Under pressure: A systematic review of the association between blood pressure variability with depression and anxiety.

Blood pressure variability (BPV) impacts brain health by influencing brain structure and cerebrovascular pathologies, though the mechanisms are poorly understood. Changes in the cerebrovasculature may lead to late-onset depression, cognitive impairment, and dementia, however the relationship between BPV with depression and anxiety remains unclear, due to methodological differences and inconsistencies in past research. This review aims to clarify the association between BPV with depression and anxiety in adults to inform understandings of the mechanisms implicating BPV in cognitive health. A systematic search from inception through to January 2024 was performed on Embase, PubMed, PsycINFO, and Web of Science. Studies that assessed BPV quantified by beat-to-beat, 24-hour, or visit-to-visit were eligible if the standardised assessment of depression and/or anxiety were reported as a linear association, or mean differences across control and affect groups. A total of 14 articles reporting on 13 samples and N = 5055 persons met the inclusion criteria (median female proportion = 61 %, range 0 % - 76 %). A meta-analysis was not possible due to methodological heterogeneity in BPV measurements and metrics across studies. Mixed results were observed across depression studies with inconsistencies and variation in the direction, strength of association, and BPV metric. There was weak evidence from only three studies to support a linear association between systolic coefficient of variation and anxiety. Collectively, the findings contribute to understanding the association between BPV and brain health, suggesting that any relationship between BPV and brain structures critical for cognitive function are independent of depression and only modestly implicate anxiety.

Accuracy of a Single-Lead ECG Device for Diagnosis of Cardiac Arrhythmias Compared Against Cardiac Electrophysiology Study.

BACKGROUND: Single-lead electrocardiogram (ECG) devices may allow detection and diagnosis of cardiac rhythms. However, data on their accuracy for detecting cardiac arrhythmias beyond atrial fibrillation are limited. We aimed to determine the accuracy of the AliveCor KardiaMobile (AC) (AliveCor Inc, Mountain View, CA, USA) for the diagnosis of arrhythmias against gold standard cardiac electrophysiology study (EPS). METHOD: Patients undergoing clinically indicated EPS underwent simultaneous rhythm recording with an AC, standard 12-lead ECG, and EP catheters for intracardiac electrograms. Rhythms recorded during EPS were classified based on electrogram, 12-lead ECG, and clinical findings. Blinded reviewers provided differential diagnoses for the single-lead AC tracings; a separate reviewer compared diagnoses made between the AC tracings and EPS findings. RESULTS: In 49 patients, 843 cardiac rhythms were captured during 502 AC recordings. Analysis of tracings containing sinus rhythm (n=273) returned an overall accuracy of 92%, with sensitivity and specificity values of 93% and 92%, respectively. Accuracy for tracings per rhythm was atrial fibrillation 91% (n=51); supraventricular tachycardia accuracy was 89% (n=191), ventricular tachycardia 91% (n=198), ventricular fibrillation 98% (n=11), and asystole 100% (n=5). Accuracy for supraventricular ectopy was 93% (n=28) and for premature ventricular complexes was 91% (n=86). Overall accuracy was 94% for solitary rhythms and 93% in tracings from patients with baseline bundle branch block. CONCLUSIONS: When compared against the gold standard EPS diagnosis, the interpretation of arrhythmias recorded by an AliveCor single-lead ECG device had reasonable diagnostic accuracy.

2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation.

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.

Arrhythmia monitoring and outcome after myocardial infarction (BIO|GUARD-MI): a randomized trial.

Objectives: Cardiac arrhythmias predict poor outcome after myocardial infarction (MI). We studied if arrhythmia monitoring with an insertable cardiac monitor (ICM) can improve treatment and outcome. Design: BIO|GUARD-MI was a randomized, international open-label study with blinded outcome assessment. Setting: Tertiary care facilities monitored the arrhythmias, while the follow-up remained with primary care physicians. Participants: Patients after ST-elevation (STEMI) or non-ST-elevation MI with an ejection fraction >35% and a CHA2DS2-VASc score ≥4 (men) or ≥5 (women). Interventions: Patients were randomly assigned to receive or not receive an ICM in addition to standard post-MI treatment. Device-detected arrhythmias triggered immediate guideline recommended therapy changes via remote monitoring. Main outcome measures: MACE, defined as a composite of cardiovascular death or acute unscheduled hospitalization for cardiovascular causes. Results: 790 patients (mean age 71 years, 72% male, 51% non-STEMI) of planned 1,400 pts were enrolled and followed for a median of 31.6 months. At 2 years, 39.4% of the device group and 6.7% of the control group had their therapy adapted for an arrhythmia [hazard ratio (HR) = 5.9, P < 0.0001]. Most frequent arrhythmias were atrial fibrillation, pauses and bradycardia. The use of an ICM did not improve outcome in the entire cohort (HR = 0.84, 95%-CI: 0.65-1.10; P = 0.21). In secondary analysis, a statistically significant interaction of the type of infarction suggests a benefit in the pre-specified non-STEMI subgroup. Risk factor analysis indicates that this may be connected to the higher incidence of MACE in patients with non-STEMI. Conclusions: The burden of asymptomatic but actionable arrhythmias is large in post-infarction patients. However, arrhythmia monitoring with an ICM did not improve outcome in the entire cohort. Post-hoc analysis suggests that it may be beneficial in non-STEMI patients or other high-risk subgroups. Clinical Trial Registration: [https://www.clinicaltrials.gov/ct2/show/NCT02341534], NCT02341534.

Incidence and progression of atrial fibrillation in patients with and without heart failure using mineralocorticoid receptor antagonists: a meta-analysis.

BACKGROUND: Mineralocorticoid receptor antagonists (MRAs) have emerged as potential therapy to target the underlying arrhythmogenic substrate in atrial fibrillation (AF). Nevertheless, there have been inconsistent results on the impact of MRAs on AF. OBJECTIVE: We sought to evaluate the effect of MRAs on AF incidence and progression in patients with and without heart failure. METHODS: Electronic databases were searched up to September, 2022 for randomized controlled trials (RCTs) that evaluated MRA use and reported AF outcomes. Primary outcome was a composite of new-onset or recurrent AF. Safety outcomes included hyperkalemia and gynecomastia risks. A random-effects meta-analysis estimated pooled odds ratios (OR) and 95% confidence intervals (CI). RESULTS: 12 RCTs, comprising 11,419 patients treated with various MRAs were included [5960 (52%) on MRA]. On follow-up (6-39 months), 714 (5.5%) patients developed AF. MRA therapy was associated with a 32% reduction in the risk of new-onset or recurrent AF [OR 0.68 (95% CI 0.51-0.92), I2 = 40%]. On subgroup analysis, the greatest benefit magnitude was demonstrated in reducing AF recurrence [OR 0.50 (95% CI 0.30-0.83)] and among patients with left ventricular dysfunction [OR 0.59 (95% CI 0.40-0.85)]. Gynecomastia, but not hyperkalemia, was associated with MRA use. Meta-regression analysis demonstrated that therapy duration was a significant interaction factor driving the effect size (Pinteraction = 0.013). CONCLUSION: MRA use is associated with a reduction in AF risk, especially AF progression. A prominent effect is seen in patients with heart failure, further augmented by therapy duration. Prospective trials are warranted to evaluate MRA use as upstream therapy for preventing this common arrhythmia.

Atrial Fibrillation Health Literacy Questionnaire (AFHLQ): The development of an AF-specific health literacy questionnaire.

Background: Health literacy is a key enabler of effective behavioural modification in chronic diseases. While patient reported outcome measures (PROMs) exists for patient with atrial fibrillation (AF), none address risk factors comprehensively. The aim of the study was to develop and qualitatively validate a disease specific PROM that incorporates knowledge on risk factors and assesses interactive and critical health literacy of people living with AF. Methods: The 47-item Atrial Fibrillation Health Literacy Questionnaire (AFHLQ) was developed and validated through a qualitative research design. Expert and Consumer focus groups, each consisting of seven participants provided opinion. Results: The 47-item questionnaire consists of 5 domains: (1) what is AF, (2) what are the symptoms of AF, (3) why do people get AF, (4) management of AF, and (5) what measures can slow or prevent the progression of AF. Recommendations resulted in several changes to the original 47 item list during the qualitative validation process: 13 original items were removed, and 13 new items were added. The response categories were also simplified from a Likert scale to "yes", "no" or "don't know". Conclusion: A 47-item AFHLQ instrument was developed and validated with modifications made through clinical expert and consumer opinion. This tool has a potential to be used to evaluate and guide interventions at a clinical and population level to understand and improve AF health literacy and outcomes.

Influence of sex on efficacy of exercise training for patients with symptomatic atrial fibrillation: insights from the ACTIVE-AF randomized controlled trial.

AIMS: Exercise training reduces recurrence of arrhythmia and symptom severity amongst patients with symptomatic, non-permanent atrial fibrillation (AF). However, there is little evidence on whether this effect is modified by patient sex. In a sub-analysis from the ACTIVE-AF (A Lifestyle-based, PhysiCal AcTIVity IntErvention for Patients With Symptomatic Atrial Fibrillation) randomized controlled trial, we compared the effects of exercise training on AF recurrence and symptom severity between men and women. METHODS AND RESULTS: The ACTIVE-AF study randomized 120 patients (69 men, 51 women) with paroxysmal or persistent AF to receive an exercise intervention combining supervised and home-based aerobic exercise over 6 months or to continue standard medical care. Patients were followed over a 12-month period. The co-primary outcomes were recurrence of AF, off anti-arrhythmic medications and without catheter ablation, and AF symptom severity scores. By 12 months, recurrence of AF was observed in 50 (73%) men and 34 (67%) women. In an intention-to-treat analysis, there was a between-group difference in favour of the exercise group for both men [hazard ratio (HR) 0.52, 95% confidence interval (CI): 0.29-0.91, P = 0.022] and women (HR 0.47, 95% CI: 0.23-0.95, P = 0.035). At 12 months, symptom severity scores were lower in the exercise group compared with controls amongst women but not for men. CONCLUSION: An exercise-based intervention reduced arrhythmia recurrence for both men and women with symptomatic AF. Symptom severity was reduced with exercise in women at 12 months. No difference was observed in symptom severity for men. REGISTRATION: Australia and New Zealand Clinical Trials Registry: ACTRN12615000734561.

This analysis examined the potential benefit of exercise training on arrhythmia recurrence and symptom severity amongst men and women with symptomatic atrial fibrillation enrolled in a randomized controlled trial of exercise and physical activity intervention compared with standard medical care. Previous studies have not provided evidence on whether men and women might benefit from exercise training to a similar degree. Our findings highlight the following key points: Both men and women in our study experienced fewer arrhythmia recurrences with exercise training compared with men and women in standard medical care.Exercise reduced arrhythmia symptoms in women, but we did not find any evidence of a reduction in symptoms amongst men.

Catheter Ablation vs Antiarrhythmic Drug Therapy for Treatment of Premature Ventricular Complexes: A Systematic Review.

There is variability in treatment modalities for premature ventricular complexes (PVCs), including use of antiarrhythmic drug (AAD) therapy or catheter ablation (CA). This study reviewed evidence comparing CA vs AADs for the treatment of PVCs. A systematic review was performed from the Medline, Embase, and Cochrane Library databases, as well as the Australian and New Zealand Clinical Trials Registry, U.S. National Library of Medicine ClinicalTrials database, and the European Union Clinical Trials Register. Five studies (1 randomized controlled trial) enrolling 1,113 patients (57.9% female) were analyzed. Four of five studies recruited mainly patients with outflow tract PVCs. There was significant heterogeneity in AAD choice. Electroanatomic mapping was used in 3 of 5 studies. No studies documented intracardiac echocardiography or contact force-sensing catheter use. Acute procedural endpoints varied (2 of 5 targeted elimination of all PVCs). All studies had significant potential for bias. CA seemed superior to AADs for PVC recurrence, frequency, and burden. One study reported long-term symptoms (CA superior). Quality of life or cost-effectiveness was not reported. Complication and adverse event rates were 0% to 5.6% for CA and 9.5% to 21% for AADs. Future randomized controlled trials will assess CA vs AADs for patients with PVCs without structural heart disease (ECTOPIA [Elimination of Ventricular Premature Beats with Catheter Ablation versus Optimal Antiarrhythmic Drug Treatment]), with impaired LVEF (PAPS [Prospective Assessment of Premature Ventricular Contractions Suppression in Cardiomyopathy] Pilot), and with structural heart disease (CAT-PVC [Catheter Ablation Versus Amiodarone for Therapy of Premature Ventricular Contractions in Patients With Structural Heart Disease]). In conclusion, CA seems to reduce recurrence, burden, and frequency of PVCs compared with AADs. There is a lack of data on patient- and health care-specific outcomes such as symptoms, quality of life, and cost-effectiveness. Several upcoming trials will offer important insights for management of PVCs.

Prevalence and Prognostic Implication of Atrial Fibrillation in Heart Failure Subtypes: Systematic Review and Meta-Analysis.

BACKGROUND: Atrial fibrillation (AF) and heart failure (HF) portends a poor outcome. The HF universal definition has incorporated Heart Failure with mildly reduced Ejection Fraction (HFmrEF). We sought to evaluate the relationship between AF and different HF subtypes, with emphasis on HFmrEF. METHODS: PubMed and Embase databases were searched up to July 2022. Studies that classified HF with EF≥50% as Heart Failure with Preserved Ejection Fraction (HFpEF); EF 40%-49% as HFmrEF; and EF <40% as Heart Failure with Reduced Ejection Fraction (HFrEF) were included. RESULTS: Fifty (50) eligible studies, with 126,720 acute HF and 109,683 chronic HF patients, were included. Ten percent (10%) and 12% of patients constituted HFmrEF subtype in patients with acute and chronic HF, respectively. The AF prevalence was 38% (95%CI [33, 44], I2=96.9%) in HFmrEF, as compared to 43% (95%CI [39, 47], I2=97.9%) in HFpEF, and 32% (95%CI [29, 35], I2=98.6%) in HFrEF in acute HF patients. Meta-regression showed HFmrEF shared age as a determinant for AF prevalence with HFrEF and HFpEF. Similar AF prevalence also was observed in chronic HF. Compared to sinus rhythm, AF was associated with an increased risk of all-cause mortality in all HF subtypes: HFmrEF (n=6; HR 1.28, 95%CI [1.08, 1.51], I2=71%), HFpEF (n=10; HR 1.14, 95%CI [1.06, 1.23], I2=55%) and HFrEF (n=9; HR 1.11, 95%CI [1.02, 1.21], I2=78%). CONCLUSION: The prevalence of AF was intermediate for HFmrEF in between HFpEF and HFrEF, with determinants shared with either HF subtype. The co-existence of AF and HF predicts an increased all-cause mortality across all categories of HF. (PROSPERO registry: CRD42021189411).

Impact of perioperative direct oral anticoagulant assays: a multicenter cohort study.

BACKGROUND: There is little evidence to guide the perioperative management of patients on a direct oral anticoagulant (DOAC) in the absence of a last known dose. Quantitative serum titers may be ordered, but there is little evidence supporting this. AIMS: This multi-center retrospective cohort study of consecutive surgical in-patients with a DOAC assay, performed over a five-year period, aimed to characterize preoperative DOAC assay orders and their impact on perioperative outcomes. MATERIALS AND METHODS: Patients prescribed regular DOAC (both prophylactic and therapeutic dosing) with a preoperative DOAC assay were included. The DOAC assay titer was evaluated against endpoints. Further, patients with an assay were compared against anticoagulated patients who did not receive a preoperative DOAC assay. The primary endpoint was major bleeding. Secondary endpoints included perioperative hemoglobin change, blood transfusions, idarucizumab or prothrombin complex concentrate administration, postoperative thrombosis, in-hospital mortality and reoperation. Adjusted and unadjusted linear regression models were used for continuous data. Binary logistic models were performed for dichotomous outcomes. RESULTS: 1065 patients were included, 232 had preoperative assays. Assays were ordered most commonly by Spinal (11.9%), Orthopedics (15.4%), and Neurosurgery (19.4%). For every 10 ng/ml increase in titer, the hemoglobin decreases by 0.5066 g/L and the odds of a preoperative reversal increases by 13%. Compared to those without an assay, patients with preoperative DOAC assays had odds 1.44× higher for major bleeding, 2.98× higher for in-hospital mortality and 16.3× higher for receiving anticoagulant reversal. CONCLUSION: A preoperative DOAC assay order was associated with worse outcomes despite increased reversal administration. However, the DOAC assay titer can reflect the patient's likelihood of bleeding.

An Exercise and Physical Activity Program in Patients With Atrial Fibrillation: The ACTIVE-AF Randomized Controlled Trial.

BACKGROUND: There are limited data on the effect of exercise interventions on atrial fibrillation (AF) recurrence and symptoms. OBJECTIVES: The aim of this study was to determine the efficacy of an exercise and physical activity intervention on AF burden and symptoms among patients with symptomatic AF. METHODS: This prospective, randomized controlled trial included 120 patients with paroxysmal or persistent, symptomatic AF, randomized 1:1 to receive an exercise intervention, combining home and supervised aerobic exercise over 6 months, or to receive usual care. The coprimary outcomes were: 1) AF recurrence, off antiarrhythmic medications and without catheter ablation; and 2) symptom severity assessed by using a validated questionnaire. RESULTS: By 12 months, freedom from AF was achieved in 24 (40%) of 60 patients in the exercise group and 12 (20%) of 60 patients in the control group (HR: 0.50: 95% CI: 0.33 to 0.78). At 6 months, AF symptom severity was lower in the exercise group compared with the control group (mean difference -2.3; 95% CI: -4.3 to -0.2; P = 0.033). This difference persisted at 12 months (-2.3; 95% CI: -4.5 to -0.1; P = 0.041). Total symptom burden was lower at 6 months in the exercise group but not at 12 months. Peak oxygen consumption was increased in the exercise group at both 6 and 12 months. There were no between-group differences in cardiac structure or function, body mass index, or blood pressure. CONCLUSIONS: Participation in an exercise-based intervention over 6 months reduced arrhythmia recurrence and improved symptom severity among patients with AF. (A Lifestyle-based, PhysiCal AcTIVity IntErvention for Patients With Symptomatic Atrial Fibrillation [the ACTIVE-AF Study]; ACTRN12615000734561).

Use of heart rate for guiding exercise training in patients with atrial fibrillation.

BACKGROUND: Heart rate reserve (HRR) is used to guide exercise training in patients with cardiovascular disease, primarily as a surrogate for oxygen uptake reserve (VO2R) as a marker of metabolic demand. However, the relationship between HRR and VO2R in patients with atrial fibrillation (AF) is not well described. We aimed to assess the validity of HRR as a surrogate for VO2R to guide exercise intensity in AF patients. METHODS: One hundred one patients with non-permanent AF undertaking a cardiopulmonary exercise test (CPET) were prospectively enrolled. HR and VO2 values were recorded throughout exercise to determine HRR and VO2R at each workload. Linear regression was used to calculate the slope and y-intercept for HRR versus VO2R with an equivalent slope defined as 1 and y-intercept of 0. The impact of rhythm during exercise, beta blockers and chronotropic incompetence (CI) on the HRR-VO2R relationship was also assessed. RESULTS: The slope of HRR-VO2R was 0.79±0.4, indicating a significant difference from an assumed slope of 1.0 (mean difference: -0.21, 95% CI: -0.30 to -0.12, P<0.001). The mean y-intercept slope was 20.1±41.6, differing significantly from 0 (mean difference: 20.1, 95% CI: 11.9-28.3, P<0.001). The presence of AF during CPET, beta-blockers or chronotropic incompetence did not independently alter the association between VO2R and HRR. CONCLUSIONS: HRR is not equivalent to VO2R in AF patients. There was no significant effect of rhythm status, chronotropic incompetence or beta-blockers on this relationship. These findings highlight that the HR prescription of exercise intensity in AF patients should be guided by an individualised HRR-VO2R relationship.

Development of a structured validated module to inculcate research skills in medical undergraduates.

Background Evidence-based research aids in decision-making in the health sector for developing health policies for prevention, diagnosis and treatment of diseases. Medical research is not taught in the undergraduate curriculum. Studies show that attributes of research knowledge, awareness and practical involvement in research are low among undergraduate students. We developed and validated a module and trained undergraduate students in research skills through an inter-ventional workshop using the structured module. Methods We did this participatory action research with a mixed-methods approach in the Department of Community Medicine at Adesh Institute of Medical Sciences and Research, Bathinda, Punjab. A structured module was developed by the core committee and validated internally and externally. Pilot testing of the module was done by delivering it in the form of a workshop to 46 students. For statistical analysis, percentage agreements, validity indices, median (interquartile range), satisfaction percentages and Wilcoxon sign test were used. Results The structured and validated module was established to have high face validity (>90%) and content validity (CVI=0.975). The module was successfully pilot tested for delivery through both onsite and online modes. The satisfaction percentage with the workshop was 91% and 100% and overall rating of the module was 74% and 91% by interns and MBBS students, and 100% by faculty. The scores of knowledge and skills were found to be significantly higher on all variables post workshop with p<0.001. All students scored satisfactory grades for research skills. Conclusions Teaching research using a structured validated module improved the knowledge and skills related to research among students. Both students and faculty were satisfied with the use of the structured module.

Impact of health literacy and its interventions on health outcomes in those with atrial fibrillation: a systematic review protocol.

INTRODUCTION: Atrial fibrillation (AF) is associated with increased risk of stroke, heart failure and death. Health literacy, an aspect that falls within precision health, has been recognised as an important factor. We will be focusing on the impact of these interventions specifically to AF and its health outcomes. METHODS AND ANALYSIS: This protocol is informed by the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols. The results will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to determine the impacts of health literacy interventions on AF outcomes. Searches will be carried out on databases including MEDLINE, EMBASE, Web of Science, CINAHL, Emcare, Cochrane Library and Google Scholar. Citations will be collected via Endnote 20, then into Covidence for duplicate removal, and article screening. Extraction will occur using a standardised extraction tool and studies will be synthesised using best evidence synthesis. Downs and Black's checklist will be used for risk of bias and assessment of overall quality of evidence will use the Grading of Recommendations, Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: Approval from human research ethics committee is not required. Dissemination will occur in peer-reviewed journals and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42022304835.