The importance of cultural tailoring of communicators and media outlets in an influenza vaccination awareness campaign: a digital randomized trial.

The COVID-19 pandemic has exposed the vulnerability of ethnic minorities again. Health inequity within ethnic minorities has been explained by factors such as higher prevalence of underlying disease, restricted access to care, and lower vaccination rates. In this study, we investigated the effect of cultural tailoring of communicators and media outlets, respectively, on vaccine willingness in an influenza vaccination campaign in the Netherlands. A total of 1226 participants were recruited from two culturally non-tailored media outlets (Dutch newspaper and Facebook), and one media outlet tailored to a large community in the Netherlands with Indian ancestry. The participants from all three media outlets were randomly exposed to a vaccination awareness video delivered by a physician with an Indian or Dutch background, followed by an online survey. Cultural tailoring compared to cultural non-tailoring of communicators showed no difference in improvement of vaccine willingness (13.9% vs. 20.7% increment, respectively, p = 0.083). However, the media outlet tailored to the community with Indian ancestry, resulted in a higher improvement of vaccine willingness compared to non-tailored media outlets (46.7% vs. 14.7% increment, respectively, p < 0.001, unadjusted OR = 5.096). These results suggest that cultural tailoring of media outlets may be critical to effectively reach out to ethnic minorities to help optimize vaccination rates and improve general health.

Accuracy of mobile 6-lead electrocardiogram device for assessment of QT interval: a prospective validation study.

INTRODUCTION: Ambulatory assessment of the heart rate-corrected QT interval (QTc) can be of diagnostic value, for example in patients on QTc-prolonging medication. Repeating sequential 12-lead electrocardiograms (ECGs) to monitor the QTc is cumbersome, but mobile ECG (mECG) devices can potentially solve this problem. As the accuracy of single-lead mECG devices is reportedly variable, a multilead mECG device may be more accurate. METHODS: This prospective dual-centre study included outpatients visiting our cardiology clinics for any indication. Participants underwent an mECG recording using a smartphone-enabled 6­lead mECG device immediately before or immediately after a conventional 12-lead ECG recording. Multiple QTc values in both recordings were manually measured in leads I and II using the tangent method and subsequently compared. RESULTS: In total, 234 subjects were included (mean ± standard deviation (SD) age: 57 ± 17 years; 58% males), of whom 133 (57%) had cardiac disease. QTc measurement in any lead was impossible due to artefacts in 16 mECGs (7%) and no 12-lead ECGs. Mean (± SD) QTc in lead II on the mECG and 12-lead ECG was 401 ± 30 and 406 ± 31 ms, respectively. Mean (± SD) absolute difference in QTc values between both modalities was 12 ± 9 ms (r = 0.856; p < 0.001). In 55% of the subjects, the absolute difference between QTc values was < 10 ms. CONCLUSION: A 6-lead mECG allows for QTc assessment with good accuracy and can be used safely in ambulatory QTc monitoring. This may improve patient satisfaction and reduce healthcare costs.

Electrocardiogram-based mortality prediction in patients with COVID-19 using machine learning.

BACKGROUND AND PURPOSE: The electrocardiogram (ECG) is frequently obtained in the work-up of COVID-19 patients. So far, no study has evaluated whether ECG-based machine learning models have added value to predict in-hospital mortality specifically in COVID-19 patients. METHODS: Using data from the CAPACITY-COVID registry, we studied 882 patients admitted with COVID-19 across seven hospitals in the Netherlands. Raw format 12-lead ECGs recorded within 72 h of admission were studied. With data from five hospitals (n = 634), three models were developed: (a) a logistic regression baseline model using age and sex, (b) a least absolute shrinkage and selection operator (LASSO) model using age, sex and human annotated ECG features, and (c) a pre-trained deep neural network (DNN) using age, sex and the raw ECG waveforms. Data from two hospitals (n = 248) was used for external validation. RESULTS: Performances for models a, b and c were comparable with an area under the receiver operating curve of 0.73 (95% confidence interval [CI] 0.65-0.79), 0.76 (95% CI 0.68-0.82) and 0.77 (95% CI 0.70-0.83) respectively. Predictors of mortality in the LASSO model were age, low QRS voltage, ST depression, premature atrial complexes, sex, increased ventricular rate, and right bundle branch block. CONCLUSION: This study shows that the ECG-based prediction models could be helpful for the initial risk stratification of patients diagnosed with COVID-19, and that several ECG abnormalities are associated with in-hospital all-cause mortality of COVID-19 patients. Moreover, this proof-of-principle study shows that the use of pre-trained DNNs for ECG analysis does not underperform compared with time-consuming manual annotation of ECG features.

Current state of artificial intelligence-based algorithms for hospital admission prediction in patients with heart failure: a scoping review.

Aims: Patients with congestive heart failure (HF) are prone to clinical deterioration leading to hospital admissions, burdening both patients and the healthcare system. Predicting hospital admission in this patient group could enable timely intervention, with subsequent reduction of these admissions. To date, hospital admission prediction remains challenging. Increasing amounts of acquired data and development of artificial intelligence (AI) technology allow for the creation of reliable hospital prediction algorithms for HF patients. This scoping review describes the current literature on strategies and performance of AI-based algorithms for prediction of hospital admission in patients with HF. Methods and results: PubMed, EMBASE, and the Web of Science were used to search for articles using machine learning (ML) and deep learning methods to predict hospitalization in patients with HF. After eligibility screening, 23 articles were included. Sixteen articles predicted 30-day hospital (re-)admission resulting in an area under the curve (AUC) ranging from 0.61 to 0.79. Six studies predicted hospital admission over longer time periods ranging from 6 months to 3 years, with AUC's ranging from 0.65 to 0.78. One study prospectively evaluated performance of a disposable sensory patch at home after hospitalization which resulted in an AUC of 0.89 for unplanned hospital admission prediction. Conclusion: AI has the potential to enable prediction of hospital admission in HF patients. Improvement of data management, adding new data sources such as telemonitoring data and ML models and prospective and external validation of current models must be performed before clinical applicability is possible.

Deep Learning-Based Data-Point Precise R-Peak Detection in Single-Lead Electrocardiograms.

Low-cost wearables with capability to record electrocardiograms (ECG) are becoming increasingly available. These wearables typically acquire single-lead ECGs that are mainly used for screening of cardiac arrhythmias such as atrial fibrillation. Most arrhythmias are characteruzed by changes in the RR-interval, hence automatic methods to diagnose arrythmia may utilize R-peak detection. Existing R-peak detection methods are fairly accurate but have limited precision. To enable data-point precise detection of R-peaks, we propose a method that uses a fully convolutional dilated neural network. The network is trained and evaluated with manually annotated R-peaks in a heterogeneous set of ECGs that contain a wide range of cardiac rhythms and acquisition noise. 700 randomly chosen ECGs from the PhysioNet/CinC challenge 2017 were used for training (n=500), validation (n=100) and testing (n=100). The network achieves a precision of 0.910, recall of 0.926, and an F1-score of 0.918 on the test set. Our data-point precise R-peak detector may be important step towards fully automatic cardiac arrhythmia detection.Clinical relevance- This method enables data-point precise detection of R-peaks that provides a basis for detection and characterization of arrhythmias.

The accuracy of heartbeat detection using photoplethysmography technology in cardiac patients.

INTRODUCTION: Photoplethysmography (PPG) in wearable sensors potentially plays an important role in accessible heart rhythm monitoring. We investigated the accuracy of a state-of-the-art bracelet (Corsano 287) for heartbeat detection in cardiac patients and evaluated the efficacy of a signal qualifier in identifying medically useful signals. METHODS: Patients from an outpatient cardiology clinic underwent a simultaneous resting ECG and PPG recording, which we compared to determine accuracy of the PPG sensor for detecting heartbeats within 100 and 50 ms of the ECG-detected heart beats and correlation and Limits of Agreement for heartrate (HR) and RR-intervals. We defined subgroups for skin type, hair density, age, BMI and gender and applied a previously described signal qualifier. RESULTS: In 180 patients 7914 ECG-, and 7880 (99%) PPG-heartbeats were recorded. The PPG-accuracy within 100 ms was 94.6% (95% CI 94.1-95.1) and 89.2% (95% CI 88.5-89.9) within 50 ms. Correlation was high for HR (R = 0.991 (95% CI 0.988-0.993), n = 180) and RR-intervals (R = 0.891 (95% CI 0.886-0.895), n = 7880). The 95% Limits of Agreement (LoA) were -3.89 to 3.77 (mean bias 0.06) beats per minute for HR and -173 to 171 (mean bias -1) for RR-intervals. Results were comparable across all subgroups. The signal qualifier led to a higher accuracy in a 100 ms range (98.2% (95% CI 97.9-98.5)) (n = 143). CONCLUSION: We showed that the Corsano 287 Bracelet with PPG-technology can determine HR and RR-intervals with high accuracy in cardiovascular at-risk patient population among different subgroups, especially with a signal quality indicator.

Adults with congenital heart disease: ready for mobile health?

PURPOSE: Mobile health (mHealth) could improve the outcome of grown-up patients with congenital heart disease (GUCH) and reduce their emergency care utilisation. Inappropriate use of mHealth, however, can lead to data overload for professionals and unnecessary data collection for patients, increasing the burden for both. We aimed to determine the clinical characteristics of patients with high emergency care utilisation and to test whether these patients were willing to start using mHealth. METHODS: Clinical characteristics and emergency care utilisation of consecutive GUCH patients who visited one of the two participating cardiologists at the outpatient clinic of the Academic Medical Centre in Amsterdam were studied retrospectively. All patients were approached to fill in an mHealth questionnaire. A frequency of three or more emergency visits in 5 years was defined as high emergency care utilisation. RESULTS: In total, 202 consecutive GUCH patients who visited one of the two participating cardiologists were studied. Median age was 41 years, 47% were male, and 51% were symptomatic. In the previous 5 years, 134 emergency visits were identified. Of all patients, 8% had high emergency care utilisation. High emergency care utilisation was associated with patients being symptomatic, using antiarrhythmic drugs or diuretics. In total, 75% of all patients with high emergency care utilisation were willing to start using mHealth. CONCLUSION: GUCH patients who are symptomatic, those on antiarrhythmic drug therapy and those on diuretics are suitable candidates for enrolment in future mHealth initiatives because of both high care utilisation and high motivation to start using mHealth.

First real-world experience with mobile health telemonitoring in adult patients with congenital heart disease.

BACKGROUND: Arrhythmias and heart failure are common and invalidating sequelae in adult patients with congenital heart disease (CHD). Mobile health (m-Health) enables daily monitoring and a timely response that might prevent deterioration. We present an observational prospective registry to evaluate feasibility of an m­Health telemonitoring program for managing arrhythmia, heart failure and blood pressure in symptomatic adults with CHD. METHODS: Symptomatic adult patients with CHD are enrolled in an m­Health telemonitoring program, which evaluates single-lead ECG, blood pressure and weight measurements. In case of symptoms extra measurements could be performed. Data are collected by mobile apps, matched with individualised thresholds. Patients are contacted if thresholds were exceeded or if arrhythmias were found, for treatment adjustments or reassurance. Data on emergency care utilisation, hospitalisation and patient-reported outcome measures are used to assess quality of life and self-management. RESULTS: 129 symptomatic CHD patients were invited to participate, 55 participated. Reasons for refusing consent included too time consuming to participate in research (30) and to monitor vital signs (14). At baseline 22 patients were in New York Heart Association class ≥ II heart failure, 43 patients had palpitations or documented arrhythmias, and 8 had hypertension. Mean follow-up was 3.0 months, one patient dropped out, and adherence was 97%. CONCLUSION: The first results indicate that this program is feasible with high adherence.

Oral anticoagulant therapy in adults with congenital heart disease and atrial arrhythmias: Implementation of guidelines.

BACKGROUND: Current guidelines on oral anticoagulation (OAC) in adults with congenital heart disease (ACHD) and atrial arrhythmias (AA) consist of heterogeneous and divergent recommendations with limited level of evidence, possibly leading to diverse OAC management and different outcomes. Therefore, we aimed to evaluate real-world implementation and outcome of three guidelines on OAC management in ACHD patients with AA. METHODS: The ESC GUCH 2010, PACES/HRS 2014 and ESC atrial fibrillation (AF) 2016 guidelines were assessed for implementation. ACHD patients with recurrent or sustained non-valvular AA from 5 tertiary centers were identified using a national ACHD registry. After two years of prospective follow-up, thromboembolism, major bleeding and death were assessed. RESULTS: In total, 225 adults (mean age 54±15years, 55% male) with various defects (simple 43%; moderate 37%; complex 20%) and AA were included. Following the most strict indication (OAC is recommended in all three guidelines), one should treat a mere 37% of ACHD patients with AA, whereas following the least strict indication (OAC is recommended in any one of the three guidelines), one should treat 98% of patients. The various guidelines were implemented in 54-80% of patients. From all recommendations, Fontan circulation, CHA2DS2-VASc≥1 and AF were independently associated with OAC prescription. Superiority of any guideline in identifying outcome (n=15) could not be demonstrated. CONCLUSIONS: The implementation of current guidelines on OAC management in ACHD patients with AA is low, probably due to substantial heterogeneity among guidelines. OAC prescription in daily practice was most consistent in patients with AF and CHA2DS2-VASc≥1 or Fontan circulation.

Clinical course of tricuspid regurgitation in repaired tetralogy of Fallot.

BACKGROUND: Little is known on the clinical course of tricuspid regurgitation (TR) in patients with repaired tetralogy of Fallot (rTOF) and which patients are at particular risk. This study aims to determine TR course, characteristics associated with TR progression, and the prognostic relevance of TR in rTOF patients. METHODS: In this dualcenter cohort study, rTOF patients from a prospective national registry with ≥1 cardiac magnetic resonance imaging study and ≥2 echocardiograms available were included. Clinical and imaging data were collected. Cox hazards regression analysis was used to assess patient characteristics associated with progression to severe TR and whether severe TR was associated with the combined clinical endpoint of tachyarrhythmia, heart failure, and death, as time-dependent factor. RESULTS: A total of 216 patients were included (57% men, age 34±12years); 11 patients (5%) had severe TR at baseline. During 7.6±3.5years of follow-up, progression to severe TR occurred in 15 patients (7%). NYHA class ≥2 (HR 5.38, 95%-C.I. 1.91-15.16, p=0.001) and moderate baseline TR (HR 13.10, 95%-C.I. 2.95-58.21, p=0.001) were independently associated with progression to severe TR. Adverse events occurred in 47 patients (22%). The occurrence of severe TR was independently associated with adverse events (HR 3.48, 95%-C.I. 1.68-7.21, p=0.001). CONCLUSIONS: In this study, severe TR was present in 12% of adult rTOF patients during 7.6years, and progression to severe TR was most likely in symptomatic patients with moderate baseline TR. In these patients, close surveillance is warranted, because the occurrence of severe TR was associated with worse prognosis.

Is cardiac CT a reproducible alternative for cardiac MR in adult patients with a systemic right ventricle?

OBJECTIVE: 20 % of patients with a systemic RV are pacemaker dependent, and unsuitable to undergo cardiac magnetic resonance (CMR). Multidetector row computed tomography (MDCT) could provide a reproducible alternative to CMR in these patients. The aim of this study was to compare variability of MDCT with CMR. METHODS: Thirty-five patients with systemic RV underwent either MDCT (n = 15) or CMR (n = 20). Systemic RV volumes and ejection fraction were obtained, and intra- and interobserver variability for both modalities were assessed and compared. RESULTS: We found the intra- and interobserver variability of volumes and function measurements of the systemic RV obtained with MDCT to be higher compared with those obtained with CMR. However, these differences in variability were not significant, the only exception being the interobserver variability of systemic RV stroke volume. CONCLUSIONS: MDCT provides a reproducible alternative to CMR for volumes and function assessment in patients with a systemic RV.

Bosentan in pulmonary arterial hypertension: a comparison between congenital heart disease and chronic pulmonary embolism.

Background. In patients with pulmonary hypertension, it is unknown whether the treatment effect of bosentan is dependent on the duration of pulmonary vessel changes. Therefore, we studied the response to bosentan in patients with life-long pulmonary vessel changes (pulmonary arterial hypertension (PAH) due to congenital heart disease (CHD)) and in patients with subacutely induced pulmonary vessel changes (chronic thromboembolic pulmonary hypertension (CTEPH)).Methods. In this open-label study, 18 patients with PAH due to CHD and 16 patients with CTEPH were treated with bosentan for at least one year. All patients were evaluated at baseline and during follow-up by means of the six-minute walk distance (6-MWD) and laboratory tests.Results. Improvement of 6-MWD was comparable in patients with PAH due to CHD (444+/-112 m to 471+/-100 m, p=0.02), and in CTEPH (376+/-152 m to 423+/-141 m, p=0.03) after three months of treatment. After this improvement, 6-MWD stabilised in both groups.Conclusion. Although duration of pulmonary vessel changes is strikingly different in patients with PAH due to CHD and CTEPH, the effect of one year of bosentan treatment was comparable. The main treatment effect appears to be disease stabilisation and decreasing the rate of deterioration. (Neth Heart J 2009;17:334-8.).

Down syndrome: a cardiovascular perspective.

This review focuses on the heart and vascular system in patients with Down syndrome. A clear knowledge on the wide spectrum of various abnormalities associated with this syndrome is essential for skillful management of cardiac problems in patients with Down syndrome. Epidemiology of congenital heart defects, cardiovascular aspects and thyroid-related cardiac impairment in patients with Down syndrome will be discussed.

Latest insights in therapeutic options for systemic right ventricular failure: a comparison with left ventricular failure.

The number of adult patients with a systemic right ventricle (RV) is steadily increasing. Survival is relatively good in these patients, but deterioration of the systemic RV seems inevitable. Although therapeutic options for patients with LV failure are well established, their role in patients with systemic RV failure is often undefined. To appreciate the potency of LV failure therapy in patients with a systemic RV, insight into pathophysiology of systemic RV failure and into recent developments in therapeutic research are indispensible. This review provides these insights, and will facilitate and ameliorate therapeutic decision making in patients with a systemic RV.

Effects of equiblocking doses of nadolol and propranolol on left ventricular performance.

Nadolol, a recently developed noncardioselective beta-adrenergic blocker, has the potential advantages of a longer oral half-life (t 1/2) than propranolol and, in animal studies, markedly fewer direct myocardial depressant effects. Neither the relative intravenous potency of nadolol and propranolol nor the comparative effects of the 2 drugs on left ventricular performance has been studied in man. We compared equiblocking intravenous doses of nadolol and propranolol in 10 subjects with ischemic wall-motion disorders. Nadolol was on the average 6.2 times as potent on a milligram-for-milligram basis. Both drugs decreased resting heart rate (p less than 0.02) and produced small rises in both mean pulmonary artery (p less than 0.03) and mean pulmonary artery wedge (p less than 0.03) pressures without significantly reducing the cardiac output. Both drugs also produced depression of the radionuclide ejection fraction (p less than 0.002). There were no significant differences between the effects of the 2 drugs on any of the aforementioned variables. Thus, the effects of nadolol on left ventricular performances are similar to those of propranolol. Because of its long oral t 1/2, nadolol may prove to be a clinically useful drug.