post-CABG surgery were randomly assigned to one of three groups: Hospital CR group (n=25), Home CR group (n=24) and Control group (n=24). Outcome measures include Incremental Shuttle Walk Test (ISWT), Metabolic Equivalent Tasks (METs), Psychosocial outcomes and body composition were recorded at baseline, eight weeks of CR intervention, and after four weeks of observation follow up. Intervention: Hospital CR program comprised of group based Aerobic Circuit Training, home based structured individualized exercise program. Each programme had 2 hours’ sessions, 3 times a week for 8 weeks, followed by four weeks of observation follow-up. The control group followed standard care comprised usual advice on post-operation precautions. Results Post intervention, there was an increase in mean ISWT score from baseline in both the home-based cardiac rehabilitation and outpatient-based cardiac rehabilitation groups (66 [0.58] m and 71 [9.19] m, respectively). No difference was observed in the control group. At the 4-week follow-up, both intervention groups showed statistically significant improvements in all outcome measures (ISWT, metabolic equivalence tasks, HADS-A, HADS-D, and Short Form-36) compared with baseline (all P &amp;lt; .001). The home-based cardiac rehabilitation group showed statistically continuous improvement compared with the outpatient-based cardiac rehabilitation group. The control group did not show any significant changes across time in outcome measures Conclusion Home-based CR is as effective as hospital-based CR at improving exercise capacity in patients following CABG surgery. Home-based CR appears to be more effective at maintaining these improvements with no further input in the longer term.

Optimisation of artefact detection in photoplethysmography heart rate data: influence of different classifiers in machine learning models

Abstract Background Heart rate (HR) tracking by wrist-worn devices using photoplethysmography (PPG) could assist in continuously following up physical activity. However, the accuracy can be impacted by (motion) artefacts. Machine learning models could help to recognise artefacts in PPG-based HR data. The choice of classifier in these machine learning models is a determing factor for task performance of the model. Purpose This study evaluates and determines the optimal classifier for a new machine learning-based approach to enhance the reliability of artefact detection in PPG-based HR data. Methods A total of 62 participants (27 cardiac rehabilitation patients, 35 healthy athletes) wore both a test device and a reference device measuring HR continuously for 24 hours. A training dataset was prepared, assigning two independent labels (i.e. anomaly and activity) to each HR episode based on the reference device data. Fitbit data were processed using our in-house designed artefact removal procedure, which involves the application of two classification models: one for anomaly detection and another for activity detection. Four distinct classifiers were employed for both models: Balanced Bagging, Balanced Bagging with Random Forest, Balanced Random Forest, and Logistic Regression. Each classifier was evaluated using area under the receiver operating characteristic curve (ROC-AUC), accuracy, sensitivity and specificity. Results Of the 1,647,328 HR data points collected, 103,095 (6.26%) were identified as artefacts. Figure 1 and Figure 2 summarise the performance of the distinct classifiers for the anomaly model and the activity model, respectively. Balanced Bagging and Balanced Bagging with Random Forest consistently demonstrate the highest AUC values and accuracies across both anomaly and activity detection models (anomaly detection: AUC = 0.95, accuracy = 89-85%; activity detection: AUC = 0.98, accuracy = 95%). Comparing these two, Balanced Bagging with Random Forest emerges as the preferred option, given the highest sensitivity in both anomaly detection (93%&amp;gt;86%) and activity detection models (99%&amp;gt;96%). In contrast, Balanced Random Forest and Logistic Regression exhibit inferior performance. In the anomaly detection model, Balanced Random Forest exhibits a lower sensitivity of 75%, while Logistic Regression performs even worse with a sensitivity of 25%. Similarly, in the activity detection model, both Balanced Random Forest and Logistic Regression demonstrate diminished performance. Conclusions Balanced Bagging with Random Forest emerges as the optimal classifier to detect anomalies and activities in continuous PPG-based HR data, thus contributing to the optimisation of our in-house designed procedure for removing artefacts. This processing aims to provide a reliable and automatic way for continuous HR monitoring, which can help monitor and guide physical activities.

The majority of 30-days survivors return to work one-year after in-hospital cardiac arrest

Abstract Background Surviving in-hospital cardiac arrest poses a significant risk of anoxic brain damage, which can impede survivors’ ability to return to work. Purpose This study aimed to examine return to work among in-hospital cardiac arrest survivors. Methods In this cohort study we included all 30-day survivors of working age (18-64 years), who experienced an in-hospital cardiac arrest between January 1st, 2013, and December 31st, 2018. Data was obtained from the national Danish in-hospital cardiac arrest registry (DANARREST) and employment status was retrieved from a registry from the Danish National Labor Market Authorities. We used a previously validated definition of "working" as any individual who was not on any social benefits, except state education fund grants, maternity leave pays, or leave-of-absence. Only patients working four weeks prior to the event were included in the study. Kaplan-Meier survival analysis was applied to estimate the probability of returning to work. Results Among 7,254 in-hospital cardiac arrest patients in Denmark from 2013-2018, 1,781 were of working-age, with 734 surviving at least 30 days. A total of 348 patients, who were working four weeks before their event, formed the final study population (Figure 1). Median age was 54 (Interquartile range (IQR) 46-59) and 70.4% were male. The cumulative incidence for return to work was 67.0% (95% CI: 62.0%-71.9%) with 4.6% (95% CI: 2.4%-6.8%) dying by one-year post-arrest as a competing risk (Figure 2). Age and sex distribution were comparable between survivors returning to work, those who did return to work, and those who died. A higher proportion of survivors returning to work had a Carlson’s Comorbidity Index score of 1 (70.8%) compared to survivors without work (58.1%) and those who died (33.3%). Additionally, an initial shockable rhythm was more frequent among survivors returning to work (49.8%) compared to survivors who did not return to work (45.2%), and those who died (9.1%). Conclusion We found that 67% of 30-day survivors of in-hospital cardiac arrest returned to work one year after their event. While survivors retuning to work shared comparable age and sex distributions with survivors who did not return to work and non-survivors, factors such as a lower Carlson’s Comorbidity Index score and a higher proportion with an initial shockable rhythm were distinguishing characteristics for those who returned to work.FlowchartCumulative incidence curves