Patient-Led Mass Screening for Atrial Fibrillation in the Older Population Using Handheld Electrocardiographic Devices Integrated With a Clinician-Coordinated Remote Central Monitoring System: Protocol for a Randomized Controlled Trial and Process Evaluation.

BACKGROUND: Atrial fibrillation (AF) is common in older people and increases the risk of stroke. The feasibility and effectiveness of the implementation of a patient-led AF screening program for older people are unknown. OBJECTIVE: This study aims to examine the feasibility and effectiveness of an AF screening program comprising patient-led monitoring of single-lead electrocardiograms (ECGs) with clinician-coordinated central monitoring to diagnose AF among community-dwelling people aged ≥75 years in Australia. METHODS: This is a nationwide randomized controlled implementation trial conducted via the internet and remotely among 200 community-dwelling adults aged ≥75 years with no known AF. Randomization will be performed in a 1:1 allocation ratio for the intervention versus control. Intervention group participants will be enrolled in the monitoring program at randomization. They will receive a handheld single-lead ECG device and training on the self-recording of ECGs on weekdays and submit their ECGs via their smartphones. The control group participants will receive usual care from their general practitioners for the initial 6 months and then commence the 6-month monitoring program. The ECGs will be reviewed centrally by trained personnel. Participants and their general practitioners will be notified of AF and other clinically significant ECG abnormalities. RESULTS: This study will establish the feasibility and effectiveness of implementing the intervention in this patient population. The primary clinical outcome is the AF detection rate, and the primary feasibility outcome is the patient satisfaction score. Other outcomes include appropriate use of anticoagulant therapy, participant recruitment rate, program engagement (eg, frequency of ECG transmission), agreement in ECG interpretation between the device automatic algorithm and clinicians, the proportion of participants who complete the trial and number of dropouts, and the impact of frailty on feasibility and outcomes. We will conduct a qualitative evaluation to examine the barriers to and acceptability and enablers of implementation. Ethics approval was obtained from the human research ethics committee at the University of Sydney (project number 2020/680). The results will be disseminated via conventional scientific forums, including peer-reviewed publications and presentations at national and international conferences. CONCLUSIONS: By incorporating an integrated health care approach involving patient empowerment, centralized clinician-coordinated ECG monitoring, and facilitation of primary care and specialist services, it is possible to diagnose and treat AF early to reduce stroke risk. This study will provide new information on how to implement AF screening using digital health technology practicably and feasibly for older and frail populations residing in the community. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621000184875; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380877. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34778.

Predictors for congestive heart failure hospitalization or death following acute pulmonary embolism: A population-linkage study.

BACKGROUND: Congestive heart failure (CHF) is a risk factor for pulmonary embolism (PE). PE is also an independent predictor of death or re-hospitalization among CHF patients. We assessed the incidence of CHF admission following acute PE using population-linkage analysis. METHODS: Patients were identified from a comprehensive single-center PE database and CHF admissions or death after their PE were tracked from the statewide Admitted Patient Data Collection and Death registries respectively. Patients were divided into two groups: Group-1 were patients without a history of CHF and left ventricular ejection fraction (LVEF) ≥50%; Group-2 were patients with a history of CHF and/or LVEF <50%. Cox regression was used to identify independent predictors for post-PE CHF admission or death. RESULTS: The study cohort comprised 515 patients (Group-1: n = 338 [65.6%]; Group-2: n = 177 [34.4%]). The incidence of first CHF hospitalization after discharge for acute PE over a mean (±SD) follow-up period of 4.7 ±â€¯3.7 years for the total cohort was 71 (13.8%), with the rate significantly higher in Group-2 than Group-1 (Group-2: [n = 58] 9.11 per-100-patient-years vs Group-1: [n = 13] 0.73 per-100-patient-years). Independent predictors for CHF admission or death after acute PE were older age, male gender, history of CHF or malignancy, low day-1 serum hemoglobin, on diuretics during index PE admission, LVEF <50%, and elevated right ventricular-atrial pressure gradient on echocardiography. CONCLUSION: We report a high incidence of CHF requiring hospital admission after acute PE. Surveillance for new-onset heart failure and close monitoring for heart failure decompensation following acute PE particularly in at-risk groups may be warranted.

Weight loss and carotid intima-media thickness-a meta-analysis.

OBJECTIVE: Obesity is a risk factor for clinical cardiovascular disease, putatively via increased burden of atherosclerosis. It remains contentious as to whether weight loss in people with obesity is accompanied by a reduction in intima-media thickness, a noninvasive marker of subclinical atherosclerosis, consistent with a lowering of risk of cardiovascular events. METHODS: A systematic literature search was performed to identify all surgical and nonsurgical weight loss interventions that reported intima-media thickness. A meta-analysis was undertaken to obtain pooled estimates for change in intima-media thickness. RESULTS: From the 3,197 articles screened, 9 studies were included in the meta-analysis, with a total of 393 participants who lost an average of 16 kg (95% CI 9.4-22.5) of body weight over an average follow-up of 20 months. The pooled mean change in carotid intima-media thickness was -0.03 mm (95% CI -0.05 to -0.01), which was similar between surgical and nonsurgical interventions. CONCLUSIONS: In people with obesity, weight loss was associated with a reduction in carotid intima-media thickness, consistent with a lowering in risk of cardiovascular events.