Diurnal Variations in Natriuretic Peptide Levels: Clinical Implications for the Diagnosis of Acute Heart Failure.

BACKGROUND: Current guidelines recommend interpreting concentrations of NPs (natriuretic peptides) irrespective of the time of presentation to the emergency department. We hypothesized that diurnal variations in NP concentration may affect their diagnostic accuracy for acute heart failure. METHODS: In a secondary analysis of a multicenter diagnostic study enrolling patients presenting with acute dyspnea to the emergency department and using central adjudication of the final diagnosis by 2 independent cardiologists, the diagnostic accuracy for acute heart failure of BNP (B-type NP), NT-proBNP (N-terminal pro-B-type NP), and MR-proANP (midregional pro-atrial NP) was compared among 1577 daytime presenters versus 908 evening/nighttime presenters. In a validation study, the presence of a diurnal rhythm in BNP and NT-proBNP concentrations was examined by hourly measurements in 44 stable individuals. RESULTS: Among patients adjudicated to have acute heart failure, BNP, NT-proBNP, and MR-proANP concentrations were comparable among daytime versus evening/nighttime presenters (all P=nonsignificant). Contrastingly, among patients adjudicated to have other causes of dyspnea, evening/nighttime presenters had lower BNP (median, 44 [18-110] versus 74 [27-168] ng/L; P<0.01) and NT-proBNP (median, 212 [72-581] versus 297 [102-902] ng/L; P<0.01) concentrations versus daytime presenters. This resulted in higher diagnostic accuracy as quantified by the area under the curve of BNP and NT-proBNP among evening/nighttime presenters (0.97 [95% CI, 0.95-0.98] and 0.95 [95% CI, 0.93-0.96] versus 0.94 [95% CI, 0.92-0.95] and 0.91 [95% CI, 0.90-0.93]) among daytime presenters (both P<0.01). These differences were not observed for MR-proANP. Diurnal variation of BNP and NT-proBNP with lower evening/nighttime concentration was confirmed in 44 stable individuals (P<0.01). CONCLUSIONS: BNP and NT-proBNP, but not MR-proANP, exhibit a diurnal rhythm that results in even higher diagnostic accuracy among evening/nighttime presenters versus daytime presenters. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifiers: NCT01831115, NCT02091427, and NCT02210897.

Artificial Intelligence for Education, Proctoring, and Credentialing in Cardiovascular Medicine.

Artificial intelligence and machine learning are rapidly gaining popularity in every aspect of cardiovascular medicine. This review discusses the past, present, and future of artificial intelligence in education, remote proctoring, credentialing, research, and publication as they pertain to cardiovascular procedures. This review describes the benefits and limitations of artificial intelligence and machine learning and the exciting potential of integrating advanced simulation, holography, virtual reality, and extended reality into disease diagnosis and patient care, as well as their roles in cardiovascular research and education. Nonetheless, much of the available data resides in electronic medical records or within industry-sponsored proprietary programs that are not compatible or standardized for current clinical application. Many areas in cardiovascular medicine would benefit from the introduction or increased use of artificial intelligence. Web-based artificial intelligence applications could be used to address unmet needs for education, on-demand procedural proctoring, credentialing, and recredentialing for interventionists and physicians in remote locations. Further progress in artificial intelligence will require further collaboration among computer scientists and researchers in order to identify and correct the most relevant problems and to implement the best data-based approach to achieving this goal. The future success of artificial intelligence in cardiovascular medicine will depend on the degree of collaboration between all pertinent experts in this field. This will undoubtedly be a prolonged, stepwise process.

Experiences with screening for atrial fibrillation: a qualitative study in general practice.

BACKGROUND: Guidelines recommend screening for atrial fibrillation (AF). Currently, screening is not considered standard care among GPs. AIM: To explore the experiences of primary care workers with different methods of screening for AF and with implementation in daily practice. DESIGN & SETTING: A qualitative study using semi-structured interviews with GPs, nurses, and healthcare assistants (HCAs) who were experienced with implementing different methods of screening. METHOD: Two independent researchers audio-recorded and analysed interviews using a thematic approach. They asked participants about their experiences with the different methods used for screening AF and which obstacles they faced when implementing screening in daily practice. RESULTS: In total 15 GPs, nurse practitioners, and HCAs from seven different practices were interviewed. The GP's office is suited for screening for AF, which ideally should be integrated with standard care. Participants considered pulse palpation, automated sphygmomanometer with AF detection, and single-lead electrocardiography (ECG) as practical tests. Participants trusted pulse palpation over the algorithm of the devices. The follow-up of a positive test with a time-consuming 12-lead ECG hindered integration of screening. The single-lead ECG device reduced the need for immediate follow-up because it can record a rhythm strip. The extra workload of screening and lack of financial coverage form obstacles for implementation. CONCLUSION: Pulse palpation, automated blood pressure measure monitors with AF detection, and single-lead ECGs might facilitate screening in a general practice setting. When implementing screening, focus should be on how to avoid disruption of consultation hours by unplanned 12-lead ECGs.

Machine learning in cardiovascular radiology: ESCR position statement on design requirements, quality assessment, current applications, opportunities, and challenges.

Machine learning offers great opportunities to streamline and improve clinical care from the perspective of cardiac imagers, patients, and the industry and is a very active scientific research field. In light of these advances, the European Society of Cardiovascular Radiology (ESCR), a non-profit medical society dedicated to advancing cardiovascular radiology, has assembled a position statement regarding the use of machine learning (ML) in cardiovascular imaging. The purpose of this statement is to provide guidance on requirements for successful development and implementation of ML applications in cardiovascular imaging. In particular, recommendations on how to adequately design ML studies and how to report and interpret their results are provided. Finally, we identify opportunities and challenges ahead. While the focus of this position statement is ML development in cardiovascular imaging, most considerations are relevant to ML in radiology in general. KEY POINTS: • Development and clinical implementation of machine learning in cardiovascular imaging is a multidisciplinary pursuit. • Based on existing study quality standard frameworks such as SPIRIT and STARD, we propose a list of quality criteria for ML studies in radiology. • The cardiovascular imaging research community should strive for the compilation of multicenter datasets for the development, evaluation, and benchmarking of ML algorithms.

After ISCHEMIA: Is coronary CTA the new gatekeeper?

The ISCHEMIA trial investigated two major principles in the therapy of coronary artery disease (CAD), i.e., symptom relief and improvement of prognosis. Specifically, it was designed to answer the question of whether, after ruling out left main stenosis, a routine interventional strategy in addition to optimal medical therapy can improve clinical outcome. Overall, this hypothesis could not be confirmed. Nevertheless, the trial yields interesting new aspects in the field of cardiac imaging. As a noninvasive diagnostic approach for individuals with suspected coronary artery disease, two different concepts are available: stress testing for ischemia (single-photon emission computed tomography, positron emission tomography, cardiac magnetic resonance imaging, stress echocardiography) and anatomic visualization of coronary artery stenosis by coronary computed tomography (CT) angiography (coronary CTA). While there was no randomized comparison between these two approaches in ISCHEMIA, the good outcome achieved by using coronary CTA as a "gatekeeper" to randomization supports the potential of coronary CTA as a diagnostic tool-both as first- and as second-line-when CAD is suspected. However, the trial also raises new questions in the field of cardiac imaging that need to be addressed in future studies.

Valores normales de aorta torácica por ecocardiografía. Registro MATEAR (Medición de Aorta Torácica por Ecocardiografía en Argentina) / Normal Values of Thoracic Aorta Dimensions by Echocardiography. The MATEAR (Measurement of Thoracic Aorta by Echocardiography in Argentina) Registry

RESUMEN Introducción: Se han encontrado diferencias en los diámetros de la aorta torácica de acuerdo al sexo, la edad y la superficie corporal. Sin embargo, los resultados son muy heterogéneos. Objetivos: Determinar los diámetros normales de la aorta (DAo) torácica por ecocardiograma transtorácico en nuestra población y analizar la influencia de las variables antropométricas, demográficas y étnicas en los DAo. Material y métodos: Se realizó un registro nacional, prospectivo y multicéntrico que incluyó 1000 adultos sanos (media de edad: 38,3 ± 12,7 años, 553 mujeres, 56,7% de origen caucásico y 38,3% de americanos nativos). Se realizaron mediciones aórticas siguiendo las recomendaciones actuales en 6 niveles: anillo, sinusal, unión sinotubular, ascendente proximal, cayado y descendente proximal. Resultados: El percentilo 95 se encontró por debajo de los 3,80 cm para todos los DAo absolutos, 2,08 cm/m para los indexados por altura y 2,11 cm/m2 para los indexados por superficie corporal (SC). El análisis global mostró correlación positiva y significativa entre todos los diámetros aórticos y la SC y la altura, así como la edad, con la excepción del anillo aórtico, que no presentó modificaciones con el paso del tiempo. En los individuos con índice de masa corporal aumentado, la SC no se correlacionó con los diámetros aórticos. Las mujeres presentaron menores DAo en todos los segmentos y en la raíz aórtica, aun luego de indexar por altura. Los americanos nativos presentaron menores diámetros aórticos absolutos e indexados que los caucásicos en todos los niveles aórticos (p < 0,01), exceptuando la aorta descendente proximal, que no mostró diferencias significativas. Conclusiones: Las variables demográficas, antropométricas y étnicas resultaron ser determinantes significativos de las dimensiones aórticas en todos sus niveles, por lo que deben tenerse en cuenta para la correcta interpretación de estas mediciones.

ABSTRACT Background: Transthoracic echocardiography (TTE) remains the screening tool of choice for thoracic aorta (TA) dilatation. Differences in TA diameters (TAD) according to gender (G), age (A) and body surface area (BSA) have been previously reported. However, these reports are limited by small sample size, different measurement sites or heterogeneous cohorts. There is scarce data on the influence of ethnicitiy on TAD. Objective: We designed a prospective nationwide multicenter registry to determine the normal diameters of the thoracic aorta at all TA segments in healthy adults of both G and their correlations with A, ethnicity and BSA. Methods: A national, prospective and multicenter registry was carried out in 1000 healthy adult people (mean age: 38.3 ± 12.7 years, 553 women, 56.7% of caucasian origin). Aortic measurements were made following the current recommendations at 6 levels: aortic annulus, sinus, sinotubular junction, proximal ascending, arch and proximal descending aorta. Pooled data showed a positive correlation between all TAD and A or BSA (p<0.001), similar in both G. In patients with obesity the correlation was better with height than BSA. Resultados: The 95th percentile was found below 3.80 cm for all absolute aortic diameters, 2.08 cm / m for those indexed by height and 2.11 cm / m2 per body surface. Nomograms were obtained for 3 age categories to predict TAD from BSA with no need of G distinction. Native americans showed significatly lower absolute and indexed TAD than caucasian (p<0.01) from annulus to isthmus. Conclusions: While age and BSA were significant determinants of aortic dimensions at six levels, we have also detected differences in TAD according to ethnicity, suggesting normative values should also be defined for each ethnic group. We propose nomograms of indexed TAD for different age and ethnic groups without G distinction.

Performance analysis of commercial rapid tests for serum troponin detection / Análise do desempenho de testes rápidos comerciais para detecção de troponina I sérica

ABSTRACT Introduction: Rapid tests represent an important diagnostic tool, providing results in a short period of time and eliminating the use of large automated equipment. Objective: To evaluate the performance of five rapid test kits for troponin I detection in serum. Materials and methods: Samples from 100 patients with suspected acute myocardial infarction (AMI) were selected from a hospital in Barbacena, MG, Brazil. They were tested in the five troponin I commercial rapid test kits and the results were compared with the study reference method (quantitative chemiluminescent immunoassay). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and correlation coefficients of the rapid tests against the reference method were defined. Results: The kits from Abon®, Interteck®, Medtest® and Wama® presented the same performance, reaching equal levels of sensitivity (98.08%), specificity (100%), PPV (100%), NPV (97.96%), and correlation coefficient (0.99). The Eco Diagnostica® kit presented lower sensitivity (82.69%), low correlation coefficient (0.91) and NPV (84.21%), not reaching ideal levels even though lying within the confidence interval. Discussion: The results obtained with the Abon®, Interteck®, Medtest® and Wama® test kits corroborate pre-existing literature data on the diagnostic accuracy of rapid tests for troponin detection. These tests are allowed for immediate decision making by physicians and can be used to reduce unnecessary hospitalization time and costs associated with a suspected AMI. Conclusion: The kits from Abon®, Interteck®, Medtest® and Wama® showed excellent diagnostic performance, what makes them an important diagnostic tool in smaller laboratories without automated equipment.

RESUMEN Introducción: Hoy en día, las pruebas rápidas representan importante herramienta diagnóstica, ofrecen resultados en corto espacio de tempo y dispensan el uso de equipos automatizados. Objetivo: Evaluar el desempeño de cinco kits de pruebas rápidas para detectar troponina I en suero. Material y métodos: Se eligieron 100 especímenes de pacientes sospechosos de infarto agudo de miocardio (IAM) de un hospital en el municipio de Barbacena, Minas Gerais, Brasil. Los especímenes fueron testados en los cinco kits comerciales de prueba rápida de troponina I y el resultado se comparó con el método considerado referencia en el estudio (inmunoensayo quimioluminiscente cuantitativo). Luego, se establecieron los niveles de sensibilidad, especificidad, valor predictivo positivo (VPP), valor predictivo negativo (VPN) y coeficiente de correlación de las pruebas rápidas con respecto al método de referencia. Resultados: Las marcas Abon®, Interteck®, Medtest® y Wama® tuvieron el mismo desempeño, alcanzando niveles iguales de sensibilidad (98,08%), especificidad (100%), VPP (100%), VPN (97,96%) y coeficiente de correlación (0,99), mientras la marca Eco Diagnóstica® presentó 82,69% de sensibilidad, 0,91 de coeficiente de correlación y 84,21% de VPN, no alcanzando los niveles ideales, aunque dentro del intervalo de confianza. Discusión: Los resultados obtenidos con las marcas Abon®, Interteck®, Medtest® e Wama® confirman datos preexistentes en la literatura sobre la precisión diagnóstica de las pruebas rápidas para detectar troponina. Esas pruebas permiten a los médicos adoptar decisiones de forma inmediata y pueden ser usados para reducir tiempo y costos de internaciones innecesarias cuando hay sospecha de IAM. Conclusión: Las marcas Abon®, Interteck®, Medtest® e Wama® presentaron excelente desempeño diagnóstico y representan importante herramienta diagnóstica en laboratorios menores, sin equipos automatizados.

RESUMO Introdução: Atualmente, os testes rápidos representam importante ferramenta diagnóstica, fornecendo resultados em curto espaço de tempo e dispensando a utilização de grandes automações. Objetivo: Avaliar o desempenho de cinco kits de testes rápidos para pesquisa sérica de troponina I. Materiais e métodos: Foram selecionadas 100 amostras de pacientes com suspeita de infarto agudo do miocárdio (IAM) de um hospital do município de Barbacena, Minas Gerais, Brasil. As amostras foram testadas nos cinco kits comerciais de teste rápido de troponina I e o resultado foi comparado com o método considerado referência no estudo (imunoensaio quimioluminescente quantitativo). Em seguida, foram definidos níveis de sensibilidade, especificidade, valor preditivo positivo (VPP), valor preditivo negativo (VPN) e coeficiente de correlação dos testes rápidos em relação ao método de referência. Resultados: Os kits Abon®, Interteck®, Medtest® e Wama® apresentaram o mesmo desempenho, atingindo níveis iguais de sensibilidade (98,08%), especificidade (100%), VPP (100%), VPN (97,96%) e coeficiente de correlação (0,99). O kit Eco Diagnóstica® apresentou 82,69% de sensibilidade, 0,91 de coeficiente de correlação e 84,21% de VPN, não atingindo os níveis ideais, mesmo dentro do intervalo de confiança. Discussão: Os resultados obtidos com os kits Abon®, Interteck®, Medtest® e Wama® confirmam dados preexistentes na literatura sobre a exatidão diagnóstica dos testes rápidos para detecção de troponina. Esses testes permitem a tomada de decisão imediata pelo médico e podem ser usados para reduzir tempo e custos de internações desnecessárias na suspeita de IAM. Conclusão: Os kits Abon®, Interteck®, Medtest® e Wama® apresentaram excelente desempenho diagnóstico e constituem importante ferramenta diagnóstica em laboratórios menores, sem equipamentos automatizados.

Multimodal Imaging of Anomalous Left Coronary Artery from the Pulmonary Artery in a 75-Year-Old Woman.

Anomalous origin of the left coronary artery from the pulmonary artery is rare and typically results in mitral regurgitation, ventricular arrhythmias, heart failure, and sudden death. The condition most often manifests itself in early childhood, but some individuals are diagnosed much later. We describe the case of a 75-year-old woman with heart failure in whom stepwise multimodal imaging revealed anomalous origin of the left coronary artery from the pulmonary artery.

Cancer Antigen 125 is Associated with Length of Stay in Patients with Acute Heart Failure.

Length of stay is the primary driver of heart-failure hospitalization costs. Because cancer antigen 125 has been associated with poor morbidity and mortality rates in heart failure, we investigated the relationship between admission cancer antigen 125 levels and lengths of stay in heart-failure patients. A total of 267 consecutive patients (184 men, 83 women) with acute decompensated heart failure were evaluated prospectively. The median length of stay was 4 days, and the patients were classified into 2 groups: those with lengths of stay ≤4 days and those with lengths of stay >4 days. Patients with longer lengths of stay had a significantly higher cancer antigen 125 level of 114 U/mL (range, 9-298 U/mL) than did those with a shorter length of stay (19 U/mL; range; 3-68) (P <0.001). The optimal cutoff level of cancer antigen 125 in the prediction of length of stay was >48 U/mL, with a specificity of 95.8% and a sensitivity of 96% (area under the curve, 0.979; 95% confidence interval [CI], 0.953-0.992). In the multivariate logistic regression model, cancer antigen 125 >48 U/mL on admission (odds ratio=4.562; 95% CI, 1.826-11.398; P=0.001), sodium level (P<0.001), creatinine level (P=0.009), and atrial fibrillation (P=0.015) were also associated with a longer length of stay after adjustment for variables found to be statistically significant in univariate analysis and correlated with cancer antigen 125 level. In addition, it appears that in a cohort of patients with acute decompensated heart failure, cancer antigen 125 is independently associated with prolonged length of stay.

Predicting Cardiovascular Events in Familial Hypercholesterolemia: The SAFEHEART Registry (Spanish Familial Hypercholesterolemia Cohort Study).

BACKGROUND: Although risk factors for atherosclerotic cardiovascular disease (ASCVD) in familial hypercholesterolemia (FH) have been described, models for predicting incident ASCVD have not been reported. Our aim was to use the SAFEHEART registry (Spanish Familial Hypercholesterolemia Cohort Study) to define key risk factors for predicting incident ASCVD in patients with FH. METHODS: SAFEHEART is a multicenter, nationwide, long-term prospective cohort study of a molecularly defined population with FH with or without previous ASCVD. Analyses to define risk factors and to build a risk prediction equation were developed, and the risk prediction equation was tested for its ability to discriminate patients who experience incident ASCVD from those who did not over time. RESULTS: We recruited 2404 adult patients with FH who were followed up for a mean of 5.5 years (SD, 3.2 years), during which 12 (0.5%) and 122 (5.1%) suffered fatal and nonfatal incident ASCVD, respectively. Age, male sex, history of previous ASCVD, high blood pressure, increased body mass index, active smoking, and low-density lipoprotein cholesterol and lipoprotein(a) levels were independent predictors of incident ASCVD from which a risk equation with a Harrell C index of 0.85 was derived. The bootstrap resampling (100 randomized samples) of the original set for internal validation showed a degree of overoptimism of 0.003. Individual risk was estimated for each person without an established diagnosis of ASCVD before enrollment in the registry by use of the SAFEHEART risk equation, the modified Framingham risk equation, and the American College of Cardiology/American Heart Association ASCVD Pooled Cohort Risk Equations. The Harrell C index for these models was 0.81, 0.78, and 0.8, respectively, and differences between the SAFEHEART risk equation and the other 2 were significant (P=0.023 and P=0.045). CONCLUSIONS: The risk of incident ASCVD may be estimated in patients with FH with simple clinical predictors. This finding may improve risk stratification and could be used to guide therapy in patients with FH. CLINICAL TRIAL REGISTRATION: URL: http://clinicaltrials.gov. Unique identifier: NCT02693548.

[Hemodynamic monitoring of critically ill patients : Bedside integration of data]. / Hämodynamisches Monitoring kritisch Kranker : Bettseitige Integration von Messdaten.

BACKGROUND: Hemodynamic monitoring of critically ill patients is a key issue in intensive care medicine. Indication and application of invasive hemodynamic monitoring is a highly complex matter and requires thorough professional education and training. MATERIALS AND METHODS: A literature review was performed. RESULTS: A pragmatic approach can be divided into several steps such as medical history, physical examination, imaging, and laboratory results, which support the primary working diagnosis and allow further clarification of the underlying pathophysiology. Invasive arterial blood pressure and cardiac output measurement as well as components of the functional hemodynamic monitoring help to assess fluid responsiveness and to guide volume loading, diuretic therapy as well as administration of vasoactive or positive inotrope substances. CONCLUSIONS: All information gathered through medical history, physical examination, imaging, and hemodynamic monitoring help to form an overall picture and should be reevaluated regularly and in individual cases very closely depending on the hemodynamic instability of the patient. Target values are strictly indicative and are not binding taking into account that each patient has its unique pathophysiological profile.

Study on the correlation between red cell distribution width and microalbuminuria in patients with chronic heart failure / 天津医药

Objective To observe changes of red blood cell distribution width (RDW) and trace albumin urine (MAU) in patients with chronic heart failure (CHF) and to explore the relationship between them and cardiac function classification. Methods A total of 190 patients with CHF were divided into mild group (NYHA grade II), moderate group (NYHA gradeⅢ) and severe group (NYHA gradeⅣ), according to the grade of cardiac function. A total of 100 subjects with normal physi?cal examination during the same period were selected as the control group. The changes of MAU, urinary creatinine (Scr) ra?tio (UACR), RDW, Scr, hemoglobin (Hb), type B urine sodium titanium (BNP) and left ventricular ejection fraction (LVEF)were compared between four groups. The correlation between UACR, RDW, Scr, Hb, BNP and LVEF were analyzed. Re?sults The levels of RDW, Scr, BNP, hypersensitive C-reactive protein (hsCRP), LVEDd, LVM, LVMI and UACR were sig?nificantly higher in chronic heart failure group than those of control, showing a trend of increase gradually with the rising of heart function classification (P<0.05). The values of Hb and LVEF showed a gradually decreasing trend with the increased heart function classification (P < 0.05). The values of UACR and RDW showed a gradually increasing trend with the in?creased heart function classification (P<0.05). There was a positive correlation between UACR and RDW, and both had a positive correlation with BNP, and a negative correlation with LVEF and Hb(P<0.05). Conclusion RDW and MAU are re?lated to the cardiac function classification, and both can be used for the evaluation of the prognosis in patients with CHF.