Self-helped detection of obstructive sleep apnea based on automated facial recognition and machine learning.

PURPOSE: The diagnosis of obstructive sleep apnea (OSA) relies on time-consuming and complicated procedures which are not always readily available and may delay diagnosis. With the widespread use of artificial intelligence, we presumed that the combination of simple clinical information and imaging recognition based on facial photos may be a useful tool to screen for OSA. METHODS: We recruited consecutive subjects suspected of OSA who had received sleep examination and photographing. Sixty-eight points from 2-dimensional facial photos were labelled by automated identification. An optimized model with facial features and basic clinical information was established and tenfold cross-validation was performed. Area under the receiver operating characteristic curve (AUC) indicated the model's performance using sleep monitoring as the reference standard. RESULTS: A total of 653 subjects (77.2% males, 55.3% OSA) were analyzed. CATBOOST was the most suitable algorithm for OSA classification with a sensitivity, specificity, accuracy, and AUC of 0.75, 0.66, 0.71, and 0.76 respectively (P < 0.05), which was better than STOP-Bang questionnaire, NoSAS scores, and Epworth scale. Witnessed apnea by sleep partner was the most powerful variable, followed by body mass index, neck circumference, facial parameters, and hypertension. The model's performance became more robust with a sensitivity of 0.94, for patients with frequent supine sleep apnea. CONCLUSION: The findings suggest that craniofacial features extracted from 2-dimensional frontal photos, especially in the mandibular segment, have the potential to become predictors of OSA in the Chinese population. Machine learning-derived automatic recognition may facilitate the self-help screening for OSA in a quick, radiation-free, and repeatable manner.

The Effects of Continuous Positive Airway Pressure Therapy for Secondary Cardiovascular Prevention in Patients with Obstructive Sleep Apnoea: A Systematic Review and Meta-Analysis.

Background: Obstructive sleep apnoea (OSA) is highly prevalent and significantly associated with major adverse cardiovascular events (MACEs). Continuous positive airway pressure (CPAP) treatment has a protective effect on cardiovascular events in OSA patients. However, whether CPAP therapy significant reduces the risk of recurrent cardiovascular (CV) events in OSA patients with established cardiovascular or cerebrovascular diseases remains disputed. We aim to evaluate the effect of CPAP on recurrent cardiovascular outcomes in moderate to severe OSA patients with previous cardiovascular or cerebrovascular diseases. Methods: We searched the electronic databases (PubMed, EMBASE, and Cochrane library) from their inception to August, 2021. Only randomized controlled trials (RCTs) that described the association of CPAP treatment in patients with cardiovascular or cerebrovascular disease and OSA were included in our analysis. The primary outcome of interest was major adverse cardiac or cerebral events (MACCEs), a composite endpoint of myocardial infraction (MI), non-fatal stroke, CV mortality; secondary outcomes included all-caused death, cardiac mortality, myocardial infraction, atrial fibrillation, heart failure, repeat revascularization, angina, stroke, and transient ischemic attack. In addition, subgroup analyses based on CPAP adherence were performed. Result: Six RCTs of 4493 participants were included in the analysis. Compared with usual care, CPAP therapy did not significantly reduce the risk of recurrent MACCEs odds ratio (OR) 0.94, 95% confidence interval (CI) 0.79-1.12, p = 0.5, CV mortality (OR 0.83, 95% CI [0.54-1.26], p = 0.37), myocardial infarction (OR 1.09, 95% CI [0.8-1.47], p = 0.6), heart failure (OR 0.94, 95% CI [0.66-1.33], p = 0.71), stroke (OR 0.9, 95% CI [0.67-1.23], p = 0.52), or all-cause death (OR 0.86, 95% CI [0.63-1.16], p = 0.32). However, the subgroup analyses revealed that CPAP can decrease the risk of CV mortality (OR 0.25, 95% CI [0.08-0.77], p = 0.02) and stoke (OR 0.39, 95% CI [0.15-0.97], p = 0.04) in patients who used it more than 4 hours. Conclusions: CPAP therapy was not associated with reduce the risk of MACCEs in OSA patients with a history of chronic cardiovascular disease who utilize CPAP < 4 hours/night, although CPAP appeared to have a positive effect on CV mortality and stroke among those who used CPAP > 4 hours. The correlation between CPAP and the prognosis of OSA patients warrants further study.

Fast assessment of left ventricular systolic function in obstructive sleep apnea patients with automated function imaging: Comparison with mitral annular plane systolic excursion.

BACKGROUND: Early detection of left ventricular (LV) subclinical dysfunction is clinically relevant before developing irreversible impairment in obstructive sleep apnea (OSA) patients. Mitral annulus plane systolic excursion (MAPSE) is a fast tool for OSA due to high prevalent obesity; another quick but more comprehensive tool is LV global longitudinal stain (GLS) based on automated function imaging (AFI). We therefore aimed to compare the feasibility and reproducibility of AFI to MAPSE in OSA patients, as a good model in whom obesity is common. METHODS: A comprehensive echocardiographic examination was done in 186 consecutive patients having polysomnography for suspected OSA. MAPSE was measured by using M-mode to calculate excursion of mitral annulus. GLS was derived by offline analysis of three long-axis views that semi-automatically detects LV endocardial boundary, which is adjusted manually as necessary with AFI measurement. Variability of AFI and MAPSE were compared among the different subgroups. RESULTS: Despite a relatively high obesity rate (42.9%), the feasibility of AFI was 94% (175/186) and that of 100% in MAPSE. AFI showed excellent correlation (r = .882) superior to MAPSE (r = .819) between the Expert and Beginner. Intra- and inter- observer variability of AFI and MAPSE in Bland-Altman analysis were 5.5% and 6.5%; 6.2% and 8.8%, respectively. In repeated measurements, AFI showed higher intra-class correlation (ICC = .95) than MAPSE (ICC = .87) (p < 0.05). Furthermore, analysis showed that AFI was feasible even in more obese patients (BMI≥28 kg/m2 ). CONCLUSIONS: Even in obese patients with OSA, AFI-GLS is feasible and more reliable for less expert operators than MAPSE in detecting LV longitudinal dysfunction.

Subclinical left ventricular systolic dysfunction detected in obstructive sleep apnea with automated function imaging and its association with nocturnal hypoxia.

BACKGROUND: Early detection of left ventricular (LV) dysfunction is crucial in obstructive sleep apnea (OSA) due to its close relationship with cardiovascular diseases. Global longitudinal strain (GLS) derived from automated function imaging (AFI) can precisely assess global longitudinal function. The aim of this study was to determine if LV GLS was reduced in patients with OSA and a normal LV ejection fraction (LVEF) and to assess any associated determinants. METHODS: Polysomnography (PSG) and echocardiography were done in consecutive patients with suspected OSA and normal LVEF in this prospective study. Patients were divided into two groups according to apnea-hypopnea index (AHI) (Group 1, normal or mild OSA: AHI < 15/h; Group 2, moderate-to-severe OSA: AHI ≥ 15/h). Clinical, PSG, and echocardiographic parameters were compared between the two groups and the associated factors were investigated. RESULTS: Of 425 consecutive patients, 244 were analyzed after exclusions. Patients in Group 2 had significantly worse GLS than those in Group 1 (p < 0.001). The prevalence of GLS reduction (defined as < - 19.7%) was 25% and 76%, respectively (χ2 = 34.19, p < 0.001). Nocturnal lowest pulse oxygen saturation (SpO2), AHI, body mass index (BMI), and gender were associated with GLS reduction (all p < 0.05). Further multivariate analysis showed that the lowest SpO2 (OR: 2.15), gender (OR: 2.45), and BMI (OR: 2.66) remained independent (all p < 0.05), and the lowest SpO2 was the most powerful determinant (χ2 = 33.0, p < 0.001) in forward regression analysis. The intra- and inter-operator variability for AFI and coefficient of repeatability was low even in those with relatively poor images. CONCLUSIONS: In patients with normal LVEF, more severe OSA was associated with a worse GLS. The major determinants were lowest nocturnal SpO2, gender, and obesity, but not AHI. GLS can be rapidly and reliably assessed using AFI.

Validation of a portable monitoring device for the diagnosis of obstructive sleep apnea: electrocardiogram-based cardiopulmonary coupling.

PURPOSE: We aimed to evaluate the validity of the cardiopulmonary coupling (CPC) device, a limited-channel portable monitoring device for obstructive sleep apnea (OSA) screening in one single-center cohort, in particular in those with some cardiovascular diseases since the cardiopulmonary coupling might be different from those without. METHODS: Consecutive patients referred to the sleep medical center for assessment of possible OSA were enrolled in this study. Patients were examined with standard polysomnography (PSG) and CPC evaluation simultaneously. The results of the two examinations were compared in all subjects and in those with or without cardiovascular abnormalities. RESULTS: A total of 179 subjects suspected with OSA were finally analyzed. According to OSA severity degree based on AHI, the area under ROC curve for the CPC device in the whole cohort patients was 0.79 (mild), 0.79 (moderate), and 0.86 (severe OSA), respectively (all p < 0.001). For patients with cardiovascular disease with different OSA severity, the area under the ROC curve was 0.86 (mild), 0.73 (moderate), and 0.83 (severe OSA), respectively (all p < 0.0001), and 0.74 (mild), 0.85 (moderate), and 0.91 (severe OSA), respectively in patients without cardiovascular disease (all p < 0.0001). CONCLUSIONS: The overall performance of CPC technique was acceptable to assess OSA in subjects with clinical suspicion of OSA, and thus it might act as a fast tool to screen OSA patients. However, the sensitivity of CPC technology for patients with cardiovascular disease was relatively insufficient. Therefore, CPC technology should be carefully interpreted in OSA screening in those with cardiovascular disease.

Heart failure with preserved or reduced ejection fraction in patients treated with peritoneal dialysis.

BACKGROUND: Heart failure is one of the most frequent complications in dialysis patients. However, little is known of the significance of the entity "heart failure with preserved ejection fraction" (HFPEF) in this population. This study aimed to determine the prevalence, clinical profiles, and long-term outcomes of peritoneal dialysis patients with HFPEF. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 220 patients treated with peritoneal dialysis were recruited from a university teaching hospital in Hong Kong. PREDICTOR: Heart failure was defined clinically based on the presence of: (1) symptoms and signs, including dyspnea, increased jugular venous pressure, and basal crepitations; (2) radiographic evidence of pulmonary venous congestion or interstitial edema; and (3) resolution of symptoms, signs, and radiographic changes with hypertonic peritoneal dialysis exchanges. Based on a combination of clinical history of heart failure and echocardiography-derived ejection fraction, patients were classified as having no heart failure, HFPEF, and heart failure with reduced ejection fraction (HFREF). OUTCOMES: All-cause mortality, cardiac death, heart failure, and fatal or nonfatal cardiovascular events. MEASUREMENTS: All patients underwent 2-dimensional echocardiography and tissue Doppler imaging at baseline and were followed up prospectively for clinical events for 4 years. RESULTS: 86 (39%) patients had heart failure, of whom 54.7% had preserved ejection fraction ≥50% and 45.3% had reduced ejection fraction <50%. Patients with HFPEF were intermediate between those with no heart failure and those with HFREF in terms of blood pressure, prevalence of coronary artery disease, diabetes, cardiac biomarkers, left ventricular mass, volume, and ratio of early mitral inflow velocity to peak mitral annulus velocity. In the multivariable Cox regression analysis, patients with HFPEF showed an increased adjusted HR for cardiac death (2.57; 95% CI, 1.20-5.50), heart failure (HR, 2.25; 95% CI, 1.28-3.96), and fatal or nonfatal cardiovascular event (HR, 2.01; 95% CI, 1.26-3.21) compared with those with no heart failure, but the risk was lower compared with those with HFREF. LIMITATIONS: The study included prevalent peritoneal dialysis patients and may introduce survival bias. CONCLUSIONS: HFPEF is common in peritoneal dialysis patients (∼55% of all heart failure) and is associated with increased risk of mortality and adverse cardiovascular outcomes compared with those with no heart failure, although the risk was lower than in patients with HFREF. This entity needs to be more recognized in peritoneal dialysis patients.

Potential role of biventricular pacing beyond advanced systolic heart failure.

Cardiac resynchronization therapy (CRT) is an effective therapy for advanced heart failure (HF) patients. The indications are well defined in recent guidelines and broadly indicate that CRT is suitable for chronic HF patients with left ventricular ejection fraction (EF) ≤35% and in NYHA class III or IV (Class I), and those with prolonged QRS duration ≥120 ms with left bundle branch block (LBBB) QRS morphology, or QRS duration ≥150 ms irrespective of QRS morphology (Class IIa). For patients with NYHA class II symptoms, CRT is recommended for patients with EF ≤30% and QRS duration ≥130 ms with LBBB QRS morphology (Class I, level of evidence: A), or QRS duration ≥150 ms irrespective of QRS morphology (Class IIa, level of evidence: A). However, CRT may benefit additional patients outside these criteria. In this review, we summarize the role of CRT in some subgroups, including patients with mild and moderate HF, upgrading to CRT from right ventricular (RV) pacing, bradycardia patients with routine pacing indications, congenital heart disease and specific cardiomyopathies. It is possible that CRT can give symptomatic and mortality benefits in some of these subgroups in the future and further clinical trials are warranted.

Systematic review and meta-analysis of the clinical outcomes of ACEI/ARB in East-Asian patients with COVID-19.

BACKGROUND: SARS-CoV-2 invades human cells and leads to COVID-19 by direct associating with angiotensin converting enzyme 2 (ACE2) receptors, the level of which may be increased by treatment with angiotensin-converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers (ARBs). This meta-analysis aimed to explore the impact of ACEI/ARB treatment on the clinical outcomes of patients with COVID-19 infections among population in the East-Asia region. METHODS: We collected clinical data published from January 2000 to May 2022 in the English databases including PubMed, Embase, and the Cochrane Library. Two reviewers independently screened and identified studies that met the prespecified criteria. Review Manager 5.3 software was used to perform the meta-analysis. RESULTS: A total of 28 articles were included in this analysis. The results showed that patients who were prescribed with ACEI/ARB had a shorter duration of hospital stay [MD = -2.37, 95%CI (-3.59, -1.14), P = 0.000 2] and a lower mortality rate [OR = 0.61, 95% CI (0.52, 0.70), P<0.000 01] than patients who were not on ACEI/ARB. Furthermore, there was no statistically significant difference in disease severity [OR = 0.99, 95% CI (0.83, 1.17), P = 0.90] between individuals receiving ACEI/ARB or not. CONCLUSIONS: This meta-analysis suggested that the use of ACEI/ARB was not associated with adverse clinical outcomes in East-Asian Covid-19 patients and a reduced mortality and shorter duration of hospital stay among East-Asian population (especially for female subjects) was found. Thus, ACEI/ARB should be continued in patients infected by Covid-19.

Increase in ventricular-arterial stiffness in patients with psoriatic arthritis.

OBJECTIVES: Ventricular and arterial stiffness is an accepted cause of myocardial diastolic dysfunction. The aim of this study is to determine whether there is increased ventricular and arterial stiffness in patients with PsA and any relationship with disease-related risk factors. METHODS: Seventy-three patients with PsA were divided into two subgroups based on the absence or presence of hypertension and/or left ventricular (LV) hypertrophy. Fifty healthy controls were enrolled for comparison. All participants underwent non-invasive assessments including conventional echocardiography with tissue Doppler imaging and pulse wave analysis. Ventricular stiffness was measured by ventricular end-systolic and diastolic elastance, whereas arterial stiffness was measured by total arterial compliance and aortic augmentation index. RESULTS: There was significantly increased ventricular and arterial stiffness in patients with PsA (P < 0.001), even in those without hypertension and/or LV hypertrophy. Based on the cut-off points derived from the controls, 38.4% of PsA patients had increased LV stiffness including 31.5% in diastole and 17.8% in systole, and 15.1% had increased arterial stiffness. Multivariable logistic regression analysis showed that long PsA disease duration (>10 years) (odds ratio = 6.55, P = 0.001) was an independent risk factor for increased LV diastolic elastance after adjusting for age, gender and hypertension. CONCLUSION: Patients with PsA may have increased ventricular and arterial stiffness even without evidence of LV remodelling, and those with long disease duration may be at a higher risk. Therefore, prolonged inflammatory burden may be an important cause of early cardiovascular disease in patients with PsA.

Atrial dysfunction and interatrial dyssynchrony predict atrial high rate episodes: insight into the distinct effects of right atrial appendage pacing.

INTRODUCTION: Right atrial (RA) appendage pacing may prolong atrial conduction time (ACT). This study aimed to investigate if RA appendage pacing can induce intra- and interatrial dyssynchrony and if atrial dysfunction and dyssynchrony can predict atrial high rate episodes (AHREs) in the first year after pacing. METHODS AND RESULTS: Patients implanted with dual-chamber pacemakers for symptomatic bradycardia were enrolled. Cumulative percentage of RA appendage pacing (Cum%AP) during 1-year follow-up and AHREs were recorded. Full Doppler echocardiography studies were performed before implantation and 1 year after pacing. ACT and peak atrial velocities (Sm-la, Em-la, Am-la) were measured. One hundred ten patients (age 70.5 ± 11 years; 53 males) were recruited and completed 1-year follow-up. ACT of both RA and left atrial (LA) were more prolonged in patients with Cum%AP > 75% than those with <25%. Intra- and interatrial dyssynchrony was more obvious in patients with Cum%AP > 75% (22.3 ± 12.2 milliseconds vs 9.5 ± 6.2 milliseconds; 53.9 ± 29.7 milliseconds vs 19.7 ± 17.3 milliseconds; both P < 0.001). AHREs occurred in 29% of patients. Atrial pump function and interatrial dyssynchrony independently predicted AHREs in multivariate analysis. Receiver operating characteristic curve provided a cutoff value of Am-la <5.3 cm/s, which predicted AHREs with a sensitivity of 71% and a specificity of 75% (area under the curve, 0.822; P < 0.001). CONCLUSION: RA appendage pacing causes atrial conduction delay with intra- and interatrial dyssynchrony. Atrial dysfunction and interatrial dyssynchrony are related to AHREs in the first year after pacing.

Ventricular resynchronization is the principle mechanism of benefit with cardiac resynchronization therapy.

Although there is little debate over the fact that cardiac resynchronization therapy (CRT) can benefit the majority of patients selected with routine indications, the precise mechanism for improvement may be considered controversial. Among patients selected with New York Heart Association functional class III or IV symptoms, left ventricular ejection fraction ≤ 35% and electrocardiographic QRS widening of at least 120-130 ms, approximately 60-80% of patients improved depending on the definition of response used. Although a reasonable assumption is that electrocardiographic QRS widening is a surrogate for delays in regional ventricular mechanical activation, a large volume of data has demonstrated that there is a subset of patients with widened QRS complexes who have no significant mechanical dyssynchrony. The reason for dissociation of electrical dispersion and mechanical dyssynchrony is unknown presently, but many studies have demonstrated the association of dyssynchrony with favorable outcome following CRT. Perhaps more importantly, several imaging studies (principally by echocardiography) have shown the lack of baseline mechanical dyssynchrony to be as a marker for a less favorable outcome after CRT. Recently, the lack of dyssynchrony before CRT has been shown to be associated with a significantly lower long-term probability of freedom from death, heart transplantation, or left ventricular assist device placement. As further mechanistic evidence for the relationship of mechanical dyssynchrony and LV functional response to CRT, it has been suggested that patients who failed to improve their tissue Doppler measures of dyssynchrony after CRT have a lower chance of reverse remodeling. This topic has been muddled by technical difficulties in measurement of mechanical dyssynchrony by all imaging approaches, the confounding variable of scar in ischemic disease, and the widely variable definitions of response used by different investigators. However, the weight of evidence from a pathophysiological basis to the recent long-term patient outcome data strongly support the notion that resynchronization is the principle mechanism of benefit from CRT.

Cardiac contractility modulation for heart failure: a meta-analysis of randomized controlled trials.

BACKGROUND: Cardiac contractility modulation (CCM) emerges as a promising device treatment for heart failure (HF). This meta-analysis aimed to systematically review the latest available randomized evidence on the effectiveness and safety of CCM in HF. METHODS: The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE were searched in November 2011 to identify eligible randomized controlled trials comparing CCM with sham treatment or usual care. Primary outcomes of interest were all-cause mortality, all-cause hospitalizations, and adverse effects. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for dichotomous data using a random-effects model. RESULTS: Three studies enrolling 641 participants were included. Pooled analysis showed that, compared to control, CCM did not significantly improve all-cause mortality (n = 629, RR 1.19, 95% CI 0.50-2.86, P = 0.69), nor was there a favorable effect in all-cause hospitalizations. No increase in adverse effects with CCM was observed. CONCLUSIONS: Meta-analysis of data from small randomized trials suggests that CCM, although with no clear benefits in improving clinical outcomes, is not associated with worsening prognosis. Large, well-designed trials are needed to confirm its role in HF patients for whom cardiac resynchronization therapy is contraindicated or unsuccessful.

Acute effects of right ventricular apical pacing on left atrial remodeling and function.

BACKGROUND: The acute effects of right ventricular apical (RVA) pacing on left atrial (LA) function in patients with normal ejection fraction are not clear. METHODS: A total of 94 patients (age 68.1 ± 11.1 years, 26 men) with implanted RVA-based dual-chamber pacemakers were recruited into this study. Patients who were pacemaker-dependent, in persistent atrial fibrillation or left ventricular ejection fraction <45% were excluded. Echocardiography (iE33, Philips, Andover, MA, USA) was performed during intrinsic ventricular conduction (V-sense) and RVA pacing (V-pace) with 15 minutes between switching modes. The total maximal LA volume (LAV(max)), preatrial contraction volume (LAV(pre)), and minimal volume (LAV(min)) were assessed by area-length method. Peak systolic, early diastolic, and peak late diastolic (atrial contractile) velocity (Sm-la, Em-la, and Am-la) and strain (ɛs-la, ɛe-la, and ɛa-la) were measured by color-coded tissue Doppler imaging (TDI) in four mid-LA walls at apical four- and two-chamber views. RESULTS: During V-pace, LA volumes increased significantly compared with V-sense (LAV(max): 52.0 ± 18.8 vs 55.2 ± 21.1 mL, P = 0.005; LAV(pre): 39.8 ± 16.4 vs 41.3 ± 16.6 mL, P = 0.014; LAV(min): 27.4 ± 14.0 vs 29.1 ± 15.1 mL, P = 0.001). TDI parameters showed significant reduction in Sm-la and Em-la. Furthermore, ɛs-la, ɛe-la, and ɛa-la decreased significantly, especially in patients with preexisting diastolic dysfunction (all P < 0.01). CONCLUSIONS: RVA pacing acutely induced LA enlargement and impaired atrial contractility. Patients with preexisting diastolic dysfunction may be more vulnerable to develop LA dysfunction and remodeling after acute RVA pacing.

Treatment of heart failure in long-term dialysis patients: a reappraisal.

Heart failure is one of the most frequent cardiac complications in patients with end-stage renal disease receiving long-term hemodialysis or peritoneal dialysis and is associated strongly with a poor prognosis. Despite the significant morbidity and mortality associated with heart failure, there are very limited therapeutic options proved to prevent and treat heart failure in dialysis patients. This limitation largely reflects the paucity of adequately powered prospective randomized clinical trials that have examined the efficacy of different therapeutic options in long-term dialysis patients with heart failure. In this article, the second in a series discussing the management of heart failure in dialysis patients, current therapeutic options for heart failure in the maintenance dialysis population are reviewed and potential novel therapeutic options are discussed.

Current perspectives on diagnosis of heart failure in long-term dialysis patients.

Cardiovascular disease is highly prevalent in patients with chronic kidney failure treated using dialysis. The risk of cardiovascular events is estimated to be at least 2- to 10-fold higher in dialysis patients than in age-, race-, and sex-matched persons with normal kidney function. A significant proportion of cardiovascular events in long-term dialysis patients is caused by heart failure, and the presence of heart failure is predictive of a poor prognosis. Despite the significant morbidity and mortality associated with heart failure, very few therapeutic options are proved to prevent and treat the progression of this complication in dialysis patients. There are several potential reasons for this, chiefly reflecting both challenges with diagnosis due to the coexistence of volume overload and a paucity of adequately powered prospective randomized controlled trials that examine the efficacy of different therapeutic options in dialysis patients with cardiac disease or heart failure. Thus, unlike in the general population, very few advances have been made in managing this severe complication in dialysis patients. In this article, an overview of the prevalence, severity, and risk factors for heart failure in maintenance dialysis patients is provided and the diagnosis of heart failure in these patients is revisited.

Echocardiography, dyssynchrony, and the response to cardiac resynchronization therapy.

Biventricular pacing or cardiac resynchronization therapy (CRT) has been a considerable advance in the therapy of chronic heart failure. However, it is clear that not all patients benefit either in terms of symptoms or cardiac function, and some may be worsened by CRT. In this review, we consider the arguments, both clinical and economical, in favour of improved selection of patients for CRT other than those in current guidelines. It also seems clear that the fundamental mechanism of CRT is correction of dyssynchrony, and we review the various methodologies available to detect dyssynchrony. Other factors are probably also important in determining outcomes such as lead position, the extent and form of myocardial damage, optimizing pacemaker performance, and clinical expertise. The potential costs of inappropriate CRT implantation are high to our patients and to the health economy, and it behooves the cardiology community to develop better selection criteria. The current guidelines can and should be improved.

Passive Prescription of Secondary Prevention Medical Therapy during Index Hospitalization for Acute Myocardial Infarction Is Prevalent and Associated with Adverse Clinical Outcomes.

Secondary prevention therapy reduces death and reinfarction after acute myocardial infarction (AMI), but it is underutilized in clinical practice. Mechanisms for this therapeutic gap are not well established. In this study, we have explored and evaluated the impact of passive continuation compared to active initiation of secondary prevention therapy for AMI during the index hospitalization. For this purpose, we have analyzed 1083 consecutive patients with AMI to a tertiary referral hospital in Hong Kong and assessed discharge prescription rates of secondary prevention therapies (aspirin, beta-blockers, statins, and ACEI/ARBs). Multivariate analysis was used to identify independent predictors of discharge medication, and Kaplan-Meier survival curve was used to evaluate 12-month survival. Overall, prescription rates of aspirin, beta-blocker, statin, and ACEI/ARBs on discharge were 94.8%, 64.5%, 83.5%, and 61.4%, respectively. Multivariate analysis showed that prior use of each therapy was an independent predictor of prescription of the same therapy on discharge: aspirin (odds ratio (OR) = 4.8, 95% CI = 1.9-12.3, P < 0.01), beta-blocker (OR = 2.5, 95% CI = 1.8-3.4, P < 0.01); statin (OR = 8.3, 95% CI = 0.4-15.7, P < 0.01), and ACEI/ARBs (OR = 2.9, 95% CI = 2.0-4.3, P < 0.01). Passive continuation of prior medication was associated with higher 1-year mortality rates than active initiation in treatment-naïve patients (aspirin (13.7% vs. 5.7%), beta-blockers (12.9% vs. 5.6%), and statins (11.0% vs. 4.6%); all P < 0.01). Overall, the use of secondary prevention medication for AMI was suboptimal. Our findings suggested that the practice of passive continuation of prior medication was prevalent and associated with adverse clinical outcomes compared to active initiation of secondary preventive therapies for acute myocardial infarction during the index hospitalization.

Obstructive sleep apnoea, intermittent hypoxia and heart failure with a preserved ejection fraction.

Obstructive sleep apnoea (OSA) is recognised to be a potent risk factor for hypertension, coronary heart disease, strokes and heart failure with a reduced ejection fraction. However, the association between OSA and heart failure with a preserved ejection fraction (HFpEF) is less well recognised. Both conditions are very common globally.It appears that there are many similarities between the pathological effects of OSA and other known aetiologies of HFpEF and its postulated pathophysiology. Intermittent hypoxia induced by OSA leads to widespread stimulation of the sympathetic nervous system, renin-angiotensin-aldosterone system and more importantly a systemic inflammatory state associated with oxidative stress. This is similar to the consequences of hypertension, diabetes, obesity and ageing that are the common precursors to HFpEF. The final common pathway is probably via the development of myocardial fibrosis and structural changes in collagen and myocardial titin that cause myocardial stiffening. Thus, considering the pathophysiology of OSA and HFpEF, OSA is likely to be a significant risk factor for HFpEF and further trials of preventive treatment should be considered.

Association Between OSA and Quantitative Atherosclerotic Plaque Burden: A Coronary CT Angiography Study.

BACKGROUND: Limited evidence is available regarding the association between OSA and coronary plaque assessed by using quantitative coronary CT angiography. RESEARCH QUESTION: Are there any associations between OSA severity-related indexes and the presence and burden of coronary plaque? STUDY DESIGN AND METHODS: Cross-sectional data from 692 patients who underwent sleep monitoring and coronary CT angiography were used for this study. Of these patients, 120 (17.3%) underwent polysomnography, and 572 (82.7%) underwent respiratory polygraphy. Multivariable logistic and linear regression analyses were used to investigate the associations of OSA severity-related indexes with the presence, volume, and composition of plaque. RESULTS: In multivariable analyses, patients with moderate to severe OSA were more likely to have coronary plaques (P = .037), and plaques were more likely to contain a noncalcified plaque (NCP) component (P = .032) and a low-density NCP (LD NCP) component (P = .030). Furthermore, the apnea-hypopnea index and oxygen desaturation index as continuous variables were both associated with the presence of plaque, NCP, and LD NCP (all, P < .05). Multivariable linear regression models showed that moderate to severe OSA was associated with NCP volume (ß = 50.328; P = .042) and LD NCP volume (ß = 15.707; P = .011). Moreover, the apnea-hypopnea index (P = .015), oxygen desaturation index (P = .005), and percentage of nighttime with oxygen saturation < 90% (P = .017) were all significant predictors of LD NCP volume. Compared with those with no or mild OSA, patients with severe OSA had a significantly higher total plaque volume (P = .036), NCP volume (P = .036), and LD NCP volume (P = .013). INTERPRETATION: OSA was independently associated with the presence and burden of coronary plaque, which suggests an increased risk of coronary events. CLINICAL TRIAL REGISTRATION: Chinese Clinical Trial Registry; No. ChiCTR-ROC-17011027; http://chictr.org.cn.