Abstract only
Introduction:
Early detection of structural heart diseases (SHD) can help improve patient outcomes. Electrocardiogram (ECG) based deep learning (DL) models have the potential to ...identify patients (pts) with undiagnosed disease in need of further testing such as echocardiography. Most models have focused on detecting a single abnormality. A few studies have attempted detection on a comprehensive aggregate set of outcomes, but with limited scope and external validation.
Hypothesis:
An ECG DL model can identify pts at risk for SHDs, with stable external validation performance regardless of hospital type (academic/community), clinical setting (inpatient/outpatient/emergency department), or demographics (race/ethnicity).
Methods:
We identified 426,659 ECG-echo study pairs since 2008 from 5 NewYork-Presbyterian-affiliated (NYP) hospitals, including Columbia, to train the EchoNext DL model. ECGs were associated with SHD if acquired within one year prior to an echo reporting left ventricular (LV) ejection fraction ≤45%, LV wall thickness ≥1.3cm, moderate or severe valvular disease, moderate or large pericardial effusion, moderate or severe right ventricular dysfunction, or pulmonary artery systolic pressure ≥45 mmHg. EchoNext was tested on unseen data from four other NYP hospitals, including Cornell.
Results:
In the external dataset (n=21,421 pts), 33% were identified with SHD. EchoNext achieved an area under the receiver operating characteristic curve (AUROC) of 0.85, with robust results with respect to individual hospital (AUROC range: 0.82-0.87), clinical setting (0.78-0.84), and patient race/ethnicity (0.84-0.86; Figure).
Conclusion:
EchoNext demonstrated excellent performance in detecting SHD in the largest multi-institutional, multi-racial external validation of such a model to date. This model may allow AI-enabled reflex referral to echocardiography from ECG. Prospective trials are ongoing to validate.
Objectives To investigate the relative benefits of unfractionated heparin, low molecular weight heparin(LMWH), fondaparinux, and bivalirudin as treatment options for patients with ST segment ...elevation myocardial infarction undergoing percutaneous coronary intervention (PCI).Design Mixed treatment comparison and direct comparison meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors.Data sources and study selection A search of Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) for randomized trials comparing unfractionated heparin plus glycoprotein IIb/IIIa inhibitor(GpIIb/IIIa inhibitor), unfractionated heparin, bivalirudin, fondaparinux, or LMWH plus GpIIb/IIIa inhibitor for patients undergoing primary PCI.Outcomes The primary efficacy outcome was short term (in hospital or within 30 days) major adverse cardiovascular event; the primary safety outcome was short term major bleeding.Results We identified 22 randomized trials that enrolled 22 434 patients. In the mixed treatment comparison models, when compared with unfractionated heparin plus GpIIb/IIIa inhibitor, unfractionated heparin was associated with a higher risk of major adverse cardiovascular events (relative risk 1.49 (95% confidence interval 1.21 to 1.84), as were bivalirudin (relative risk 1.34 (1.01 to 1.78)) and fondaparinux (1.78 (1.01 to 3.14)). LMWH plus GpIIb/IIIa inhibitor showed highest treatment efficacy, followed (in order) by unfractionated heparin plus GpIIb/IIIa inhibitor, bivalirudin, unfractionated heparin, and fondaparinux. Bivalirudin was associated with lower major bleeding risk compared with unfractionated heparin plus GpIIb/IIIa inhibitor (relative risk 0.47 (0.30 to 0.74)) or unfractionated heparin (0.58 (0.37 to 0.90)). Bivalirudin, followed by unfractionated heparin, LMWH plus GpIIb/IIIa inhibitor, unfractionated heparin plus GpIIb/IIIa inhibitor, and fondaparinux were the hierarchy for treatment safety. Results were similar in direct comparison meta-analyses: bivalirudin was associated with a 39%, 44%, and 65% higher risk of myocardial infarction, urgent revascularization, and stent thrombosis respectively when compared with unfractionated heparin with or without GpIIb/IIIa inhibitor. However, bivalirudin was associated with a 48% lower risk of major bleeding compared with unfractionated heparin plus GpIIb/IIIa inhibitor and 32% lower compared with unfractionated heparin alone.Conclusions In patients undergoing primary PCI, unfractionated heparin plus GpIIb/IIIa inhibitor and LMWH plus GpIIb/IIIa inhibitor were most efficacious, with the lowest rate of major adverse cardiovascular events, whereas bivalirudin was safest, with the lowest bleeding. These relationships should be considered in selecting anticoagulant therapies in patients undergoing primary PCI.
Atrial fibrillation (AF) symptom relief is a primary indication for catheter ablation, but AF symptom resolution is not well characterized. The study objective was to describe AF symptom ...documentation in electronic health records (EHRs) pre- and post-ablation and identify correlates of post-ablation symptoms.
We conducted a retrospective cohort study using EHRs of patients with AF (n = 1293), undergoing ablation in a large, urban health system from 2010 to 2020. We extracted symptom data from clinical notes using a natural language processing algorithm (F score: 0.81). We used Cochran's Q tests with post-hoc McNemar's tests to determine differences in symptom prevalence pre- and post-ablation. We used logistic regression models to estimate the adjusted odds of symptom resolution by personal or clinical characteristics at 6 and 12 months post-ablation. In fully adjusted models, at 12 months post-ablation patients, patients with heart failure had significantly lower odds of dyspnoea resolution odds ratio (OR) 0.38, 95% confidence interval (CI) 0.25-0.57, oedema resolution (OR 0.37, 95% CI 0.25-0.56), and fatigue resolution (OR 0.54, 95% CI 0.34-0.85), but higher odds of palpitations resolution (OR 1.90, 95% CI 1.25-2.89) compared with those without heart failure. Age 65 and older, female sex, Black or African American race, smoking history, and antiarrhythmic use were also associated with lower odds of resolution of specific symptoms at 6 and 12 months.
The post-ablation symptom patterns are heterogeneous. Findings warrant confirmation with larger, more representative data sets, which may be informative for patients whose primary goal for undergoing an ablation is symptom relief.
Most guidelines for treatment of hypertension including the Joint National Committee-7 recommend a blood pressure (BP) goal of <140/90 mm Hg for hypertensive patients and a more aggressive goal of ...<130/80 mm Hg for patients with coronary artery disease (CAD), based largely on expert consensus.
To evaluate the BP targets in patients with CAD DATA SOURCES: PUBMED, EMBASE and CENTRAL Study Selection: Randomised clinical trials (RCTs) of antihypertensive therapy in patients with CAD, enrolling at least 100 patients, with achieved systolic pressure of <=135 mm Hg in the 'intensive BP' group and <=140 mm Hg in the 'standard BP' group with follow-up for at least 1 year and evaluating cardiovascular outcomes.
The following efficacy outcomes were extracted- all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, angina pectoris, heart failure and revascularisation.
We identified 15 RCTs enrolling 66,504 participants with 276,328 patient-years of follow-up. Intensive BP group (≤ 135 mm Hg) was associated with a 15% decrease in heart failure rate and 10% decrease in stroke rate, driven largely by trials with a more intensive BP group (≤ 130 mm Hg), with similar outcomes for death and cardiovascular death and was associated with a 105% increase in the risk of hypotension. More intensive BP group (≤ 130 mm Hg) was also associated with a reduction in myocardial infarction and angina pectoris. The results were similar in a Bayesian random effects model. In addition, lower seemed to be better (based on regression analysis) for the outcomes of myocardial infarction, stroke, heart failure and perhaps angina.
The present body of evidence suggests that in patients with CAD, intensive systolic BP control to ≤ 135 mm Hg and possibly to ≤ 130 mm Hg is associated with a modest reduction in stroke and heart failure but at the expense of hypotension. Lower was better, although not consistently so for myocardial infarction, stroke, heart failure and perhaps angina. Further trials are needed to prove these findings.
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