Undiagnosed Heart Disease Research Articles

Systematic review and meta-analysis of prevalence of undiagnosed major cardiac comorbidities in COPD.

It is often stated that heart disease is underdiagnosed in COPD. Evidence for this statement comes from primary studies, but these have not been synthesised to provide a robust estimate of the burden of undiagnosed heart disease. A systematic review of studies using active diagnostic techniques to establish the prevalence of undiagnosed major cardiac comorbidities in patients with COPD was carried out. MEDLINE, Embase, Scopus and Web of Science were searched for terms relating to heart failure (specifically, left ventricular systolic dysfunction (LVSD), coronary artery disease (CAD) and atrial fibrillation), relevant diagnostic techniques and COPD. Studies published since 1980, reporting diagnosis rates using recognised diagnostic criteria in representative COPD populations not known to have heart disease were included. Studies were classified by condition diagnosed, diagnostic threshold used and whether participants had stable or exacerbated COPD. Random-effects meta-analysis of prevalence was conducted where appropriate. In general, prevalence estimates for undiagnosed cardiac comorbidities in COPD had broad confidence intervals, with significant study heterogeneity. Most notably, a prevalence of undiagnosed LVSD of 15.8% (11.1-21.1%) was obtained when defined as left ventricular ejection fraction <50%. Undiagnosed CAD was found in 2.3-18.0% of COPD patients and atrial fibrillation in 1.4% (0.3-3.5%). Further studies using recent diagnostic advances, and investigating therapeutic interventions for patients with COPD and heart disease are needed.

Prevalence and factors associated with undiagnosed and uncontrolled heart disease: A study based on self-reported chronic heart disease and symptom-based angina pectoris among middle-aged and older Indian adults.

This study aimed to examine the prevalence of heart diseases and angina pectoris and associated factors among middle-aged and older Indian adults. Additionally, the study examined the prevalence and associated factors of undiagnosed and uncontrolled heart disease among middle-aged and older adults based on self-reported chronic heart disease (CHD) and symptom-based angina pectoris (AP). We used cross-sectional data from the first wave of the Longitudinal Ageing Study of India, 2017-18. The sample consists of 59,854 individuals (27, 769 males and 32,085 females) aged 45 years and above. Maximum likelihood binary logistic regression models were employed to examine the associations between morbidities, other covariates (demographic factors, socio-economic factors and behavioral factors) and heart disease and angina. A proportion of 4.16% older males and 3.55% older females reported the diagnosis of heart diseases. A proportion of 4.69% older males and 7.02% older females had symptom-based angina. The odds of having heart disease were higher among those who were hypertensive and who had family history of heart disease, and it was higher among those whose cholesterol levels were higher. Individuals with hypertension, diabetes, high cholesterol and family history of heart disease were more likely to have angina than their healthy counterparts. The odds of undiagnosed heart disease were lower but the odds of uncontrolled heart disease were higher among those who were hypertensive than non-hypertensive individuals. Those having diabetes were less likely to have undiagnosed heart disease while among the diabetic people the odds of uncontrolled heart disease were higher. Similarly, higher odds were observed among people with high cholesterol, having stroke and also among those who had a history of heart disease than their counterparts. The present study provided a comparative prevalence of heart disease and agina and their associations with chronic diseases among middle-aged and older adults in India. The higher prevalence of undiagnosed and uncontrolled heart disease and their risk factors among middle-aged and older Indians manisfest alarming public health concerns and future health demand.

The Role of the Electrocardiogram (ECG) In the Screening and Prevention of Sudden Cardiac Death in Sports

The Role of the Electrocardiogram (ECG) In the Screening and Prevention of Sudden Cardiac Death in Sports Abstract: Athletes carry a higher risk for sports-related sudden cardiac death compared to the general population. The majority of these athletes suffer from an undiagnosed heart disease. Since physical activity is an essential trigger for sudden cardiac death in individuals with undiagnosed, usually hereditary, heart disease, sports can lead to sudden cardiac death in these athletes. Different heart diseases lead to sudden cardiac death at different ages during sports. The electrocardiogram (ECG) is an important screening tool to identify individuals of all ages with heart disease that are associated with sports-related sudden cardiac death. These individuals can then be treated and lives can be saved.

Emerging Life Sciences Series: Q&amp;A with the Editor

Emerging Life Sciences Series: Q&amp;A with the Editor

Live longer and better without aortic valve stenosis

Live longer and better without aortic valve stenosis

RECHOmmend: An ECG-Based Machine Learning Approach for Identifying Patients at Increased Risk of Undiagnosed Structural Heart Disease Detectable by Echocardiography.

Background:Timely diagnosis of structural heart disease improves patient outcomes, yet many remain underdiagnosed. While population screening with echocardiography is impractical, ECG-based prediction models can help target high-risk patients. We developed a novel ECG-based machine learning approach to predict multiple structural heart conditions, hypothesizing that a composite model would yield higher prevalence and positive predictive values to facilitate meaningful recommendations for echocardiography.Methods:Using 2 232 130 ECGs linked to electronic health records and echocardiography reports from 484 765 adults between 1984 to 2021, we trained machine learning models to predict the presence or absence of any of 7 echocardiography-confirmed diseases within 1 year. This composite label included the following: moderate or severe valvular disease (aortic/mitral stenosis or regurgitation, tricuspid regurgitation), reduced ejection fraction <50%, or interventricular septal thickness >15 mm. We tested various combinations of input features (demographics, laboratory values, structured ECG data, ECG traces) and evaluated model performance using 5-fold cross-validation, multisite validation trained on 1 site and tested on 10 independent sites, and simulated retrospective deployment trained on pre-2010 data and deployed in 2010.Results:Our composite rECHOmmend model used age, sex, and ECG traces and had a 0.91 area under the receiver operating characteristic curve and a 42% positive predictive value at 90% sensitivity, with a composite label prevalence of 17.9%. Individual disease models had area under the receiver operating characteristic curves from 0.86 to 0.93 and lower positive predictive values from 1% to 31%. Area under the receiver operating characteristic curves for models using different input features ranged from 0.80 to 0.93, increasing with additional features. Multisite validation showed similar results to cross-validation, with an aggregate area under the receiver operating characteristic curve of 0.91 across our independent test set of 10 clinical sites after training on a separate site. Our simulated retrospective deployment showed that for ECGs acquired in patients without preexisting structural heart disease in the year 2010, 11% were classified as high risk and 41% (4.5% of total patients) developed true echocardiography-confirmed disease within 1 year.Conclusions:An ECG-based machine learning model using a composite end point can identify a high-risk population for having undiagnosed, clinically significant structural heart disease while outperforming single-disease models and improving practical utility with higher positive predictive values. This approach can facilitate targeted screening with echocardiography to improve underdiagnosis of structural heart disease.

Burden of Undiagnosed Valvular Heart Disease in the Elderly in the Community – Heart of New Ulm Valve

Burden of Undiagnosed Valvular Heart Disease in the Elderly in the Community – Heart of New Ulm Valve

Abstract 9599: Rechommend: An Ecg-Based Machine-Learning Approach for Identifying Patients at High-Risk of Undiagnosed Structural Heart Disease Detectable by Echocardiography

Introduction: Timely diagnosis of structural heart disease improves patient outcomes, yet millions remain undiagnosed. ECG-based prediction models can help identify high-risk patients for targeted screening, but existing individual disease models often have low positive predictive values (PPV) and limited clinical utility. Hypothesis: An ECG-based composite model can predict one of multiple, actionable structural heart conditions and yield higher prevalence and PPVs than individual models. Methods: Using 2,141,366 ECGs linked to echocardiography and EHR records from 461,466 adults from 1984-2021, we trained machine learning models to predict any of 7 echocardiography-confirmed diseases within 1 year. This composite label included: moderate or severe valvular disease (aortic stenosis or regurgitation, mitral stenosis or regurgitation, tricuspid regurgitation), reduced ejection fraction of &amp;lt;50%, or interventricular septal thickness &amp;gt;15mm. We tested various combinations of inputs and evaluated model performance with 1) cross-validation and 2) a simulated retrospective deployment. We measured area under the receiver operating characteristic curve (AUROC) and precision-recall curve (AUPRC), and PPV at 90% sensitivity. Results: Our composite "rECHOmmend" model using age, sex and ECG traces had an AUROC of 0.91, AUPRC of 0.78, and PPV of 52% at 90% sensitivity and 23% disease prevalence. Individual disease models had similar AUROCs (0.88-0.93), but lower AUPRCs (0.07-0.71) and PPVs (2%-41%; Figure). Across inputs, model AUROCs ranged from 0.85 to 0.93. Our simulated deployment model classified 22% of at-risk patients in 2010 as high-risk, of whom 40% developed true, echo-confirmed disease within 1 year. Conclusions: An ECG-based machine learning model using a composite endpoint can predict undiagnosed structural heart disease, outperforming single disease models with higher PPVs to facilitate targeted screening with echocardiography.

Undiagnosed cyanotic heart disease - A challenge to emergency medical professionals

Cyanotic heart disease characterized by pulmonary hypertension with reversal or bidirectional shunt associated with atrioventricular septal defects or patent ductus arteriosus is known as Eisenmenger syndrome. Pregnancy-associated decreased systemic vascular resistance increases the degree of right to left shunting and hypoxemia, thereby increasing substantially both the maternal mortality and fetal wastage which is reported to be as high as 70%. Ideally, this is a contraindication for conceiving but if there is strong desire of pregnancy, it should be a supervised antenatally by multidisciplinary team. We present a case of a young primigravida who had cesarean delivery under subarachnoid block at 37 weeks of gestation and was referred after fall in oxygen saturation. It can be a challenge to manage these cases at a peripheral unit if the condition is undiagnosed.

COVID-19 and cardiovascular disease

Coronavirus disease 2019 (COVID-19), a spectrum of disease spanning from a barely symptomatic infection to critical illness, is caused by the new coronavirus - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although lung injury and acute respiratory distress syndrome have been at a centre stage as the most dreadful complications of COVID-19, the heart damage has recently emerged as yet another grim outcome in the virus’s repertoire of possible complications. The cardiac involvement occurs as a direct invasion of cardiomyocytes by the virus via the angiotensin‐converting enzyme 2 (ACE2) receptors and also indirectly by the inflammatory reaction due to cytokine storm. COVID-19 increases the severity of an already pre-existing heart disease and also unmasks the cardiac symptoms in a previously undiagnosed heart disease as well. Apart from this the drugs that are repurposed and are supposed to have a preventive or a therapeutic potential are also supposedly causing cardiac side effects. In the absence of substantial database all these seem to be a hypothetical correlation and one needs to rely on clinical skills and acumen. Keywords: COVID-19; SARS-CoV-2; cardiovascular disease; acute respiratory distress syndrome

Sisters can claim compensation after seeing father die from undiagnosed heart disease, says judge

Two young sisters who were horrified when they saw their father collapse and die from a heart attack have been given the go ahead to claim compensation for psychiatric injuries from the NHS trust that failed to diagnose his coronary artery disease 14 months previously. Saffron and Mya Paul’s claim was struck out by a High Court master, a procedural judge who deals with issues before trial, who ruled that it had no chance of success. But a High Court judge has overturned that decision on appeal and allowed the claim to proceed. Mr Justice Chamberlain said several other cases had been put on hold pending the result of the sisters’ appeal. The outcome could open the way for more claims against …

Recommendations of the Spanish Society of Paediatric Cardiology and Congenital Heart Disease as regards the use of drugs in attention deficit hyperactivity disorder in children and adolescents with a known heart disease, as well as in the general paediatric population: position statement by the Spanish Paediatric Association

IntroductionApproved drugs for attention deficit hyperactivity disorder (ADHD) in Spain are methylphenidate, lisdexamphetamine, atomoxetine and guanfacine. Due to adverse cardiovascular effects, mainly increased blood pressure and heart rate, its use in patients with known or undiagnosed heart disease may be controversial. ObjectiveTo obtain a consensus document from the Spanish Society of Paediatric Cardiology and Congenital Heart Diseases (SECPCC) and experts from other Agencies and Societies as a guide for the paediatric cardiologist and physicians who treat children and adolescents with ADHD. MethodAn analysis was performed on the bibliography and Clinical Practice Guidelines, technical data sheets approved by the Spanish Agency of Medicines and Health Devices, and the Spanish Ministry of Health Guidelines. A Working Group was formed, with a Coordinator, as well as members of the Clinical Cardiology Working Group and Arrhythmia Group of the SECPCC. This Group produced a preliminary document that was reviewed by a group of external experts (List 1) and a group of internal experts of the SECPCC (List 2) with a consensus being reached on the final document. ResultsThe recommendations of the SECPCC and the group of experts are presented on cardiovascular evaluation prior to treatment in children and adolescents with unknown cardiovascular disease and with known cardiovascular disease.The recommendations of the SECPCC and the group of experts are also presented on the use of medications for ADHD in children and adolescents with cardiological symptoms with no evidence of heart disease, congenital heart disease, cardiomyopathy, Marfan syndrome and other aortic diseases, hypertension, and arrhythmias.

Acute Decompensated Heart Failure Following Cesarean Delivery: A Case of Undiagnosed Rheumatic Heart Disease [14B

INTRODUCTION: Heart failure is a leading cause of maternal morbidity and mortality in the United States. It commonly occurs in the peripartum period—the last trimester and five months following delivery. It stems from multiple etiologies, most commonly peripartum cardiomyopathy and preexisting cardiac disease. The diagnosis of heart failure in the peripartum period is often delayed or misdiagnosed because its symptoms closely resemble those seen during normal pregnancy, pulmonary embolism, preeclampsia, and HELLP syndrome - including fatigue, shortness of breath and edema. METHODS: A 25-year-old G2P2 Burmese patient with no prior medical history presented five-days post cesarean delivery with chief complaint of shortness of breath, chest pressure, and palpitations. She was found to have tachypnea, tachycardia to the 140's, and hypoxemia with an oxygen saturation of 85%. Her EKG demonstrated atrial fibrillation with rapid ventricular response. Echocardiogram revealed findings consistent with undiagnosed Rheumatic Heart Disease (RHD) including bi-atrial enlargement, moderate mitral valve regurgitation, moderate tricuspid valve regurgitation, severe aortic valve regurgitation, moderate pulmonic valve regurgitation, and an LVEF of 55-60%. CONCLUSION: Diagnosis of RHD is rare in developed countries due to near eradication from improved efforts to administer antibiotic treatment. We hope our presentation sheds light on the burden of RHD that persists in developing nations and encourages providers to assess the possibility of this diagnosis in a subset of patients. Prompt diagnosis requires heightened awareness among multidisciplinary teams, a high degree of suspicion, and confirmation via echocardiographic studies. Treatment with targeted therapies can recover ventricular function in the majority of cases.

Unmasking Valvular Heart Disease in Pregnancy [31B

INTRODUCTION: Hemodynamic changes of the heart during pregnancy including increased stroke volume, heart rate, and cardiac output can result as cardiac decompensation in women with valvular heart disease. These hemodyamic changes can unmask faulty valves in women putting them at an increased risk of acute respiratory distress and heart failure. METHODS: We present two cases of previously undiagnosed valvular heart disease that was unmasked in late pregnancy and during labor. The first patient was a previously healthy 27-year-old female who presented at 38 weeks gestation with shortness of breath. She was diagnosed with pneumonia and developed pulmonary edema and acute respiratory failure. She was intubated and an emergency cesarean delivery was performed. Echocardiogram revealed severe mitral stenosis, tricuspid regurgitation, and congestive heart failure with valvular changes consistent with rheumatic heart disease. Patient was extubated on postpartum day 11 and later underwent a mitral valve replacement. Our second patient was a 29-year-old obese gravida 6 para 3 who presented at term in labor. Pregnancy was complicated by chronic hypertension. During labor, she developed acute pulmonary edema. After a spontaneous vaginal delivery, post-delivery echo showed severe mitral and tricuspid regurgitation with cardiomegaly. Patient was scheduled for valve replacement 6 months postpartum, but was non-complaint and eventually became pregnant again. She is scheduled for a mitral valve repair possible replacement 2 months postpartum. RESULTS: NA. CONCLUSION: The hemodynamic changes of late pregnancy and labor uncovered previously undiagnosed valvular disease in these two patients. Clinicians should have a heightened suspicion for valvular disease in women presenting with respiratory complaints.

Valvular heart disease in the elderly: more questions than answers.

We are grateful for the opportunity to respond to Chen and Yiu’s editorial comment on our article “Large-scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: the OxVALVE population cohort study” (1).

Large-scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: the OxVALVE Population Cohort Study.

Valvular heart disease (VHD) is expected to become more common as the population ages. However, current estimates of its natural history and prevalence are based on historical studies with potential sources of bias. We conducted a cross-sectional analysis of the clinical and epidemiological characteristics of VHD identified at recruitment of a large cohort of older people. We enrolled 2500 individuals aged ≥65 years from a primary care population and screened for undiagnosed VHD using transthoracic echocardiography. Newly identified (predominantly mild) VHD was detected in 51% of participants. The most common abnormalities were aortic sclerosis (34%), mitral regurgitation (22%), and aortic regurgitation (15%). Aortic stenosis was present in 1.3%. The likelihood of undiagnosed VHD was two-fold higher in the two most deprived socioeconomic quintiles than in the most affluent quintile, and three-fold higher in individuals with atrial fibrillation. Clinically significant (moderate or severe) undiagnosed VHD was identified in 6.4%. In addition, 4.9% of the cohort had pre-existing VHD (a total prevalence of 11.3%). Projecting these findings using population data, we estimate that the prevalence of clinically significant VHD will double before 2050. Previously undetected VHD affects 1 in 2 of the elderly population and is more common in lower socioeconomic classes. These unique data demonstrate the contemporary clinical and epidemiological characteristics of VHD in a large population-based cohort of older people and confirm the scale of the emerging epidemic of VHD, with widespread implications for clinicians and healthcare resources.

Sudden Death Due to Undiagnosed Rheumatic Heart Disease in a Child

We report the case of a 5-year-old boy who died from complications of rheumatic heart disease with atypical presentation. He was hospitalized for recent inflammatory and neurological symptoms. He was diagnosed with viral encephalitis. He died the day after he was discharged. The macroscopic autopsy findings were unremarkable. Histology revealed typical rheumatic heart disease. Neuropathology showed cerebral infarction due to an embolic event linked with the rheumatic valvulitis. The cause of death was determined as heart failure due to rheumatic heart disease secondary to an undiagnosed acute rheumatic fever. It is related to an autoimmune response to infection with group A streptococcus. It mainly affects children in developing countries. In our case, viral encephalitis was consistent with the medical history and the proper diagnosis was made on histological analysis. Forensic pathologists should consider this diagnosis facing a sudden unexpected death in childhood, even in industrialized countries.

Preoperative evaluation and comprehensive risk assessment for children with Down syndrome.

Down syndrome is a common chromosome disorder affecting all body systems. This creates unique physiologic concerns that can affect safety during anesthesia and surgery. Little consensus exists, however, on the best way to evaluate children with Down syndrome in preparation for surgery. We review a number of salient topics affecting these children in the perioperative period, including cervical spine instability, cardiovascular abnormalities, pulmonary hypertension, upper airway obstruction, hematologic disturbances, prematurity, low birth weight, and the use of supplements and alternative therapies. Recommendations include obtaining a complete blood count to detect an increased risk for bleeding or stroke, and cardiology evaluation to identify patients with pulmonary hypertension, as well as undiagnosed or residual heart disease. Pediatric cardiac anesthesiologists and intensivists should be involved as needed. The potential for cervical spine instability should be considered, and the anesthesiologist may wish to have several options available both for the medications and equipment used. The child's family should always be asked if he or she is on any nutritional supplements, as some products marketed to families may have secondary effects such as inhibition of platelet function. Using this evaluation in presurgical planning will allow physicians to better consider the individual circumstances for their patients with Down syndrome. Our goal was to optimize patient safety by choosing the most appropriate setting and perioperative personnel, and to mitigate those risk factors amenable to intervention.

Prevalence of Undiagnosed Structural Heart Disease in Children Undergoing Echocardiography for Kawasaki Disease.

Prevalence of Undiagnosed Structural Heart Disease in Children Undergoing Echocardiography for Kawasaki Disease.

Detection of Undiagnosed Ischemic Heart Disease in Hemodialysis Patients Using Myocardial Perfusion Imaging

uremic individuals. Objectives: The aim of this study was to detect undiagnosed ischemic heart disease (IHD) using dipyridamole myocardial perfusion imaging (MPI) in HD patients. Patients and Methods: In this cross-sectional descriptive study, HD patients who met the inclusion criteria were selected. Demographic, clinical, and paraclinical data were obtained via interviews and medical records. Bedside electrocardiography, resting echocardiography, and nuclear MPI with dipyridamole were done. The data were analyzed using descriptive statistical methods for detecting the prevalence of undiagnosed IHD in the HD patients. The chi-square test and the independent t-test were used to identify the high-risk HD patients. Results: Sixty-nine HD patients were studied using dipyridamole MPI with Tc 99 m sestamibi. The mean age, body mass index, and mean duration of HD were 52.1 ± 13.8 years, 21.23 ± 4.79 kg/m2, and 48.2 ± 34.9 months, respectively. The patients were divided into two groups based on MPI: IHD-positive group (21.7%) and IHD-negative group (78.3%). IHD was more prevalent in the patients with diabetes mellitus, hypertension, positive family history of CAD, low HD adequacy index (Kt/V < 1.2), left ventricular hypertrophy, high intact parathyroid hormone levels, electrocardiographic abnormalities, and low ferritin levels. A statistically significant correlation was also detected between IHD and aging (P < 0.05). Conclusions: The prevalence of undiagnosed IHD in the HD patients was considerable. We, therefore, suggest that IHD be assessed in HD patients, especially those at high risk due to positive family history of CAD, hypertension, left ventricular hypertrophy, diabetes mellitus, Kt/V < 1.2, low ferritin levels, and high levels of intact parathyroid hormone.