Use of Artificial Intelligence in Improving Outcomes in Heart Disease: A Scientific Statement From the American Heart Association.

A major focus of academia, industry, and global governmental agencies is to develop and apply artificial intelligence and other advanced analytical tools to transform health care delivery. The American Heart Association supports the creation of tools and services that would further the science and practice of precision medicine by enabling more precise approaches to cardiovascular and stroke research, prevention, and care of individuals and populations. Nevertheless, several challenges exist, and few artificial intelligence tools have been shown to improve cardiovascular and stroke care sufficiently to be widely adopted. This scientific statement outlines the current state of the art on the use of artificial intelligence algorithms and data science in the diagnosis, classification, and treatment of cardiovascular disease. It also sets out to advance this mission, focusing on how digital tools and, in particular, artificial intelligence may provide clinical and mechanistic insights, address bias in clinical studies, and facilitate education and implementation science to improve cardiovascular and stroke outcomes. Last, a key objective of this scientific statement is to further the field by identifying best practices, gaps, and challenges for interested stakeholders.

Tumor necrosis factor alpha induced protein 3, interleukin 10, tumor necrosis factor alpha, and interleukin 17 F genes polymorphisms in Algerian patients with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) is a systemic autoimmune disease with chronic inflammation. Its pathogenesis involves immunological, genetic, and environmental factors. We investigate the association between Tumor Necrosis Factor α Protein 3 (TNFAIP3), Interleukin 10 (IL10), Tumor Necrosis Factor α (TNF α), and Interleukin 17 F (IL17F) polymorphisms with susceptibility to RA. METHODS AND RESULTS: 191 patients with RA diagnosed according to the American College of Rheumatology (ACR)/ European League Against Rheumatism (EULAR) classification and 190 healthy subjects were recruited. Rheumatoid factor (RF), anti-citrullinated peptide antibodies (ACPA), and C-reactive protein (CRP) were measured. Genotyping of the polymorphisms was performed by real-time PCR. Analysis of the allelic frequencies of TNFAIP3 showed a positive association OR (95% CI) = 1.46 (1.01-2.09); p = 0.04, but failed to meet the criteria of significance after Bonferroni Correction. The genotypic and allelic distribution of the IL10, IL17F, and TNFα showed no significant difference when comparing the RA group with controls. Furthermore, the genotype codominant model shows a moderate positive association in the presence of ACPA (OR (95% CI) = 2.82 (1.22-6.24); p = 0.01. None of the polymorphisms studied was associated with RF and CRP production. CONCLUSION: Our results show that there is a tendency for the AG genotype of IL10-1082 to be associated with the production of ACPA in patients with RA. None of the variants studied were associated with RA susceptibility in Algerians.

Incorporation of Serial 12-Lead Electrocardiogram With Machine Learning to Augment the Out-of-Hospital Diagnosis of Non-ST Elevation Acute Coronary Syndrome.

STUDY OBJECTIVE: Ischemic electrocardiogram (ECG) changes are subtle and transient in patients with suspected non-ST-segment elevation (NSTE)-acute coronary syndrome. However, the out-of-hospital ECG is not routinely used during subsequent evaluation at the emergency department. Therefore, we sought to compare the diagnostic performance of out-of-hospital and ED ECG and evaluate the incremental gain of artificial intelligence-augmented ECG analysis. METHODS: This prospective observational cohort study recruited patients with out-of-hospital chest pain. We retrieved out-of-hospital-ECG obtained by paramedics in the field and the first ED ECG obtained by nurses during inhospital evaluation. Two independent and blinded reviewers interpreted ECG dyads in mixed order per practice recommendations. Using 179 morphological ECG features, we trained, cross-validated, and tested a random forest classifier to augment non ST-elevation acute coronary syndrome (NSTE-ACS) diagnosis. RESULTS: Our sample included 2,122 patients (age 59 [16]; 53% women; 44% Black, 13.5% confirmed acute coronary syndrome). The rate of diagnostic ST elevation and ST depression were 5.9% and 16.2% on out-of-hospital-ECG and 6.1% and 12.4% on ED ECG, with ∼40% of changes seen on out-of-hospital-ECG persisting and ∼60% resolving. Using expert interpretation of out-of-hospital-ECG alone gave poor baseline performance with area under the receiver operating characteristic (AUC), sensitivity, and negative predictive values of 0.69, 0.50, and 0.92. Using expert interpretation of serial ECG changes enhanced this performance (AUC 0.80, sensitivity 0.61, and specificity 0.93). Interestingly, augmenting the out-of-hospital-ECG alone with artificial intelligence algorithms boosted its performance (AUC 0.83, sensitivity 0.75, and specificity 0.95), yielding a net reclassification improvement of 29.5% against expert ECG interpretation. CONCLUSION: In this study, 60% of diagnostic ST changes resolved prior to hospital arrival, making the ED ECG suboptimal for the inhospital evaluation of NSTE-ACS. Using serial ECG changes or incorporating artificial intelligence-augmented analyses would allow correctly reclassifying one in 4 patients with suspected NSTE-ACS.

Impact of daily use of emollient 'plus' on corticosteroid consumption in patients with atopic dermatitis: An open, randomized controlled study.

BACKGROUND: Emollients are the baseline treatment for mild or moderate atopic dermatitis (AD) to improve the epidermal barrier and provide anti-irritant and anti-pruritic effects. Emollient 'plus' can influence the skin microbiome of atopic eczema patients. OBJECTIVES: To evaluate the benefits of using Emollient 'plus' to reduce corticosteroid consumption. METHODS: In an open, single-centre, randomized, controlled study, patients with mild to moderate AD (Severity scoring of AD [SCORAD] score 20-30) were randomized 1:1 to apply the Emollient 'plus' twice daily for 28 days or to continue with their usual classical emollient (Control group). In addition, each patient received topical corticosteroids to use when necessary and according to the dermatologist's prescription. Assessments included SCORAD, PO-SCORAD, local SCORAD, quality of life questionnaires, and tolerability. RESULTS: A total of 119 patients were included in the PP population with a mean age of 26.50 ± 17.5 years old (min-max 3-71 years). Between baseline and day 28, the mean amount of corticosteroid used was lower for the Emollient 'plus' versus Control group (6.03 vs. 9.16 g; p = 0.041) and corticosteroid was applied on fewer days (37.5% vs. 46.9% of days; p = 0.0256) with fewer applications per day (0.55 vs. 0.71 applications per day; p = 0.0203). Similar improvements were observed in both groups for SCORAD, PO-SCORAD, local SCORAD, skin sensation score, AD burden scale, patient benefit index >1, as well as subject and investigator efficacy and tolerability questionnaire assessments. CONCLUSIONS: Between baseline and day 28, there was significant corticosteroid-sparing in the Emollient 'plus' group compared to the Control group in quantity, number of applications per day and number of days of use, whilst efficacy was maintained with no significant differences between the two groups for all clinical evaluations, as well as for tolerability.

Does the use of lactic acid as an antibiotic substitute in broiler diets affect growth, carcass traits, blood indices and intestinal microbiota?

The objective of the current study was to determine the impact of lactic acid (LAC) as an antibiotic alternative in broiler diets on growth performance, carcass traits, blood indices and intestinal microbial load. A total of 300 broiler chicks one day old (Ross 208) were allotted to five experimental groups in a complete randomized design experiment. Each group was subdivided into six replicates, each of ten unsexed chicks. The treatments were as follows: NC: negative control (basal diet); PC: positive control (basal diet + 0.5 g Colistin® antibiotic/kg diet); LAC2, LAC4, and LAC6: basal diet + 2, 4, and 6 cm3 lactic acid/kg diet, respectively. Results showed no significant effects of dietary treatments (antibiotic or lactic acid) on growth performance traits (body weight, BW; daily body weight gain, DBWG; feed intake, FI and feed conversion ratio, FCR) and carcass characteristics except for Thigh %. All blood biochemical traits were affected (p > 0.01) by dietary treatments. The highest values of blood total protein and albumin were found in birds of LAC2 group. Adding graded doses of LAC to broiler diets inhibited the activity of liver enzymes and reduced the concentration of blood urea. The positive effect of LAC supplementation excelled that of antibiotics regarding the antioxidant status parameters. The lowest pathogenic bacteria (E. coli and Salmonella) were recorded by LAC4 and LAC6 groups. It could be concluded that dietary supplementation of lactic acid did not significantly affect most growth performance traits. But its use could have beneficial impacts on blood parameters, oxidative status and intestinal microbial counts. Based on our results, the highest level (6 cm3 LAC/kg diet) is the recommended level for the best results.

Productive performance, lipid profile, immunity, and antioxidant parameters of quail breeders fed low protein diets supplemented with different zinc sources.

The current study was conducted to study the impact of low-CP protein diets with different sources of zinc (zinc oxide-ZnO and zinc methionine-Zn-Met) on performance, lipid profile, immune and antioxidant parameters of quail breeders. A total number of 216 Japanese quail at 8 weeks of age were randomly distributed into nine (3 × 3) groups, with four replicates, each of six quails (four females and two males). Quails were fed three levels of CP (16, 18, and 20%) and three sources of Zn (0, 0.1 g ZnO, and 0.1 g Zn-Met/kg diets). No significant differences in daily feed intake (FI), feed conversion ratio (FCR), and egg mass are due to the main effect of protein levels or zinc sources at all ages. Dietary CP (16 and 20%) in growing quail diets increased SOD and GSH, while IgG levels were improved by 18%. Finally, it can be recommended that 16% CP and zinc source (Zn-Met or ZnO) can maintain egg mass, as well as lipid profile, immunological and antioxidant parameters in Japanese quails breeders. This level (16% CP) is enough during the production stage and a valuable way for mitigating ammonia pollution and reducing feeding costs.

Magnetostructural Properties of Some Doubly-Bridged Phenoxido Copper(II) Complexes.

Three new tripod tetradentate phenolate-amines (H2L1, H2L4 and H2L9), together with seven more already related published ligands, were synthesized, and characterized. With these ligands, two new dinuclear doubly-bridged-phenoxido copper(II) complexes (3, 4), and six more complexes (1, 2, 5-8), a new trinuclear complex (9) with an alternative doubly-bridged-phenoxido and -methoxido, as well as the 1D polymer (10) were synthesized, and their molecular structures were characterized by spectroscopic methods and X-ray single crystal crystallography. The Cu(II) centers in these complexes exhibit distorted square-pyramidal arrangement in 1-4, mixed square pyramidal and square planar in 5, 6, and 9, and distorted octahedral (5+1) arrangements in 7 and 8. The temperature dependence magnetic susceptibility study over the temperature range 2-300 K revealed moderate-relatively strong antiferromagnetic coupling (AF) (|J| = 289-145 cm-1) in complexes 1-6, weak-moderate AF (|J| = 59 cm-1) in the trinuclear complex 9, but weak AF interactions (|J| = 3.6 & 4.6 cm-1) were obtained in 7 and 8. No correlation was found between the exchange coupling J and the geometrical structural parameters of the four-membered Cu2O2 rings.

Insights into the Spin Dynamics of Mononuclear Cerium(III) Single-Molecule Magnets.

Four novel CeIII mononuclear complexes of formulas [Ce(ntfa)3(MeOH)2] (1), [Ce(ntfa)3(5,5'-Me2bipy)] (2), [Ce(ntfa)3(terpy)] (3), and [Ce(ntfa)3(bipy)2] (4), where ntfa = 4,4,4-trifluoro-1-(naphthalen-2-yl)butane-1,3-dionato, 5,5'-Me2bipy = 5,5'-dimethyl-2,2'-dipyridyl, terpy = 2,2':6',2″-terpyridine, and bipy = 2,2'-bipyridine, have been synthesized and structurally characterized with CeIII displaying coordination numbers of 8, 8, 9, and 10, respectively. Magnetic measurements indicate that all the complexes show a field-induced single-ion magnet behavior under a small applied dc field. The magnetic analysis shows the relevance of the different spin relaxation mechanisms in the magnetic relaxation of the CeIII compounds, with special emphasis on the local-mode process. Multiconfigurational calculations were also performed to get more information on the axiality of the compounds.

Exploring decision making 'noise' when interpreting the electrocardiogram in the context of cardiac cath lab activation.

In this commentary paper, we discuss the use of the electrocardiogram to help clinicians make diagnostic and patient referral decisions in acute care settings. The paper discusses the factors that are likely to contribute to the variability and noise in the clinical decision making process for catheterization lab activation. These factors include the variable competence in reading ECGs, the intra/inter rater reliability, the lack of standard ECG training, the various ECG machine and filter settings, cognitive biases (such as automation bias which is the tendency to agree with the computer-aided diagnosis or AI diagnosis), the order of the information being received, tiredness or decision fatigue as well as ECG artefacts such as the signal noise or lead misplacement. We also discuss potential research questions and tools that could be used to mitigate this 'noise' and improve the quality of ECG based decision making.

Magnetic and Luminescence Properties of 8-Coordinate Holmium(III) Complexes Containing 4,4,4-Trifluoro-1-Phenyl- and 1-(Naphthalen-2-yl)-1,3-Butanedionates.

A new series of mononuclear Ho3+ complexes derived from the ß-diketonate anions: 4,4,4-trifluoro-1-phenyl-1,3-butanedioneate (btfa-) and 4,4,4-trifuoro-1-(naphthalen-2-yl)-1,3-butanedionate (ntfa-) have been synthesized, [Ho(btfa)3(H2O)2] (1a), [Ho(ntfa)3(MeOH)2] (1b), (1), [Ho(btfa)3(phen)] (2), [Ho(btfa)3(bipy)] (3), [Ho(btfa)3(di-tbubipy)] (4), [Ho(ntfa)3(Me2bipy)] (5), and [Ho(ntfa)3(bipy)] (6), where phen is 1,10-phenantroline, bipy is 2,2'-bipyridyl, di-tbubipy is 4,4'-di-tert-butyl-2,2'-bipyridyl, and Me2bipy is 4,4'-dimethyl-2,2'-bipyridyl. These compounds have been characterized by elemental microanalysis and infrared spectroscopy as well as single-crystal X-ray difraction for 2-6. The central Ho3+ ions in these compounds display coordination number 8. The luminescence-emission properties of the pyridyl adducts 2-6 display a strong characteristic band in the visible region at 661 nm and a series of bands in the NIR region (excitation wavelengths (λex) of 367 nm for 2-4 and 380 nm for 5 and 6). The magnetic properties of the complexes revealed magnetically uncoupled Ho3+ compounds with no field-induced, single-molecule magnet (SMMs).

Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks Into Perspective-An Update: A Scientific Statement From the American Heart Association.

Epidemiological and biological plausibility studies support a cause-and-effect relationship between increased levels of physical activity or cardiorespiratory fitness and reduced coronary heart disease events. These data, plus the well-documented anti-aging effects of exercise, have likely contributed to the escalating numbers of adults who have embraced the notion that "more exercise is better." As a result, worldwide participation in endurance training, competitive long distance endurance events, and high-intensity interval training has increased markedly since the previous American Heart Association statement on exercise risk. On the other hand, vigorous physical activity, particularly when performed by unfit individuals, can acutely increase the risk of sudden cardiac death and acute myocardial infarction in susceptible people. Recent studies have also shown that large exercise volumes and vigorous intensities are both associated with potential cardiac maladaptations, including accelerated coronary artery calcification, exercise-induced cardiac biomarker release, myocardial fibrosis, and atrial fibrillation. The relationship between these maladaptive responses and physical activity often forms a U- or reverse J-shaped dose-response curve. This scientific statement discusses the cardiovascular and health implications for moderate to vigorous physical activity, as well as high-volume, high-intensity exercise regimens, based on current understanding of the associated risks and benefits. The goal is to provide healthcare professionals with updated information to advise patients on appropriate preparticipation screening and the benefits and risks of physical activity or physical exertion in varied environments and during competitive events.

Overview of featurization techniques used in traditional versus emerging deep learning-based algorithms for automated interpretation of the 12-lead ECG.

Automated interpretation of the 12-lead ECG has remained an underpinning interest in decades of research that has seen a diversity of computing applications in cardiology. The application of computers in cardiology began in the 1960s with early research focusing on the conversion of analogue ECG signals (voltages) to digital samples. Alongside this, software techniques that automated the extraction of wave measurements and provided basic diagnostic statements, began to emerge. In the years since then there have been many significant milestones which include the widespread commercialisation of 12-lead ECG interpretation software, associated clinical utility and the development of the related regulatory frameworks to promote standardised development. In the past few years, the research community has seen a significant rejuvenation in the development of ECG interpretation programs. This is evident in the research literature where a large number of studies have emerged tackling a variety of automated ECG interpretation problems. This is largely due to two factors. Specifically, the technical advances, both software and hardware, that have facilitated the broad adoption of modern artificial intelligence (AI) techniques, and, the increasing availability of large datasets that support modern AI approaches. In this article we provide a very high-level overview of the operation of and approach to the development of early 12-lead ECG interpretation programs and we contrast this to the approaches that are now seen in emerging AI approaches. Our overview is mainly focused on highlighting differences in how input data are handled prior to generation of the diagnostic statement.

The role of machine learning applications in diagnosing and assessing critical and non-critical CHD: a scoping review.

Machine learning uses historical data to make predictions about new data. It has been frequently applied in healthcare to optimise diagnostic classification through discovery of hidden patterns in data that may not be obvious to clinicians. Congenital Heart Defect (CHD) machine learning research entails one of the most promising clinical applications, in which timely and accurate diagnosis is essential. The objective of this scoping review is to summarise the application and clinical utility of machine learning techniques used in paediatric cardiology research, specifically focusing on approaches aiming to optimise diagnosis and assessment of underlying CHD. Out of 50 full-text articles identified between 2015 and 2021, 40% focused on optimising the diagnosis and assessment of CHD. Deep learning and support vector machine were the most commonly used algorithms, accounting for an overall diagnostic accuracy > 0.80. Clinical applications primarily focused on the classification of auscultatory heart sounds, transthoracic echocardiograms, and cardiac MRIs. The range of these applications and directions of future research are discussed in this scoping review.

Androgen therapy in inherited bone marrow failure syndromes: analysis from the Canadian Inherited Marrow Failure Registry.

Progressive cytopenia is a serious complication among paediatric patients with inherited bone marrow failure syndromes (IBMFS). Androgens have been used to improve blood counts in different bone marrow failure conditions. Little is known about efficacy and toxicity with new androgens (i.e., danazol) in different types of IBMFS. We identified 29 patients from the Canadian Inherited Marrow Failure Registry, who received oxymetholone or danazol. Sixteen (55%) had haematological response including patients with unclassified IBMFS (45%). Danazol showed a better toxicity profile and similar efficacy compared to oxymetholone. Androgens are an effective and safe option to ameliorate bone marrow failure in IBMFS.

Exploring the complex interactions of baseline patient factors to improve nursing triage of acute coronary syndrome.

Emergency department (ED) nurses need to identify patients with potential acute coronary syndrome (ACS) rapidly because treatment delay could impact patient outcomes. Aims of this secondary analysis were to identify key patient factors that could be available at initial ED nurse triage that predict ACS. Consecutive patients with chest pain who called 9-1-1, received a 12-lead electrocardiogram in the prehospital setting, and were transported via emergency medical service were included in the study. A total of 750 patients were recruited. The sample had an average age of 59 years old, was 57% male, and 40% Black. One hundred and fifteen patients were diagnosed with ACS. Older age, non-Caucasian race, and faster respiratory rate were independent predictors of ACS. There was an interaction between heart rate by Type II diabetes receiving insulin in the context of ACS. Type II diabetics requiring insulin for better glycemic control manifested a faster heart rate. By identifying patient factors at ED nurse triage that could be predictive of ACS, accuracy rates of triage may improve, thus impacting patient outcomes.

Five-Coordinated Geometries from Molecular Structures to Solutions in Copper(II) Complexes Generated from Polydentate-N-Donor Ligands and Pseudohalides.

A novel series of mononuclear five-coordinated pseudohalido-Cu(II) complexes displaying distorted square bipyramidal: [Cu(L1)(NCS)2] (1), [Cu(L2)(NCS)2] (2) and [Cu(L3)(NCS)]ClO4 (5) as well as distorted trigonal bipyramidal: [Cu(isp3tren)(N3)]ClO4 (3), [Cu(isp3tren)(dca)]ClO4 (4) and [Cu(tedmpza)(dca)]ClO4·0.67H2O (6) geometries had been synthesized and structurally characterized using X-ray single crystal crystallography, elemental microanalysis, IR and UV-vis spectroscopy, and molar conductivity measurements. Different N-donor amine skeletons including tridentate: L1 = [(2-pyridyl)-2-ethyl)-(3,4-dimethoxy)-2-methylpyridyl]methylamine and L2 = [(2-pyridyl)-2-ethyl)-(3,5-dimethyl-4-methoxy)-2-methyl-pyridyl]methylamine, and tetradentate: L3 = bis(2-ethyl-di(3,5-dimethyl-1H-pyrazol-1-yl)-[2-(3,4-dimethoxy-pyridylmethyl)]amine, tedmpza = tris[(2-(3,5-dimethyl-1H-pyrazol-1-yl)ethyl]amine and isp3tren = tris[(2-isopropylamino)ethyl)]amine ligands were employed. Molecular structural parameters such as nature of coligand, its chelate ring size and steric environment incorporated into its skeleton, which lead to adopting one of the two limiting geometries in these complexes and other reported compounds are analyzed and correlated to their assigned geometries in solutions. Similar analysis were extended to other five-coordinated halido-Cu(II) complexes.

Comparison of clinical risk scores for triaging high-risk chest pain patients at the emergency department.

BACKGROUND: Many of the clinical risk scores routinely used for chest pain assessment have not been validated in patients at high risk for acute coronary syndrome (ACS). We performed an independent comparison of HEART, TIMI, GRACE, FRISC, and PURSUIT scores for identifying chest pain due to ACS and for predicting 30-day death or re-infarction in patients arriving through Emergency Medical Services (EMS). METHODS AND RESULTS: We enrolled consecutive EMS patients evaluated for chest pain at three emergency departments. A reviewer blinded to outcome data retrospectively reviewed patient charts to compute each risk score. The primary outcome was ACS diagnosed during the primary admission, and the secondary outcome was death or re-infarction within 30-days of initial presentation. Our sample included 750 patients (aged 59 ±â€¯17 years, 42% female), of whom 115 (15.3%) had ACS and 33 (4.4%) had 30-day death or re-infarction. The c-statistics of HEART, TIMI, GRACE, FRISC, and PURSUIT for identifying ACS were 0.87, 0.86, 0.73, 0.84, and 0.79, respectively, and for predicting 30-day death or re-infarction were 0.70, 0.73, 0.72, 0.72, and 0.62, respectively. Sensitivity/negative predictive value of HEART ≥ 4 and TIMI ≥ 3 for ACS detection were 0.94/0.98 and 0.87/0.97, respectively. CONCLUSIONS: In chest pain patients admitted through EMS, HEART and TIMI outperform other scores for identifying chest pain due to ACS. Although both have similar negative predictive value, HEART has better sensitivity and lower rate of false negative results, thus it can be used preferentially over TIMI in the initial triage of this population.

The role of heart rate variability, heart rate turbulence, and deceleration capacity in predicting cause-specific mortality in chronic heart failure.

BACKGROUND: The volume of regional denervated myocardium (D-M) on positron emission tomography has been recently suggested as a strong independent predictor of cause-specific mortality from sudden cardiac arrest (SCA) in chronic heart failure. We sought to evaluate whether ECG indices of global autonomic function predict risk of SCA to a similar degree as regional D-M. METHODS: Subjects enrolled in the Prediction of Arrhythmic Events using Positron Emission Tomography (PAREPET) study were included in this study. Patients completed a 24-hour Holter ECG at enrollment and were followed up at 3-month intervals. SCA events were adjudicated by two board-certified cardiologists. Other cardiovascular death events were classified as nonsudden cardiac death (NSCD). Eight measures of heart rate variability were analyzed: SDNN, RMSSD, low-frequency (LF) and high-frequency (HF) power, heart rate turbulence onset and slope, and acceleration and deceleration capacity. We used competing risk regression to delineate cause-specific mortality from SCA versus NSCD. RESULTS: Our sample included 127 patients (age 67 ±â€¯12, 92% male). After a median follow-up of 4.1 years, there were 22 (17%) adjudicated SCA and 18 (14%) adjudicated NSCD events. In multivariate Cox-regression, LF power was the only HRV parameter to predict time-to-SCA. However, in competing risk analysis, reduced LF power was preferentially associated with NSCD rather than SCA (HR = 0.92 [0.85-0.98], p = 0.019). CONCLUSION: Depressed LF power might indicate impaired vagal reflex, which suggests that increasing vagal tone in these patients would have a protective effect against NSCD beyond that achieved by the mere slowing of heart rate using ß-blockers.

Diurnal, weekly and seasonal variations of chest pain in patients transported by emergency medical services.

OBJECTIVES: Chest pain is among the leading causes for emergency medical services (EMS) activation. Acute myocardial infarction (MI) is not only one of the most critical aetiologies of chest pain, but also one of few conditions encountered by EMS that has been shown to follow a circadian pattern. Understanding the diurnal relationship between the inflow of chest pain patients and the likelihood of acute MI may inform prehospital and emergency department (ED) healthcare providers regarding the prediction, and hence prevention, of dire outcomes. METHODS: This was a secondary analysis of previously collected data from an observational prospective study that enrolled consecutive chest pain patients transported by a large metropolitan EMS system in the USA. We used the time of EMS call to determine the time-of-day of the indexed encounter. Two independent reviewers examined available medical data to determine our primary outcome, the presence of MI, and our secondary outcomes, infarct size and 30-day major adverse cardiac events (MACE). We estimated infarct size using peak troponin level. RESULTS: We enrolled 2065 patients (age 56±17, 53% males, 7.5% with MI). Chest pain encounters increased from 9:00 AM to 2:00 PM, with a peak at 1:00 PM and a nadir at 6:00 AM. Acute MI had a bimodal distribution with two peaks: 10 AM in ST-elevation MI, and 10 PM in non-ST-elevation MI. ST-elevation MI with afternoon onset was an independent predictor of infarct size. Acute MI with winter and early spring presentation was an independent predictor of 30-day MACE. CONCLUSIONS: EMS-attended chest pain calls follow a diurnal pattern, with the most vulnerable patients encountered during afternoons and winter/spring seasons. These data can inform prehospital and ED healthcare providers regarding the time of presentation where patients are more likely to have an underlying MI and subsequently worse outcomes.

Circulation of Influenza A(H5N8) Virus, Saudi Arabia.

Highly pathogenic avian influenza A(H5N8) viruses have been detected in several continents. However, limited viral sequence data are available from countries in the Middle East. We report full-genome analyses of highly pathogenic H5N8 viruses recently detected in different provinces in Saudi Arabia.