The AFLETES Study: Atrial Fibrillation in Veteran Athletes and the Risk of Stroke.

OBJECTIVES: Endurance athletes are at an increased risk of atrial fibrillation (AF) when compared with the general population. However, the risk of stroke in athletes with AF is unknown. DESIGN AND SETTING: We aimed to assess this risk using an international online survey. PATIENTS: Individuals that had competed in ≥1 competitive events and were ≥40 years old were included. INTERVENTIONS: Self-reported demographic, medical history, and training history data were collected, and a CHA 2 DS 2 -VASc was calculated. MAIN OUTCOME MEASURES: Binary logistic regression was used to assess variables associated with AF and stroke. RESULTS: There were 1002 responses from participants in 41 countries across Africa, Asia, Australasia, Europe, and North and South America, and 942 were included in the final analysis. The average age was 52.4 ± 8.5 years, and 84% were male. The most common sports were cycling (n = 677, 72%), running (n = 558, 59%), and triathlon (n = 245, 26%). There were 190 (20%) individuals who reported AF and 26 individuals (3%) who reported stroke; of which, 14 (54%) had AF. Lifetime exercise dose [odds ratio (OR), 1.02, 95% confidence interval (95% CI),1.00-1.03, P = 0.02] and swimming (OR, 1.56, 95% CI, 1.02-2.39, P = 0.04) were associated with AF in multivariable analysis, independent of other risk factors. Atrial fibrillation was associated with stroke (OR, 4.18, 95% CI, 1.80-9.72, P < 0.01), even in individuals with a low (0/1) CHA 2 DS 2 -VASc score (OR, 4.20, 95% CI, 1.83-9.66, P < 0.01). CONCLUSIONS: This survey provides early evidence that veteran endurance athletes who develop AF may be at an increased risk of developing stroke, even in those deemed to be at low risk by CHA 2 DS 2 -VASc score.

The Direct and Indirect Effects of COVID-19 on Acute Coronary Syndromes.

The novel SARS-CoV-2 has directly and indirectly impacted patients with acute coronary syndrome (ACS). The onset of the COVID-19 pandemic correlated with an abrupt decline in hospitalizations with ACS and increased out-of-hospital deaths. Worse outcomes in ACS patients with concomitant COVID-19 have been reported, and acute myocardial injury secondary to SARS-CoV-2 infection is recognized. A rapid adaptation of existing ACS pathways has been required such that overburdened health care systems may manage both a novel contagion and existing illness. As SARS-CoV-2 is now endemic, future research is required to better define the complex interplay of COVID-19 infection and cardiovascular disease.

Exercise, inflammation and acute cardiovascular events.

Individuals who participate in regular exercise over time have a markedly reduced risk of cardiovascular disease. Paradoxically, in susceptible individuals with underlying, often undiagnosed, disease states, exercise may acutely increase an individual's risk of cardiovascular events during and immediately following physical exertion. Exercise is thought to evoke conditions that trigger atheromatous plaque rupture or trigger life threatening arrhythmias in individuals with pre-existing, vulnerable coronary artery and inherited cardiovascular disease respectively. This transient increased risk may be driven by the inflammatory trigger provided by physical exertion where exercise is associated with an upregulation of inflammatory mediators in the acute phase. Conversely, habitual exercise can lead to a modulation of the inflammatory response over time. This review explores: exercise related inflammation; acute cardiovascular events related to exercise and strategies to mitigate these risks.

An algorithm to assist novices with electrocardiogram interpretation: Validation with the Delphi Method.

PURPOSE: Electrocardiograms (ECG) are often poorly interpreted by novices and this can delay time-sensitive, critical intervention. This study aimed to assess, improve and validate a stepwise ECG algorithm designed to assist with ECG interpretation by novices by soliciting the opinions of an international cohort of expert cardiologists. METHODS: The Delphi Method was used, and an online questionnaire was sent to an international panel of cardiologists. Experts were required to evaluate each step of the algorithm and offer comments. Feedback was analysed by the investigators, changes to the algorithm were made and these were sent back to the experts until a consensus was reached. Two rounds of the Delphi Method were required to achieve consensus. RESULTS: Overall, 55 responses were achieved (round one = 33, round two = 22). The average agreement in round one was 90.2% with 25 changes from 124 comments. Round two achieved 93.4% agreement with 12 changes from 57 comments. The threshold for consensus was set at 90% and was confirmed as being reached by all four investigators of this study. A final algorithm was therefore established. The ECG algorithm was validated through a rigorous two-stage development and review process. CONCLUSIONS: The algorithm was validated as a safe, informative tool for novices to use to improve ECG interpretation. Real-world user validation is now required to further improve the algorithm.

Palpitation referrals from primary care to a secondary care cardiology outpatient clinic: assessing adherence to guidelines.

BACKGROUND AND AIMS: Palpitations are a common presentation in primary care. Guidelines have been developed to identify patients with palpitations who require further assessment by a cardiologist in secondary care. However, patients that do not meet guideline thresholds for referrals are still referred to secondary care services. This audit evaluated the adherence to referral guidelines at our trust and assessed the characteristics of patients who were referred appropriately versus those referred without meeting guideline referral thresholds (inappropriate referral). RESULTS: Palpitation referrals to a single cardiology outpatient clinic were assessed (n = 66). Half the patients referred for palpitations were referred inappropriately (n = 34, 51.5%). Patients referred inappropriately were more likely to have a benign diagnosis after assessment (91.2%). These patients also had significantly fewer investigations [mean difference of 1.1 (confidence interval: 0.6-1.6)]. Specialist investigations, such as cardiac event recorders (P < 0.05) and cardiac magnetic resonance imaging (P < 0.05) were less likely to be used in inappropriately referred patients. CONCLUSIONS: The results from this audit provide early evidence that there are a significant number of patients who are being referred that could be managed in primary care. Further studies are needed to confirm our findings in larger cohorts and to establish the underlying reasons for inappropriate referrals.

Aspirin for the primary prevention of cardiovascular disease in individuals with chronic kidney disease: a systematic review and meta-analysis.

AIMS: Cardiovascular disease (CVD) is the major cause of morbidity and mortality in individuals with chronic kidney disease (CKD). This study assessed the risks and benefits of aspirin in the primary prevention of CVD in individuals with CKD. METHODS AND RESULTS: Ovid MEDLINE was searched from 2015 to 15th of September 2020 to include randomized controlled trials that assessed aspirin versus placebo in adults with non-end stage CKD without a previous diagnosis of CVD. A pre-specified protocol was registered with PROSPERO (identification number CRD42014008860). A random effects model was used to calculate a pooled hazard ratio (HR), pooled risk difference, and the number needed to treat or harm (NNT/NNH). The primary endpoint was CVD. Secondary endpoints included: all-cause mortality; coronary heart disease; stroke; and major and minor bleeding events. Five trials were identified (n = 7852 total, n = 3935 aspirin, n = 3917 placebo). Overall, 434 CVD events occurred. There was no statistically significant reduction in CVD events (HR 0.76, 95% confidence interval (CI) 0.54-1.08; P = 0.13, I2 = 63%), all-cause mortality (HR 0.94, 95% CI 0.74-1.19; P = 0.60, I2 = 21%), coronary heart disease events (HR 0.66, 95% CI 0.27-1.63; P = 0.37, I2 = 64%) or stroke (HR 0.87, 95% CI 0.6-1.27; P = 0.48, I2 = 24%) from aspirin therapy. The risk of major bleeding events were increased by approximately 50% (HR 1.53, 95% CI 1.13-2.05; P = 0.01, I2 = 0%) and minor bleeding events were more than doubled (HR 2.64, 95% CI 1.64-4.23; P < 0.01, I2 = 0%). CONCLUSIONS: Aspirin cannot be routinely recommended for the primary prevention of CVD in individuals with CKD as there is no evidence for its benefit but there is an increased risk of bleeding.

The Direct and Indirect Effects of COVID-19 on Acute Coronary Syndromes.

The novel SARS-CoV-2 has directly and indirectly impacted patients with acute coronary syndrome (ACS). The onset of the COVID-19 pandemic correlated with an abrupt decline in hospitalizations with ACS and increased out-of-hospital deaths. Worse outcomes in ACS patients with concomitant COVID-19 have been reported, and acute myocardial injury secondary to SARS-CoV-2 infection is recognized. A rapid adaptation of existing ACS pathways has been required such that overburdened health care systems may manage both a novel contagion and existing illness. As SARS-CoV-2 is now endemic, future research is required to better define the complex interplay of COVID-19 infection and cardiovascular disease.

The Influence of Environmental Air Pollution on Ventricular Arrhythmias: A Scoping Review.

INTRODUCTION: Exposure to air pollution is a recognised risk factor for cardiovascular disease and has been associated with supraventricular arrhythmias. The effect of air pollution on ventricular arrhythmias is less clear. This scoping review assessed the effects of particulate and gaseous air pollutants on the incidence of ventricular arrhythmias. METHODS: MEDLINE and EMBASE databases were searched for studies assessing the effects of air pollutants on ventricular tachycardia and ventricular fibrillation. These pollutants were particulate matter (PM) 2.5, PM10, Nitrogen Dioxide (NO2), Carbon Monoxide (CO), Sulphur Dioxide (SO2), and Ozone (O3). RESULTS: This review identified 27 studies: nine in individuals with implantable cardioverter defibrillators, five in those with ischaemic heart disease, and 13 in the general population. Those with ischaemic heart disease appear to have the strongest association with ventricular arrhythmias in both gaseous and particulate pollution, with all three studies assessing the effects of PM2.5 demonstrating some association with ventricular arrythmia. Results in the general and ICD population were less consistent. CONCLUSION: Individuals with ischaemic heart disease may be at an increased risk of ventricular arrhythmias following exposure to air pollution.

Shared decision making in athletes with cardiovascular disease: what we can learn from a masters athlete.

A 75-year-old male cyclist began suffering from palpitations on exertion. Symptoms terminated spontaneously with cessation of physical activity. The episodes caused significant distress with an impact on physical performance and quality of life. An echocardiogram showed a dilated left atrium, and an exercise ECG demonstrated that episodes of atrial fibrillation developed when his ventricular rate was above 140 beats per minute. Rate control could not be offered due to a history of sinus bradycardia nor rhythm control due to low likelihood of success. Anticoagulant therapy was commenced but discontinued at patient request as he considered risks to outweigh benefits given his desire to continue cycling. Management of athletes with atrial fibrillation is based on guidelines for the general population; however, treatment goals for athletes may differ. Shared decision making is essential to allow patients to make informed decisions about their care, accepting that individuals view treatment risks and benefits differently.

Neck of Femur Fractures in the First Eight Months of the COVID-19 Pandemic: A UK Systematic Review and Meta-Analysis.

Neck of femur (NOF) fracture patients have significant 30-day mortality. The incidence of NOF fractures remained high during the coronavirus disease 2019 (COVID-19) pandemic in the United Kingdom. Consequently, numerous cases were complicated with concurrent severe acute respiratory syndrome coronavirus 2 infection. We performed a systematic review and meta-analysis of all studies from the United Kingdom related to NOF fractures and 30-day mortality outcomes during the pandemic.   A systematic review and meta-analysis was performed and reported as per the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Two reviewers independently searched on Medline for studies that were published between the 1st of March 2020 and the 1st of November 2020 in the United Kingdom. The following outcomes were compared: 30-day mortality, time to surgery, and anaesthetic risk.   A total of five articles were included in this review. In total, 286 patients with NOF fractures and COVID-19 infection were identified, with 30-day mortality ranging from 30.5% to 50% (odds ratio = 6.02; 95% confidence interval = 4.10-8.85; χ2 = 4.82; I2 = 58%). Increased time to surgery due to COVID-19-related delays was also noted for the majority of patients in some studies. Mortality scores (Charlson Comorbidity Index, Nottingham Hip Fracture Score) failed to accurately predict the mortality risk. Concurrent infection of COVID-19 in patients with NOF fractures increases the 30-day mortality sixfold compared to the COVID-19-negative group. Efforts should be made to optimise time to surgery as well as consideration of postoperative care in higher dependency units. Future updates in mortality predicting scores should include COVID-19 infection as a significant factor.

The Underrepresentation of Females in Studies Assessing the Impact of High-Dose Exercise on Cardiovascular Outcomes: a Scoping Review.

High-dose exercise-induced cardiac outcomes may vary between sexes. However, many studies investigating the cardiovascular effects of high-dose exercise have excluded or under-recruited females. This scoping review aimed to describe the recruitment of females in studies assessing the impact of high-dose exercise on cardiovascular outcomes and describe how this has changed over time. This scoping review followed the protocol outlined by Arksey and O'Malley and is reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines. The OVID and EMBASE databases were searched for studies that assessed the effects of high-dose exercise on cardiovascular outcomes. Both professional and nonprofessional groups were included. The review found 2973 studies, and 250 met the inclusion criteria including cumulatively 17,548,843 subjects. Over half the studies (n = 127) excluded females entirely, and only 8 (3.2%) studies recruited all-female participants. The overall mean percentage of females recruited was 18.2%. The mean percentage was 14.5% in studies conducted before 2011 and 21.8% in studies conducted after 2011. Females are an underrepresented group in studies assessing the cardiovascular outcomes related to high-dose exercise. As cardiovascular outcomes vary between sexes, translating findings from a largely male-based evidence may not be appropriate. Future investigators should aim to establish and overcome barriers to female recruitment.

The association of blood pressure variability with adverse outcomes in a primary care chronic kidney disease cohort.

BACKGROUND: Hypertension is common in individuals with chronic kidney disease and both conditions are associated with adverse outcomes including cardiovascular morbidity. Therefore, it is clinically important to identify methods of risk prediction in individuals with chronic kidney disease. Blood pressure variability has recently emerged as a predictor of cardiovascular events and mortality in the general population, with growing evidence indicating that it may play a similar role in individuals with chronic kidney disease. However, there have been no large studies assessing blood pressure variability in individuals with chronic kidney disease in primary care, where the majority of these patients are managed. METHOD: Using a retrospective observational study design, we analyzed routinely collected blood pressure readings from 16 999 individuals in The Leicester and County Chronic Kidney Disease cohort. Standard deviation, coefficient of variation and average real variability of SBP were used to calculate blood pressure variability. RESULTS: During a median follow-up of 5.0 (IQR 3.3--5.0) years, 2053 (12.1%) patients had cardiovascular events, death occurred in 5021 (29.6%) individuals and 156 (0.9%) individuals had endstage kidney disease events. In adjusted models, standard deviation and coefficient of variation were associated with cardiovascular events, all-cause mortality and endstage kidney disease. Average real variability was associated with all-cause mortality and cardiovascular events, but not endstage kidney disease. CONCLUSION: Blood pressure variability may be an accessible, routinely collected, noninvasive measure for stratifying the risk of adverse events in individuals with chronic kidney disease in a primary care setting.

Visual Dysfunction in Huntington's Disease: A Systematic Review.

It is well-documented that patients with Huntington's disease (HD) exhibit specific deficits in visual cognition. A less well-documented literature also exists that suggests people with HD experience a number of disease-related changes to more rudimentary sensory visual processing. Here, we review evidence for the effects of HD on the integrity of the early visual pathways in humans along with changes to low-level visual sensitivity. We find evidence for reduced structural and functional integrity of the visual pathways, marked by retinal thinning, reduced VEP amplitude, and cell loss and thinning in visual cortex. We also find evidence of visual perceptual deficits, particularly for colour and motion. We suggest that future studies with well-defined HD and HD-related groups in appropriate numbers that systematically examine the relationship between structural changes to the visual system, basic visual perceptual deficits and disease stage/severity are therefore likely to yield promising results.