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Clinical Research in Cardiology :... Jan 2022Impaired left-ventricular ejection-fraction (LV-EF) is a known risk factor for ischemic stroke and systemic embolism in patients with heart failure (HF) even in the... (Review)
Review
Impaired left-ventricular ejection-fraction (LV-EF) is a known risk factor for ischemic stroke and systemic embolism in patients with heart failure (HF) even in the absence of atrial fibrillation. While stroke risk is inversely correlated with LV-EF in HF patients with sinus rhythm, strategies using anticoagulation with Vitamin-K antagonists (VKA) were futile as the increase in major bleedings outweighed the potential benefit in stroke reduction. Non-Vitamin K oral anticoagulants (NOACs) proved to be an effective and in general safer approach for stroke prevention in patients with atrial fibrillation and may also have a favourable risk-benefit profile in HF patients. In HF patients with sinus rhythm, the COMPASS trial suggested a potential benefit for rivaroxaban, whereas the more dedicated COMMANDER-HF trial remained neutral on overall ischemic benefit owed to a higher mortality which was not influenced by anticoagulation. More recent data from subgroups in the COMMANDER-HF trial, however, suggest that there might be a benefit of rivaroxaban regarding stroke prevention under certain circumstances. In this article, we review the existing evidence for NOACs in HF patients with atrial fibrillation, elaborate the rationale for stroke prevention in HF patients with sinus rhythm, summarise the available data from anticoagulation trials in HF with sinus rhythm, and describe the patient who might eventually profit from an individualised strategy aiming to reduce stroke risk.
Topics: Anticoagulants; Atrial Fibrillation; Heart Failure; Humans; Stroke; Stroke Volume
PubMed: 34448932
DOI: 10.1007/s00392-021-01930-y -
Journal of the American College of... Jun 2022Inappropriate sinus tachycardia (IST) is a clinical syndrome that generally affects young patients and is associated with distressing symptoms. Although the most common... (Review)
Review
Inappropriate sinus tachycardia (IST) is a clinical syndrome that generally affects young patients and is associated with distressing symptoms. Although the most common symptom is palpitations, it can be accompanied by a myriad of symptoms, including anxiety, dizziness, presyncope, and syncope. The pathogenesis of IST is not well understood and considered multifactorial, with autonomic dysfunction being the central abnormality. IST is a diagnosis of exclusion. Management presents a clinical challenge. The overall efficacy of lifestyle modifications and medical therapy may be limited. Recent advances in catheter and surgical sinus node sparing ablation techniques have led to improvement in outcomes. In addition, increased focus has led to development of multimodality team-based interventions to improve outcomes in this group of patients. In this review, we discuss the mechanistic basis of IST, review current approaches to diagnosis, and outline contemporary therapeutic approaches.
Topics: Catheter Ablation; Heart Rate; Humans; Sinoatrial Node; Syndrome; Tachycardia, Sinus
PubMed: 35710196
DOI: 10.1016/j.jacc.2022.04.019 -
Lancet (London, England) Sep 2019Atrial fibrillation is frequently asymptomatic and thus underdetected but is associated with stroke, heart failure, and death. Existing screening methods require...
An artificial intelligence-enabled ECG algorithm for the identification of patients with atrial fibrillation during sinus rhythm: a retrospective analysis of outcome prediction.
BACKGROUND
Atrial fibrillation is frequently asymptomatic and thus underdetected but is associated with stroke, heart failure, and death. Existing screening methods require prolonged monitoring and are limited by cost and low yield. We aimed to develop a rapid, inexpensive, point-of-care means of identifying patients with atrial fibrillation using machine learning.
METHODS
We developed an artificial intelligence (AI)-enabled electrocardiograph (ECG) using a convolutional neural network to detect the electrocardiographic signature of atrial fibrillation present during normal sinus rhythm using standard 10-second, 12-lead ECGs. We included all patients aged 18 years or older with at least one digital, normal sinus rhythm, standard 10-second, 12-lead ECG acquired in the supine position at the Mayo Clinic ECG laboratory between Dec 31, 1993, and July 21, 2017, with rhythm labels validated by trained personnel under cardiologist supervision. We classified patients with at least one ECG with a rhythm of atrial fibrillation or atrial flutter as positive for atrial fibrillation. We allocated ECGs to the training, internal validation, and testing datasets in a 7:1:2 ratio. We calculated the area under the curve (AUC) of the receiver operatoring characteristic curve for the internal validation dataset to select a probability threshold, which we applied to the testing dataset. We evaluated model performance on the testing dataset by calculating the AUC and the accuracy, sensitivity, specificity, and F1 score with two-sided 95% CIs.
FINDINGS
We included 180 922 patients with 649 931 normal sinus rhythm ECGs for analysis: 454 789 ECGs recorded from 126 526 patients in the training dataset, 64 340 ECGs from 18 116 patients in the internal validation dataset, and 130 802 ECGs from 36 280 patients in the testing dataset. 3051 (8·4%) patients in the testing dataset had verified atrial fibrillation before the normal sinus rhythm ECG tested by the model. A single AI-enabled ECG identified atrial fibrillation with an AUC of 0·87 (95% CI 0·86-0·88), sensitivity of 79·0% (77·5-80·4), specificity of 79·5% (79·0-79·9), F1 score of 39·2% (38·1-40·3), and overall accuracy of 79·4% (79·0-79·9). Including all ECGs acquired during the first month of each patient's window of interest (ie, the study start date or 31 days before the first recorded atrial fibrillation ECG) increased the AUC to 0·90 (0·90-0·91), sensitivity to 82·3% (80·9-83·6), specificity to 83·4% (83·0-83·8), F1 score to 45·4% (44·2-46·5), and overall accuracy to 83·3% (83·0-83·7).
INTERPRETATION
An AI-enabled ECG acquired during normal sinus rhythm permits identification at point of care of individuals with atrial fibrillation.
FUNDING
None.
Topics: Adult; Aged; Algorithms; Atrial Fibrillation; Atrial Flutter; Case-Control Studies; Electrocardiography; Female; Humans; Male; Middle Aged; Neural Networks, Computer; Predictive Value of Tests; ROC Curve; Retrospective Studies
PubMed: 31378392
DOI: 10.1016/S0140-6736(19)31721-0 -
Frontiers in Neuroscience 2023The heart and brain have bi-directional influences on each other, including autonomic regulation and hemodynamic connections. Heart rate variability (HRV) measures... (Review)
Review
The heart and brain have bi-directional influences on each other, including autonomic regulation and hemodynamic connections. Heart rate variability (HRV) measures variation in beat-to-beat intervals. New findings about disorganized sinus rhythm (erratic rhythm, quantified as heart rate fragmentation, HRF) are discussed and suggest overestimation of autonomic activities in HRV changes, especially during aging or cardiovascular events. When excluding HRF, HRV is regulated the central autonomic network (CAN). HRV acts as a proxy of autonomic activity and is associated with executive functions, decision-making, and emotional regulation in our health and wellbeing. Abnormal changes of HRV (e.g., decreased vagal functioning) are observed in various neurological conditions including mild cognitive impairments, dementia, mild traumatic brain injury, migraine, COVID-19, stroke, epilepsy, and psychological conditions (e.g., anxiety, stress, and schizophrenia). Efforts are needed to improve the dynamic and intriguing heart-brain interactions.
PubMed: 36937689
DOI: 10.3389/fnins.2023.1055445 -
Heart (British Cardiac Society) Nov 2023To investigate heart rate differences between non-dihydropyridine calcium channel blockers and beta-blockers in patients with non-permanent atrial fibrillation (AF). (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To investigate heart rate differences between non-dihydropyridine calcium channel blockers and beta-blockers in patients with non-permanent atrial fibrillation (AF).
METHODS
Using data from 'A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation' (AFFIRM), where patients were randomised 1:1 rate or rhythm control, we compared the effect of rate control drugs on heart rate during AF as well as during sinus rhythm. Multivariable logistic regression was used to adjust for baseline characteristics.
RESULTS
A total of 4060 patients were enrolled in the AFFIRM trial, mean age was 70±9 years, 39% were women. Out of the total, 1112 patients were in sinus rhythm at baseline and used either non-dihydropyridine channel blockers or beta-blockers. Of them, 474 had AF during follow-up while remaining on the same rate control drugs, 218 (46%) on calcium channel blockers and 256 (54%) on beta-blockers. Mean age of calcium channel blocker patients was 70±8 years and 68±8 for beta-blocker patients (p=0.003), 42% were women. A resting heart rate <110 beats per min during AF was achieved in 92% of patients using calcium channel blockers and 92% of patients using beta-blockers (p=1.00). Bradycardia during sinus rhythm occurred in 17% of patients using calcium channel blockers vs 32% using beta-blockers (p<0.001). After adjusting for patient characteristics, calcium channel blockers were associated with a reduction in bradycardia during sinus rhythm (OR 0.41, 95% CI 0.19 to 0.90).
CONCLUSION
In patients with non-permanent AF, calcium channel blockers instituted for rate control were associated with less bradycardia during sinus rhythm compared with beta-blockers.
Topics: Humans; Female; Middle Aged; Aged; Male; Atrial Fibrillation; Calcium Channel Blockers; Bradycardia; Adrenergic beta-Antagonists; Heart Rate; Anti-Arrhythmia Agents
PubMed: 37433659
DOI: 10.1136/heartjnl-2023-322635