Psoas Muscle Area as a Predictor of Transcatheter Aortic Valve Implantation Outcomes.

BACKGROUND: Frailty is a well-recognised predictor of outcomes after transcatheter aortic valve implantation (TAVI). Psoas muscle area (PMA) is a surrogate marker for sarcopaenia and is a validated assessment tool for frailty. The objective of this study was to examine frailty as a predictor of outcomes in TAVI patients and assess the prognostic usefulness of adding PMA to established frailty assessments. METHODS: Frailty assessments were performed on 220 consecutive patients undergoing TAVI. These assessments used four markers (serum albumin, handgrip strength, gait speed, and a cognitive assessment), which were combined to form a composite frailty score. Preprocedural computed tomography scans were used to calculate cross-sectional PMA for each patient. The primary outcomes were all-cause mortality at 1-year and post-procedure length of hospital stay. RESULTS: Frailty status, as defined by the composite frailty score, was independently predictive of length of hospital stay (p=0.001), but not predictive of 1-year mortality (p=0.161). Albumin (p=0.036) and 5-metre walk test (p=0.003) were independently predictive of 1-year mortality. The PMA, when adjusted for gender, and normalised according to body surface area, was not predictive of 1-year mortality. Normalised PMA was associated with increased post-procedure length of stay within the female population (p=0.031). CONCLUSIONS: A low PMA is associated with increased length of hospital stay in female TAVI patients but does not provide additional predictive value over traditional frailty scores. The PMA was not shown to correlate with TAVI-related complications or 1-year mortality.

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).

Predictive role of atrial fibrillation in cognitive decline: a systematic review and meta-analysis of 2.8 million individuals.

AIMS: To systematic review and meta-analyse the association and mechanistic links between atrial fibrillation (AF) and cognitive impairment. METHODS AND RESULTS: PubMed, EMBASE, and Cochrane Library were searched up to 27 March 2021 and yielded 4534 citations. After exclusions, 61 were analysed; 15 and 6 studies reported on the association of AF and cognitive impairment in the general population and post-stroke cohorts, respectively. Thirty-six studies reported on the neuro-pathological changes in patients with AF; of those, 13 reported on silent cerebral infarction (SCI) and 11 reported on cerebral microbleeds (CMB). Atrial fibrillation was associated with 39% increased risk of cognitive impairment in the general population [n = 15: 2 822 974 patients; hazard ratio = 1.39; 95% confidence interval (CI) 1.25-1.53, I2 = 90.3%; follow-up 3.8-25 years]. In the post-stroke cohort, AF was associated with a 2.70-fold increased risk of cognitive impairment [adjusted odds ratio (OR) 2.70; 95% CI 1.66-3.74, I2 = 0.0%; follow-up 0.25-3.78 years]. Atrial fibrillation was associated with cerebral small vessel disease, such as white matter hyperintensities and CMB (n = 8: 3698 patients; OR = 1.38; 95% CI 1.11-1.73, I2 = 0.0%), SCI (n = 13: 6188 patients; OR = 2.11; 95% CI 1.58-2.64, I2 = 0%), and decreased cerebral perfusion and cerebral volume even in the absence of clinical stroke. CONCLUSION: Atrial fibrillation is associated with increased risk of cognitive impairment. The association with cerebral small vessel disease and cerebral atrophy secondary to cardioembolism and cerebral hypoperfusion may suggest a plausible link in the absence of clinical stroke. PROSPERO CRD42018109185.

Professionalism and clinical short answer question marking with machine learning.

Machine learning may assist in medical student evaluation. This study involved scoring short answer questions administered at three centres. Bidirectional encoder representations from transformers were particularly effective for professionalism question scoring (accuracy ranging from 41.6% to 92.5%). In the scoring of 3-mark professionalism questions, as compared with clinical questions, machine learning had a lower classification accuracy (P < 0.05). The role of machine learning in medical professionalism evaluation warrants further investigation.

Medical student knowledge and critical appraisal of machine learning: a multicentre international cross-sectional study.

To utilise effectively tools that employ machine learning (ML) in clinical practice medical students and doctors will require a degree of understanding of ML models. To evaluate current levels of understanding, a formative examination and survey was conducted across three centres in Australia, New Zealand and the United States. Of the 245 individuals who participated in the study (response rate = 45.4%), the majority had difficulty with identifying weaknesses in model performance analysis. Further studies examining educational interventions addressing such ML topics are warranted.

Role of Indices Incorporating Power, Force and Time in AF Ablation: A Systematic Review of Literature.

INTRODUCTION: Successful pulmonary vein isolation (PVI) for atrial fibrillation (AF) depends on the formation of durable transmural lesions. Recently, novel indices have emerged to guide lesion delivery. The aim of the systematic review of literature was to determine AF recurrence following ablation guided by indices incorporating force, power and time, and compare acute procedural outcomes and 12-month AF recurrence with ablation guided by contact force (CF) guided only. METHODS: PubMed, EMBASE, and Web of Science Core Collection databases were searched on 27 January 2020 using the keywords; catheter ablation, ablation index (AI), lesion size index (LSI), contact force, atrial fibrillation. RESULTS: After exclusions, seven studies were included in the analysis. AI-guided catheter ablation was associated with a 91% (n=5, 0.91 95% CI; 0.88-0.93) and 80% (n=5, 0.80, 95% CI; 0.77-0.84) freedom from AF at 12 months with and without the use of anti-arhythmic drugs respectively. As compared to CF guided ablation, AI-guided catheter ablation was associated with a 49% increase in successful first pass isolation (n=3; RR: 1.49, 95% CI; 1.38, 1.61), a 50% decrease in number of acute reconnections (n=4; RR: 0.50, 95% CI; 0.39-0.65) and a 22% (n=4, RR: 1.22, 95% CI; 1.10-1.35) increase in AF freedom without anti-arrhythmic drugs at 12 months. CONCLUSIONS: Radiofrequency ablation guided by AI was associated with higher successful first pass isolation and lower rates of acute reconnection which translates to greater freedom from AF at 12 months [CRD42019131469].

Tandem lesions associate with angiographic progression of coronary artery stenoses.

Background: Although the clinical factors associated with progression of coronary artery disease have been well studied, the angiographic predictors are less defined. Objectives: Our objective was to study the clinical and angiographic factors that associate with progression of coronary artery stenoses. Methods: We conducted a retrospective analysis of consecutive patients undergoing multiple, clinically indicated invasive coronary angiograms with an interval greater than 6 months, between January 2013 and December 2016. Lesion segments were analysed using Quantitative Coronary Angiography (QCA) if a stenosis ≥ 20 % was identified on either angiogram. Stenosis progression was defined as an increase ≥ 10 % in stenosis severity, with progressor groups analysed on both patient and lesion levels. Mixed-effects regression analyses were performed to evaluate factors associated with progression of individual stenoses. Results: 199 patients were included with 881 lesions analysed. 108 (54.3 %) patients and 186 (21.1 %) stenoses were classified as progressors. The median age was 65 years (IQR 56-73) and the median interval between angiograms was 2.1 years (IQR 1.2-3.0). On a patient level, age, number of lesions and presence of multivessel disease at baseline were each associated with progressor status. On a lesion level, presence of a stenosis downstream (OR 3.07, 95 % CI 2.04-4.63, p < 0.001) and circumflex artery stenosis location (OR 1.81, 95 % CI 1.21-2.7, p = 0.004) were associated with progressor status. Other lesion characteristics did not significantly impact progressor status or change in stenosis severity. Conclusion: Coronary lesions which have a downstream stenosis may be at increased risk of stenosis progression. Further research into the mechanistic basis of this finding is required, along with its implications for plaque vulnerability and clinical outcomes.

Aortic valve replacement reduces mortality in moderate aortic stenosis: a systematic review and meta-analysis.

BACKGROUND: With the introduction of transcatheter aortic valve replacement and an evolving understanding of the natural progression and history of aortic stenosis, the potential for earlier intervention in appropriate patients is promising; however, the benefit of aortic valve replacement in moderate aortic stenosis remains unclear. METHODS: Pubmed, Embase, and the Cochrane Library databases were searched up until 30th of December 2021 using keywords including moderate aortic stenosis and aortic valve replacement. Studies reporting all-cause mortality and outcomes in early aortic valve replacement (AVR) compared to conservative management in patients with moderate aortic stenosis were included. Hazard ratios were generated using random-effects meta-analysis to determine effect estimates. RESULTS: 3470 publications were screened with title and abstract review, which left 169 articles for full-text review. Of these studies, 7 met inclusion criteria and were included, totalling 4,827 patients. All studies treated AVR as a time-dependent co-variable in cox-regression multivariate analysis of all-cause mortality. Intervention with surgical or transcatheter AVR was associated with a 45% decreased risk of all-cause mortality (HR = 0.55 [0.42-0.68], I 2 = 51.5%, P < 0.001). All studies were representative of the overall cohort with appropriate sample sizes, with no evidence of publication, detection, or information biases in any of the studies. CONCLUSION: In this systematic review and meta-analysis, we report a 45% reduction in all-cause mortality in patients with moderate aortic stenosis who were treated with early aortic valve replacement compared to a strategy of conservative management. Randomised control trials are awaited to determine the utility of AVR in moderate aortic stenosis.

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.

Systematic review and meta-analysis of the clinical characteristics and outcomes of spontanous coronary artery dissection.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an uncommon, non-iatrogenic, non-atherosclerotic cause of acute coronary syndrome. A lack of large prospective cohort studies and randomised controlled trials means that important questions about clinical characteristics and outcomes of patients with SCAD are yet to be fully answered. METHOD: A literature search of PUBMED, EMBASE and SCOPUS was undertaken up to and including the 23rd January 2020. Studies reporting any cohort of 10 or more SCAD patients presenting with acute coronary syndrome, with appropriate clinical follow-up data were included in the analysis. Incidences of major adverse cardiovascular events (MACE), myocardial infarction and SCAD recurrence were meta-analysed using Poisson regression. RESULTS: 19 studies, totalling p=2,172 patients, were included in the analysis. There was significant heterogeneity across the studies in all baseline characteristics and clinical outcomes. Prevalence of traditional cardiovascular risk factors was low; however, hypertension had a prevalence of 45% (95% CI; [35-54]) and fibromuscular dysplasia (FMD) was present in 68% (95% CI; [61-74]). Across all cohorts, the incidence of MACE in patients with SCAD was 7.80 per 100 person years (n=19, p=2172, 95% CI; [4.50-13.54]) and SCAD recurrence was 5.49 per 100 person years (n=13, p=1408, 95% CI; [3.75-8.02]). CONCLUSIONS: This meta-analysis confirms that SCAD is not an inconsequential cause of acute coronary syndrome and heralds the need for further prospective research to identify predictors of recurrent events and therapies to prevent them.

Clinical utility of cardiac magnetic resonance imaging to assess the left atrium before catheter ablation for atrial fibrillation - A systematic review and meta-analysis.

AIMS: This systematic review and meta-analysis aims to clarify the role of pre-procedural cardiac magnetic resonance imaging (MRI) in identifying the association between left atrial (LA) characteristics and post-ablation atrial fibrillation (AF) recurrence. These characteristics include LA fibrosis, emptying function, sphericity, volume, volume index, peak strain and post-contrast T1 relaxation time. METHODS: PubMed, EMBASE, and Cochrane were searched up to July 2020 for English language articles reporting the use of cardiac MRI in catheter ablation for AF. Studies reporting the prognostic value of pre-ablation cardiac MRI were included. All references and citations were filtered for relevant manuscripts. RESULTS: Twenty-four publications were identified. Every 10% increase in LA fibrosis was associated with a 1.54-fold increase in post-ablation AF recurrence (95%CI: 1.39-1.70, I2 = 50.1%). Every 10 ml increase in LA volume resulted in a hazard ratio of 1.07 (95%CI:1.03-1.12; I2 = 41.4%) for post-ablation AF recurrence. For LA sphericity, there was no significant association with post-ablation AF recurrence (HR: 1.032 [95%CI: 0.962-1.103, I2 = 49.6%). Egger's test was non-significant for publication bias in all meta-analyses. LA volume index, emptying function, peak strain and post-contrast LA T1 relaxation time had insufficient compatible publications to conduct a meta-analysis. CONCLUSION: LA fibrosis quantified by cardiac MRI is associated with risk of AF recurrence after AF ablation, while increased LA volume is associated with AF recurrence to a lesser extent. There remains insufficient evidence to support the routine measurement of LA sphericity, LA volume index, LA emptying function, peak strain and LA T1 relaxation time to predict AF recurrence after AF ablation.

Risk and predictors of sudden death in cardiac sarcoidosis: A systematic review and meta-analysis.

BACKGROUND: To evaluate the risk for ventricular arrhythmia (VA) and sudden cardiac death (SCD) in patients with cardiac sarcoidosis (CS) and determine the prognostic factors. METHODS AND RESULTS: PUBMED, EMBASE and SCOPUS were searched up to 14th April 2020. Studies reporting the incidence of SCD, appropriate ICD therapy in CS patients, or relevant prognostic information in patients having undergone MRI, PET, or programmed electrical stimulation (PES) were included. Nineteen studies consisting of 1247 patients, reported the risk of ICD therapies or SCD over a follow-up period of 1.7-7 years. 22.7% (n = 9; 22.7, 95%CI [16.10-29.36]) of patients in primary and 58.4% (n = 9; 58.42, 95% CI [38.61-78.22]) in secondary prevention cohorts experienced appropriate device therapy or SCD events. 18% (n = 2; 18, 95%CI [14-23]) of patients received ≥5 appropriate therapies. 9 out of 664 patients with confirmed cardiac sarcoidosis but without implanted ICDs died suddenly. 17.9% of patients (n = 4; 17.9, 95%CI [10.80-25.03]) experienced inappropriate device therapy. Positive LGE-MRI and PES were associated with an 8.6-fold (n = 6; RR = 8.60, 95%CI [3.80-19.48]) and 9-fold (n = 5; RR = 9.07, 95%CI [4.65-17.68]) increased risk of VA respectively. Positive LGE-MRI and PET with associated with a 6.8-fold (n = 12; RR = 6.82, 95%CI [4.57-10.18]) and 3.4-fold (n = 7; RR = 3.41, 95%CI [2.03-5.74]) respectively for increased risk of major adverse cardiac events. CONCLUSIONS: The risk of appropriate ICD therapy or sudden cardiac death is high in patients with CS. The presence of LGE-MRI and positive electrophysiology study identify patients at increased risk of ventricular arrhythmias. [CRD42019124220].

Current state-of-play in spontaneous coronary artery dissection.

For over 80 years, spontaneous coronary artery dissection (SCAD) has been recognised as a cause of myocardial infarction. SCAD is described as a non-iatrogenic, non-atherosclerotic coronary artery dissection, resulting in formation of a false lumen or intramural haematoma in the coronary artery wall that compresses the true lumen, often compromising myocardial blood flow. In early literature, the incidence of SCAD in acute coronary syndrome (ACS) was underestimated. Recent advances in awareness and widespread early angiographic investigation in ACS has led to important shifts in our understanding of the prevalence, predisposing causes, natural history, aetiology, clinical and angiographic features, management, and prognosis of SCAD. It is now well understood that SCAD predominantly affects women and is responsible for around 20% of ACS presentations in females below the age of 60. Despite this, SCAD is still often overlooked and misdiagnosed as atherosclerotic disease. Misdiagnosis is multifactorial; with contributing factors including a low clinical index of suspicion, particularly in young females, a lack of clinician familiarity with angiographic variants, and limitations of angiography. Although increasing evidence suggests that optimal management is distinct from atherosclerotic coronary artery disease, many questions remain unanswered regarding the pathogenesis and optimal treatment of SCAD, heralding prospective research to answer these questions. This review aims to give a current clinical perspective on SCAD and highlight the importance of familiarity and vigilance with this condition when diagnosing and treating ACS.

Magnetic resonance imaging and positron emission tomography in anti-NMDA receptor encephalitis: A systematic review.

Due to a variety of clinical manifestations anti-N-methyl-d-aspartate (NMDA) receptor encephalitis may be difficult to diagnose. Magnetic resonance imaging (MRI) may be used as a component of the workup for encephalopathy. However, the use of MRI in anti-NMDA encephalitis is complicated by wide-ranging reports regarding the frequency of normal MRI findings in this disease. Positron emission tomography (PET) is a modality of imaging that may assess functional rather than structural disturbances. Therefore, this review was conducted to summarise published studies regarding the use of MRI and PET in the diagnosis of anti-NMDA receptor encephalitis. The terms (MR OR magnetic resonance OR PET OR positron emission tomography) AND (NMDA encephalitis OR N-methyl-d-aspartate encephalitis) were used to search the databases PubMed, EMBASE and Scopus on 10/5/2017. These searches returned 1534 results. Sixty studies met the inclusion criteria. The results indicated that fewer than half of MRIs in anti-NMDA receptor encephalitis show abnormal findings. When abnormal findings are present they most commonly include T2/FLAIR medial temporal and frontal hyperintensity, and leptomeningeal contrast enhancement. Cortical grey matter changes were reported in the same number of patients as subcortical white matter changes. The only MRI finding with prognostic significance at this stage is progressive cerebellar atrophy. FDG-PET has been assessed in a few small studies and can demonstrate abnormalities in cases where MRI does not. Further research should aim for larger sample sizes and to report (and attempt to control for) the time between symptom onset and the scan being conducted, and pre-imaging treatments.