Patients with atrial fibrillation (AF) have an increased risk of cognitive decline, potentially resulting from clinically unrecognized vascular brain lesions.
This study sought to assess the ...relationships between cognitive function and vascular brain lesions in patients with AF.
Patients with known AF were enrolled in a multicenter study in Switzerland. Brain magnetic resonance imaging (MRI) and cognitive testing using the Montreal Cognitive Assessment (MoCA) were performed in all participants. Large noncortical or cortical infarcts (LNCCIs), small noncortical infarcts (SNCIs), microbleeds, and white matter lesions were quantified by a central core laboratory. Clinically silent infarcts were defined as infarcts on brain MRI in patients without a clinical history of stroke or transient ischemic attack.
The study included 1,737 patients with a mean age of 73 ± 8 years (28% women, 90% taking oral anticoagulant agents). On MRI, LNCCIs were found in 387 patients (22%), SNCIs in 368 (21%), microbleeds in 372 (22%), and white matter lesions in 1715 (99%). Clinically silent infarcts among the 1,390 patients without a history of stroke or transient ischemic attack were found in 201 patients with LNCCIs (15%) and 245 patients with SNCIs (18%). The MoCA score was 24.7 ± 3.3 in patients with and 25.8 ± 2.9 in those without LNCCIs on brain MRI (p < 0.001). The difference in MoCA score remained similar when only clinically silent LNCCIs were considered (24.9 ± 3.1 vs. 25.8 ± 2.9; p < 0.001). In a multivariable regression model including all vascular brain lesion parameters, LNCCI volume was the strongest predictor of a reduced MoCA (β = −0.26; 95% confidence interval: −0.40 to −0.13; p < 0.001).
Patients with AF have a high burden of LNCCIs and other brain lesions on systematic brain MRI screening, and most of these lesions are clinically silent. LNCCIs were associated with worse cognitive function, even among patients with clinically silent infarcts. Our findings raise the question of MRI screening in patients with AF.
Systemic hypertension and type 2 diabetes mellitus are associated with impaired left atrial (LA) function, but whether LA functional abnormalities also occur in patients with hypertension and ...diabetes who have normal LA sizes is unknown. The aim of this study was to explore LA strain using speckle-tracking echocardiography in patients with hypertension or diabetes and normal LA size.
LA strain was studied by speckle-tracking echocardiography in 155 patients with hypertension or diabetes with LA volume indexes < 28 mL/m(2) (83 with hypertension, 34 with diabetes, and 38 with both diabetes and hypertension) and 36 age-matched controls. The following indexes were measured: peak atrial longitudinal strain, time to peak atrial longitudinal strain, atrial longitudinal strain during early diastole and late diastole, and peak LA strain rate during ventricular systole, early diastole, and late diastole.
Peak atrial longitudinal strain was lower in patients with hypertension (29.0 ± 6.5%) and those with diabetes (24.7 ± 6.4%) than in controls (39.6 ± 7.8%) and further reduced in patients with diabetes and hypertension (18.3 ± 5.0%) (P < .0001). Similar results were found for atrial longitudinal strain during early diastole, atrial longitudinal strain during late diastole, and peak LA strain rate during ventricular systole and early diastole (P < .0001 for all). An inverse trend was found for time to peak atrial longitudinal strain, whereas no differences in peak LA strain rate during late diastole were observed. Two-way analysis of variance showed no interactions between hypertension and diabetes. In multivariate analyses, hypertension and diabetes were both independently associated with decreases in all LA strain and strain rate indexes, with the exception of peak LA strain rate during late diastole.
LA deformation mechanics are impaired in patients with hypertension or diabetes with normal LA size. The coexistence of both conditions further impairs LA performance in an additive fashion. Speckle-tracking echocardiography may be considered a promising tool for the early detection of LA strain abnormalities in these patients.
Aims
The implantable cardiac defibrillator/cardiac resynchronization therapy with defibrillator‐based HeartLogic™ algorithm has recently been developed for early detection of impending decompensation ...in heart failure (HF) patients; but whether this novel algorithm can reduce HF hospitalizations has not been evaluated. We investigated if activation of the HeartLogic algorithm reduces the number of hospital admissions for decompensated HF in a 1 year post‐activation period as compared with a 1 year pre‐activation period.
Methods and results
Heart failure patients with an implantable cardiac defibrillator/cardiac resynchronization therapy with defibrillator with the ability to activate HeartLogic and willingness to have remote device monitoring were included in this multicentre non‐blinded single‐arm trial with historical comparison. After a HeartLogic alert, the presence of HF symptoms and signs was evaluated. If there were two or more symptoms and signs apart from the HeartLogic alert, lifestyle advices were given and/or medication was adjusted. After activation of the algorithm, patients were followed for 1 year. HF events occurring in the 1 year prior to activation and in the 1 year after activation were compared. Of the 74 eligible patients (67.2 ± 10.3 years, 84% male), 68 patients completed the 1 year follow‐up period. The total number of HF hospitalizations reduced from 27 in the pre‐activation period to 7 in the post‐activation period (P = 0.003). The number of patients hospitalized for HF declined from 21 to 7 (P = 0.005), and the hospitalization length of stay diminished from average 16 to 7 days (P = 0.079). Subgroup analysis showed similar results (P = 0.888) for patients receiving cardiac resynchronization therapy during the pre‐activation period or not receiving cardiac resynchronization therapy, meaning that the effect of hospitalizations cannot solely be attributed to reverse remodelling. Subanalysis of a single‐centre Belgian subpopulation showed important reductions in overall health economic costs (P = 0.025).
Conclusion
Activation of the HeartLogic algorithm enables remote monitoring of HF patients, coincides with a significant reduction in hospitalizations for decompensated HF, and results in health economic benefits.
Out-of-hospital cardiac arrest (OHCA) in the absence of evident structural heart disease is rare and can be due to subclinical cardiomyopathy and primary electrical disorders, including idiopathic ...ventricular fibrillation (IVF) with early repolarization (ER) pattern. Aim of this study was to investigate prevalence, clinical features, and long-term prognosis of IVF in OHCA survivors with otherwise normal 12-lead electrocardiograms (ECGs).
Patients with IVF in the absence of ER pattern or atrioventricular conduction abnormalities were considered eligible for this study. A total of 3407 OHCAs occurred in our region from 2000 to 2014. Out-of-hospital cardiac arrests of presumed cardiac origin were 2192; of them, 644 presented with a ventricular arrhythmia (VT/VF) as first shockable rhythm. Among them, a total of 74 implantable cardioverter-defibrillators were implanted for secondary prevention. Ventricular arrhythmia was considered idiopathic in 11 (15%) of these patients. Over a mean follow-up time of 85 ± 47 months (median: 42 months), ECG was found abnormal in three cases. In the remaining eight patients (6 males; median age: 45 years), no ECG or structural abnormalities were detected during the follow-up. Prevalence of IVF in OHCA survivors with first-shockable rhythm was 1.2%. During the long-term follow-up, no patient died or experienced ICD interventions. No new echocardiographic abnormal findings were revealed.
Idiopathic ventricular fibrillation is rare occurring in 1.2% of OHCA survivors presenting with a shockable rhythm. The initial diagnosis can change in up to 27% of cases. Patients with IVF and no ER pattern or AV conduction disturbances have a good prognosis during a long-term follow-up.
This study assessed the clinical utility and feasibility of concomitant of combined left atrial appendage (LAA) closure and positioning of miniaturized pacemaker (Micra TPS). All consecutive patients ...who underwent VVI-PM implant from November 2015 to October 2016 were considered. VVI-PM implant was conducted either using transvenous approach or by positioning Micra TPS. In selected patients with concomitant contraindication to OAC, Micra TPS was combined with LAA occlusion (“combined approach”), performed in general anesthesia and guided by multimodality imaging; procedural and follow-up data of these specific patients were registered. Sixty patients were treated with VVI-PM implant. Six patients (10.0%) presented OAC contraindication, of which 4 (6.7%) were eligible for the “combined procedure”; 2 of 4 of these patients presented chronic hemodialysis-dependent renal failure. The combined approach was successful in all 4 patients without intra- or periprocedural complications. No adverse events linked to the combined approach occurred during mid-term follow-up (7.5, interquartile range 5.0 to 7.9 months). In conclusion, VVI-PM indication and concomitant contraindication to OAC is not uncommon; in selected patients, combined LAA closure and positioning of Micra TPS may be a feasible therapeutic option.
Limited bystander assistance and delayed emergency medical service arrival reduce the chances of survival in cardiac arrest victims. Early basic life support through trained first responders (FR) and ...automatic external defibrillation both improve the outcome. Well-organized FR networks have shown promise, but guidance on effective implementation is lacking. This study evaluates two FR networks, in Belgium and in Switzerland, to identify main advancements in the development of such systems.
Direct comparison is made of the barriers and facilitators in the development of both FR systems from 2006 up until December 2022, and summarized within a roadmap.
The Roadmap comprises four integral steps: exploration, installation, initiation, and implementation. Exploration involves understanding the national legislation, engaging with advisory bodies, and establishing local steering committees. The installation phase focuses on FR recruitment, engaging specific professional groups such as firemen, registering public Automated External Defibrillators (AEDs), and requesting feedback. The initiation step includes implementing improvement cycles and fidelity measures. Finally, implementation expands the network, leading to increased survival rates and the integration of these practices into legislation. A significant focus is placed on FR's psychological wellbeing. Moreover, the roadmap highlights the use of efficient geo-mapping to simplify optimal AED placement and automatically assign FRs to tasks.
The importance of FR networks for early resuscitation is increasingly recognized and various systems are being developed. Key developmental strategies of the EVapp and Ticino Cuore app system may serve as a roadmap for other systems and implementations within Europe and beyond.
Abstract Aim We compared the time to initiation of cardiopulmonary resuscitation (CPR) by lay responders and/or first responders alerted either via Short Message Service (SMS) or by using a mobile ...application-based alert system (APP). Methods The Ticino Registry of Cardiac Arrest collects all data about out-of-hospital cardiac arrests (OHCAs) occurring in the Canton of Ticino. At the time of a bystander’s call, the EMS dispatcher sends one ambulance and alerts the first-responders network made up of police officers or fire brigade equipped with an automatic external defibrillator, the so called “traditional” first responders, and − if the scene was considered safe − lay responders as well. We evaluated the time from call to arrival of traditional first responders and/or lay responders when alerted either via SMS or the new developed mobile APP. Results Over the study period 593 OHCAs have occurred. Notification to the first responders network was sent via SMS in 198 cases and via mobile APP in 134 cases. Median time to first responder/lay responder arrival on scene was significantly reduced by the APP-based system (3.5 2.8-5.2) compared to the SMS-based system (5.6 4.2-8.5 min, p 0.0001). The proportion of lay responders arriving first on the scene significantly increased (70% vs. 15%, p<0.01) with the APP. Earlier arrival of a first responder or of a lay responder determined a higher survival rate. Conclusions The mobile APP system is highly efficient in the recruitment of first responders, significantly reducing the time to the initiation of CPR thus increasing survival rates.
Aims To determine the out-of-hospital cardiac arrest (OHCA) rates and occurrences at municipality level through a novel statistical model accounting for temporal and spatial heterogeneity, space-time ...interactions and demographic features. We also aimed to predict OHCAs rates and number at municipality level for the upcoming years estimating the related resources requirement. Methods All the consecutive OHCAs of presumed cardiac origin occurred from 2005 until 2018 in Canton Ticino region were included. We implemented an Integrated Nested Laplace Approximation statistical method for estimation and prediction of municipality OHCA rates, number of events and related uncertainties, using age and sex municipality compositions. Comparisons between predicted and real OHCA maps validated our model, whilst comparisons between estimated OHCA rates in different yeas and municipalities identified significantly different OHCA rates over space and time. Longer-time predicted OHCA maps provided Bayesian predictions of OHCA coverages in varying stressful conditions. Results 2344 OHCAs were analyzed. OHCA incidence either progressively reduced or continuously increased over time in 6.8% of municipalities despite an overall stable spatio-temporal distribution of OHCAs. The predicted number of OHCAs accounts for 89% (2017) and 90% (2018) of the yearly variability of observed OHCAs with prediction error less than or equal to1OHCA for each year in most municipalities. An increase in OHCAs number with a decline in the Automatic External Defibrillator availability per OHCA at region was estimated. Conclusions Our method enables prediction of OHCA risk at municipality level with high accuracy, providing a novel approach to estimate resource allocation and anticipate gaps in demand in upcoming years.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Electrocardiography (ECG) is an important tool to triage patients with out-of-hospital cardiac arrest (OHCA) after return of spontaneous circulation (ROSC). An immediate coronary angiography after ...ROSC is recommended only in patients with an ECG that is diagnostic of ST-segment elevation myocardial infarction (STEMI). To date, the benefit of this approach has not been demonstrated in patients with a post-ROSC ECG that is not diagnostic of STEMI.
To assess whether the time from ROSC to ECG acquisition is associated with the diagnostic accuracy of ECG for STEMI.
This retrospective, multicenter cohort study (the Post-ROSC Electrocardiogram After Cardiac Arrest study) analyzed consecutive patients older than 18 years who were resuscitated from OHCA between January 1, 2015, and December 31, 2018, and were admitted to 1 of the 3 participating centers in Europe (Pavia, Italy; Lugano, Switzerland; and Vienna, Austria).
Only patients who underwent coronary angiography during hospitalization and who acquired a post-ROSC ECG before the angiography were enrolled. Patients with a nonmedical cause of OHCAs were excluded.
The primary end point was false-positive ECG findings, defined as the percentage of patients with post-ROSC ECG findings that met STEMI criteria but who did not show obstructive coronary artery disease on angiography that was worthy of percutaneous coronary angioplasty.
Of 586 consecutive patients who were admitted to the 3 participating centers, 370 were included in the analysis (287 men 77.6%; median age, 62 years interquartile range, 53-70 years); 121 (32.7%) were enrolled in the participating center in Pavia, Italy; 38 (10.3%) in Lugano, Switzerland; and 211 (57.0%) in Vienna, Austria. The percentage of false-positive ECG findings in the first tertile of ROSC to ECG time (≤7 minutes) was significantly higher than that in the second (8-33 minutes) and third (>33 minutes) tertiles: 18.5% in the first tertile vs 7.2% in the second (odds ratio OR, 0.34; 95% CI, 0.13-0.87; P = .02) and 5.8% in the third (OR, 0.27; 95% CI, 0.15-0.47; P < .001). These differences remained significant when adjusting for sex (≤7 minutes: reference; 8-33 minutes: OR, 0.32; 95% CI, 0.12-0.85; P = .02; >33 minutes: OR, 0.26; 95% CI, 0.14-0.47; P < .001), age (≤7 minutes: reference; 8-33 minutes: OR, 0.34; 95% CI, 0.13-0.89; P = .03; >33 minutes: OR, 0.27; 95% CI, 0.15-0.46; P < .001), number of segments with ST-elevation (≤7 minutes: reference; 8-33 minutes: OR, 0.35; 95% CI, 0.15-0.81; P = .01; >33 minutes: OR, 0.28; 95% CI, 0.15-0.52; P < .001), QRS duration (≤7 minutes: reference; 8-33 minutes: OR, 0.35; 95% CI, 0.14-0.87; P = .02; >33 minutes: OR, 0.27; 95% CI, 0.15-0.48; P < .001), heart rate (≤7 minutes: reference; 8-33 minutes: OR, 0.35; 95% CI, 0.13-0.93; P = .04; >33 minutes: OR, 0.29; 95% CI, 0.15-0.55; P < .001), epinephrine administered (≤7 minutes: reference; 8-33 minutes: OR, 0.35; 95% CI, 0.13-0.98; P = .045; >33 minutes: OR, 0.27; 95% CI, 0.16-0.48; P < .001), shockable initial rhythm (≤7 minutes: reference; 8-33 minutes: OR, 0.35; 95% CI, 0.13-0.96; P = .04; >33 minutes: OR, 0.26; 95% CI, 0.15-0.46; P < .001), and 3 or more shocks administered (≤7 minutes: reference; 8-33 minutes: OR, 0.36; 95% CI, 0.13-1.00; P = .05; >33 minutes: OR, 0.27; 95% CI, 0.16-0.48; P < .001) in bivariable analyses.
This study suggests that early ECG acquisition after ROSC in patients with OHCA is associated with a higher percentage of false-positive ECG findings for STEMI. It may be reasonable to delay post-ROSC ECG by at least 8 minutes after ROSC or repeat the acquisition if the first ECG is diagnostic of STEMI and is acquired early after ROSC.
We propose a Bayesian spatiotemporal statistical model for predicting out‐of‐hospital cardiac arrests (OHCAs). Risk maps for Ticino, adjusted for demographic covariates, are built for explaining and ...forecasting the spatial distribution of OHCAs and their temporal dynamics. The occurrence intensity of the OHCA event in each area of interest, and the cardiac risk‐based clustering of municipalities are efficiently estimated, through a statistical model that decomposes OHCA intensity into overall intensity, demographic fixed effects, spatially structured and unstructured random effects, time polynomial dependence, and spatiotemporal random effect. In the studied geography, time evolution and dependence on demographic features are robust over different categories of OHCAs, but with variability in their spatial and spatiotemporal structure. Two main OHCA incidence‐based clusters of municipalities are identified.
PDF
