Factors associated with cardiac implantable electronic device-related infections, New South Wales, 2016-21: a retrospective cohort study.

OBJECTIVES: To quantify the rate of cardiac implantable electronic device (CIED)-related infections and to identify risk factors for such infections. DESIGN: Retrospective cohort study; analysis of linked hospital admissions and mortality data. SETTING, PARTICIPANTS: All adults who underwent CIED procedures in New South Wales between 1 January 2016 and 30 June 2021 (public hospitals) or 30 June 2020 (private hospitals). MAIN OUTCOME MEASURES: Proportions of patients hospitalised with CIED-related infections (identified by hospital record diagnosis codes); risk of CIED-related infection by patient, device, and procedural factors. RESULTS: Of 37 675 CIED procedures (23 194 men, 63.5%), 500 were followed by CIED-related infections (median follow-up, 24.9 months; interquartile range, 11.2-40.8 months), including 397 people (1.1%) within twelve months of their procedures, and 186 of 10 540 people (2.5%) at high risk of such infections (replacement or upgrade procedures; new cardiac resynchronisation therapy with defibrillator, CRT-D). The overall infection rate was 0.50 (95% confidence interval [CI], 0.45-0.54) per 1000 person-months; it was highest during the first month after the procedure (5.60 [95% CI, 4.89-6.42] per 1000 person-months). The risk of CIED-related infection was greater for people under 65 years of age than for those aged 65-74 years (adjusted hazard ratio [aHR], 1.71; 95% CI, 1.32-2.23), for people with CRT-D devices than for those with permanent pacemakers (aHR, 1.46; 95% CI, 1.02-2.08), for people who had previously undergone CIED procedures (two or more v none: aHR, 1.51; 95% CI, 1.02-2.25) or had CIED-related infections (aHR, 11.4; 95% CI, 8.34-15.7), or had undergone concomitant cardiac surgery (aHR, 1.62; 95% CI, 1.10-2.39), and for people with atrial fibrillation (aHR, 1.33; 95% CI, 1.11-1.60), chronic kidney disease (aHR, 1.54; 95% CI, 1.27-1.87), chronic obstructive pulmonary disease (aHR, 1.37; 95% CI, 1.10-1.69), or cardiomyopathy (aHR 1.60; 95% CI, 1.25-2.05). CONCLUSIONS: Knowledge of risk factors for CIED-related infections can help clinicians discuss them with their patients, identify people at particular risk, and inform decisions about device type, upgrades and replacements, and prophylactic interventions.

Real-world evidence on the association between cardiac implantable electronic device infection and all-cause mortality.

AIMS: An infection following cardiac implantable electronic device (CIED) procedure is a serious complication, but its association with all-cause mortality is inconsistent across observational studies. To quantify the association between CIED infection and all-cause mortality in a large, contemporary cohort from New South Wales, Australia. METHODS AND RESULTS: This retrospective cohort study used linked hospital and mortality data and included all patients aged >18 years who underwent a CIED procedure between July 2017 and September 2022. Cardiac implantable electronic device infection was defined by the presence of relevant diagnosis codes. Cox regression to estimate adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for the association of CIED infection with mortality, at 1-year, and at the end of follow-up, with CIED infection included as a time-dependent variable, and other potential risk factors for mortality included as fixed covariates. We followed 37,750 patients with CIED procedures {36% female, mean age [standard deviation (SD)] 75.8 [12.7] years}, and 487 (1.3%) CIED infections were identified. We observed 5771 (15.3%) deaths during an average follow-up of 25.2 (SD 16.8) months. Compared with no infection group, patients with CIED infection had a higher Kaplan-Meier mortality rate (19.4 vs. 6.8%) and adjusted hazard of mortality (aHR 2.73, 95% CI 2.10-3.54) at 12 months post-procedure. These differences were attenuated but still remained significant at the end of follow-up (aHR 1.83, 95% CI 1.52-2.19). CONCLUSION: In a complete, state-wide cohort of CIED patients, infection was associated with higher risks of both short-term and long-term mortality.

Novel student roles in health care delivery: An example emerging from the COVID-19 health care crisis in 2021.

In 2021, the rapid rise in COVID-19 infections put overwhelming demand on health care services. It was recognised that patients could be managed in the community if an appropriate monitoring service existed. Medical students were recruited for roles that combined technology, teamwork and clinical skills. This is an example of how novel roles can provide solutions in times of health care crises.

Prognostically relevant periprocedural myocardial injury and infarction associated with percutaneous coronary interventions: a Consensus Document of the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI).

A substantial number of chronic coronary syndrome (CCS) patients undergoing percutaneous coronary intervention (PCI) experience periprocedural myocardial injury or infarction. Accurate diagnosis of these PCI-related complications is required to guide further management given that their occurrence may be associated with increased risk of major adverse cardiac events (MACE). Due to lack of scientific data, the cut-off thresholds of post-PCI cardiac troponin (cTn) elevation used for defining periprocedural myocardial injury and infarction, have been selected based on expert consensus opinions, and their prognostic relevance remains unclear. In this Consensus Document from the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI), we recommend, whenever possible, the measurement of baseline (pre-PCI) cTn and post-PCI cTn values in all CCS patients undergoing PCI. We confirm the prognostic relevance of the post-PCI cTn elevation >5× 99th percentile URL threshold used to define type 4a myocardial infarction (MI). In the absence of periprocedural angiographic flow-limiting complications or electrocardiogram (ECG) and imaging evidence of new myocardial ischaemia, we propose the same post-PCI cTn cut-off threshold (>5× 99th percentile URL) be used to define prognostically relevant 'major' periprocedural myocardial injury. As both type 4a MI and major periprocedural myocardial injury are strong independent predictors of all-cause mortality at 1 year post-PCI, they may be used as quality metrics and surrogate endpoints for clinical trials. Further research is needed to evaluate treatment strategies for reducing the risk of major periprocedural myocardial injury, type 4a MI, and MACE in CCS patients undergoing PCI.

Burden of cardiovascular diseases in older adults using aged care services.

OBJECTIVE: To quantify the burden of cardiovascular diseases (CVD) in older adults using community and residential care services. METHODS: The study population comprised people aged 45+ from the 45 and Up Study (2006-09, n = 266,942) in Australia linked with records for hospital stays, aged care service and deaths for the period 2006-14. Follow-up time for each person was allocated to three categories of service use: no aged care, community care and residential care, with censoring at date of death. We calculated the prevalence at baseline and entry to aged care, and incidence rates for major CVD and six cardiovascular diagnoses, seven cardiovascular interventions (collectively CV interventions), cardiovascular-related intensive care unit stays and cardiovascular death. RESULTS: The prevalence of major CVD at entry into community care and residential care was 41% and 58% respectively. Incidence per 1,000 person-years of all major CVD hospitalisations and CV interventions, respectively, was 182.8 (95% CI: 180.0-185.8) and 37.0 (95% CI: 35.6-38.4) for people using community care, and 280.7 (95% CI: 272.2-289.4) and 11.7 (95% CI: 9.8-13.9) for people using residential care. Similar trends were observed for each of the CVD diagnoses and interventions. Crude incidence rates for cardiovascular deaths per 1,000 person-years were 1.4 (95% CI: 1.3-1.5) in no aged care, 13.3 (95% CI: 12.6-14.1) in community care, and 149.7 (95% CI: 144.4-155.2) in residential care. CONCLUSION: Our findings demonstrate the significant burden of CVD in people using both community-based and residential aged care services and highlights the importance of optimising cardiovascular care for older adults.

Resting Full-Cycle Ratio (RFR) in the Assessment of Left Main Coronary Disease: Caution Required.

Hyperaemia-free indices have been gaining traction in recent times due to the practical advantages they offer over the fractional flow reserve (FFR) in the evaluation of angiographically intermediate coronary lesions. More recently, a new hyperaemia-free index, the resting full-cycle ratio (RFR), was described and found to correlate closely with the instantaneous wave-free ratio (iFR). The comparison between FFR and these hyperaemia-free indices, however, is nuanced and remains an ongoing area of debate and investigation. Herein, we highlight one of the important differences between the RFR and FFR, specifically in relation to the assessment of left main coronary lesion. We contend that the interchangeability of these indices cannot always be assumed and clinicians need to be aware of these limitations in their clinical practice.

BioMonitor 2 Pilot Study: Early Experience With Implantation of the Biotronik BioMonitor 2 Implantable Cardiac Monitor.

BACKGROUND: The BioMonitor 2 Pilot Study assessed the implantation procedure, the sensing amplitude and the remote monitoring transmission success rate of the second generation implantable cardiac monitor, the BioMonitor 2 (Biotronik, Berlin, Germany). METHODS: This was a prospective, multi-centre, single-arm, non-randomised study involving seven operators in five sites across Australia. Data were collected at implantation, during clinic visits at 1 week and 1 month post-implantation, and through wireless remote monitoring. RESULTS: Thirty patients with indications for long-term cardiac monitoring underwent successful insertion of a study device. The median implantation time was 9 minutes (interquartile range (IQR) 5-14 mins). The mean R-wave amplitude at 1 week was 0.75±0.39mV and remained stable over the follow-up period. Within 1 day, 97% of the patients connected to the remote monitoring network and daily messages were transmitted on 93.8% of all study days. Seventy-six per cent of patients transmitted at least one subcutaneous ECG (sECG), with a median number of sECGs per patient of seven (IQR 3-37) within 28 days. CONCLUSIONS: The results of the BioMonitor 2 Pilot study confirm the excellent sensing amplitudes afforded by this new device and the utility of the implantation tools and technique. Patient compliance with and the transmission success rate of the home monitoring system were excellent.

Design and Rationale for the Endothelin-1 Receptor Antagonism in the Prevention of Microvascular Injury in Patients with non-ST Elevation Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention (ENDORA-PCI) Trial.

PURPOSE: Peri-procedural myocardial infarction (PMI) occurs in a small but significant portion of patients undergoing percutaneous intervention (PCI). The underlying mechanisms are complex and may include neurohormonal activation and release of vasoactive substances resulting in disruption of the coronary microcirculation. Endothelin in particular has been found in abundance in atherosclerotic plaques and in systemic circulation following PCI, and may be a potential culprit for PMI through its action on microvascular vasoconstriction, and platelet and neutrophil activation. In this study we aim to characterize the behavior of the coronary microcirculation during a PCI with the index of microvascular resistance (IMR) and the effect of peri-procedural endothelin antagonism. METHODS: The ENDORA-PCI trial is a randomized, double-blind, placebo-controlled, single-center clinical trial designed to evaluate the efficacy of endothelin antagonism in attenuating the peri-procedural rise in IMR as a surrogate marker for PMI. The patients of interest are those with non-ST elevation acute coronary syndrome (NSTEACS) undergoing PCI, and we aim to recruit 52 patients overall to give the study a power of 80 % at an α level of 5 %. Patients will be randomized in a 1:1 fashion to either Ambrisentan, an endothelin antagonist, or placebo, prior to their PCI. IMR will be measured before and after PCI. The primary endpoint is the difference in peri-procedural changes in patients' IMR between the two groups. CONCLUSION: The ENDORA-PCI study will investigate whether endothelin antagonism with Ambrisentan attenuates the peri-procedural rise in IMR in patients with NSTEACS undergoing PCI, and thus potentially the risk of PMI.

High Intensity Interval versus Moderate Intensity Continuous Training in Patients with Coronary Artery Disease: A Meta-analysis of Physiological and Clinical Parameters.

INTRODUCTION: Exercise-based cardiac rehabilitation for patients with coronary artery disease (CAD) significantly improves their outcome, although the optimal mode of exercise training remains undetermined. Previous analyses have been constrained by small sample sizes and a limited focus on clinical parameters. Further, results from previous studies have been contradicted by a recently published large RCT. METHOD: We performed a meta-analysis of published randomised controlled trials to compare high intensity interval training (HIIT) and moderate intensity continuous training (MCT) in their ability to improve patients' aerobic exercise capacity (VO2peak) and various cardiovascular risk factors. We included patients with established coronary artery disease without or without impaired ejection fraction. RESULTS: Ten studies with 472 patients were included for analyses (218 HIIT, 254 MCT). Overall, HIIT was associated with a more pronounced incremental gain in participants' mean VO2peak when compared with MCT (+1.78mL/kg/min, 95% CI: 0.45-3.11). Moderate intensity continuous training however was associated with a more marked decline in patients' mean resting heart rate (-1.8/min, 95% CI: 0.71-2.89) and body weight (-0.48kg, 95% CI: 0.15-0.81). No significant differences were noted in the level of glucose, triglyceride and HDL at the end of exercise program between the two groups. CONCLUSION: High intensity interval training improves the mean VO2peak in patients with CAD more than MCT, although MCT was associated with a more pronounced numerical decline in patients' resting heart rate and body weight. The underlying mechanisms and clinical relevance of these results are uncertain, and remain a potential focus for future studies.

Complete Angiographic Resolution of Cocaine Induced Coronary Artery Dissection within Eight Days without Coronary Stenting--A Case Report.

INTRODUCTION: Coronary dissection is a rarely reported complication of cocaine use for which there are no specific guidelines on management despite the widespread use of the drug. METHODS: We report a case of a 26-year-old otherwise fit and healthy Caucasian male smoker who presented to our facility with an infero-lateral ST elevation myocardial infarction (STEMI) following nasal inhalation of 1 gram of cocaine. Coronary angiography showed a mid left anterior descending (LAD) artery dissection with distal occlusive embolism and another dissection of the distal right coronary artery (RCA) with embolism and occlusion of the distal posterolateral branch. OUTCOME: Wiring of both vessels with a High-Torque Floppy wire successfully re-established TIMI 3 flow with relief of pain and resolution of his ST-segment elevation. Given the absence of any flow-limiting lesions, stenting was avoided. He was subsequently put on a combination of therapeutic dose enoxaparin, aspirin, ticagrelor, atorvastatin and metoprolol. A repeat angiogram eight days later showed complete healing of the dissections. CONCLUSION: This case shows that percutaneous management without stenting coupled with aggressive anti-coagulation of cocaine induced coronary dissection may result in an acceptable outcome especially in a young otherwise fit and healthy patient.

Drug-eluting Balloon Versus Second Generation Drug Eluting Stents in the Treatment of In-stent Restenosis: A Systematic Review and Meta-analysis.

BACKGROUND: In-stent restenosis (ISR) remains a significant mode of stent failure following PCI. The optimal treatment strategy, however, remains undefined and the role of drug-eluting balloons (DEB) in the management of ISR is also unclear. METHODS: A meta-analysis was performed to compare the efficacy of DEB in the treatment of ISR against second generation drug eluting stents (DES). RESULTS: Seven studies comprised of 1,065 patients were included for analysis. The follow-up period ranged from 12-25 months. The use of DEB was associated with an inferior acute gain in minimal luminal diameter (MLD) (0.36, 95% CI: 0.16-0.57mm), higher late loss in MLD (0.11, 0.02-0.19mm) and a higher binary restenosis rate at follow-up (risk ratio: 2.24, 1.49-3.37). No significant differences were noted in the overall incidence of the analysed clinical parameters between the two groups. When only the randomised controlled trials (RCT) were considered however, there was a strong trend towards higher target lesion revascularisation (TLR; 9.9% vs. 3.6%; RR: 2.5, p=0.07) and a significantly higher major adverse cardiovascular event (MACE) rate (15.7% vs. 8.8%; RR 1.78; p=0.02) with DEB. CONCLUSION: While equipoise has been demonstrated in selected clinical outcomes between DEB and second generation DES in the treatment of ISR, the suboptimal angiographic outcome at follow-up and the higher TLR and MACE rates associated with DEB observed in the RCT are concerning. The results of the present analysis should be regarded as preliminary, although the generalised adoption of DEB in the treatment of ISR currently cannot be recommended.

Ankyrin-B syndrome: a case of sinus node dysfunction, atrial fibrillation and prolonged QT in a young adult.

Ankyrin-B protein is involved in regulating expression and localisation of cardiac ion channels and transporters. Mutations of the ANK2 gene in the rare condition Ankyrin-B syndrome result in loss of function of the ankyrin-B protein which in turn leads to abnormal regulation of intracellular sodium and calcium and a predisposition to cardiac arrhythmia including torsades de pointes. We describe a rare case of this condition characterised by sinus node dysfunction, atrial fibrillation and prolonged QT syndrome in a young patient with a family history of sudden death. The management of Ankyrin-B syndrome may include avoidance of QT prolonging medications, insertion of a permanent pacemaker for sinus node dysfunction, or a cardioverter defibrillator for those at high-risk of sudden death from torsades de pointes.

Everolimus-eluting Bioresorbable Vascular Scaffold Implantation in Real World and Complex Coronary Disease: Procedural and 30-day Outcomes at Two Australian Centres.

BACKGROUND: The Absorb BVS is a new generation of coronary stent designed to provide coronary arteries with mechanical support of a temporary nature, following balloon angioplasty. Clinical trials of the device have shown promising results thus far, however concern surrounds the deliverability of the device in real-world and complex coronary disease, and the possible higher incidence of early scaffold thrombosis when compared to conventional metallic drug-eluting stents. METHODS: Implantation of the Absorb BVS was attempted in 152 lesions in 100 patients at two Sydney teaching hospitals, as part of a prospective registry. Lesions treated reflected a wide spectrum of real-world disease. Young patient age, long lesion length and involvement of the mid-portion of the left anterior descending artery were the strongest factors likely to influence the decision to use the Absorb BVS over conventional metallic stents. There were no restrictions on the lesion length, or on the number of lesions or vessels treated. Type C lesions made up 37% of all lesions treated with 64% of these being long lesions (>20mm). The Absorb BVS was successfully implanted in 98.8% of cases. Post-dilatation was performed in 95% of scaffolds. Peri-procedural non-ST elevation myocardial infarction occurred in four cases. Scaffold thrombosis did not occur in any patient at 30 days follow-up. There was no death, or need for target lesion revascularisation in-hospital or at 30 days. CONCLUSIONS: High rates of procedural success were achieved with minimal complications with use of the Absorb BVS in real-world coronary disease, including complex disease. These results suggest that the reduced deliverability of the device can be largely overcome by meticulous lesion preparation, and that early scaffold thrombosis may be minimised through scaffold post-dilatation.

Prognostic Significance of Peri-procedural Myocardial Infarction in the Era of High Sensitivity Troponin: A Validation of the Joint ACCF/AHA/ESC/WHF Universal Definition of Type 4a Myocardial Infarction with High Sensitivity Troponin T.

AIMS: This study aims to validate the joint ACCF/AHA/ESC/WHF Universal Definition of peri-procedural myocardial infarction (PMI) with high sensitivity troponin T (hsTnT). METHODS: A retrospective cohort study encompassing patients admitted to our institution between May 2012 and April 2013 was performed. RESULTS: 630 patients underwent percutaneous coronary interventions during the study period. Among them, 459 patients met the inclusion criteria and were eligible for analyses. 76.9% of these patients were male, while the mean age was 68.6. PMI was observed in 4.3% of the patients based on the Universal Definition. The predictors of PMI were chronic kidney disease (OR: 3.0, p=0.026), family history of cardiovascular disease (OR: 2.7, p=0.043) and use of IIb/IIIa inhibitors (OR 4.2, p=0.01). MACE was reported in 4.4% of the patients at 12 months, and was significantly and independently associated with PMI (OR 7.3, p=0.003) in a multivariate model which accounted for lesion complexity, patients' baseline clinical information, dual-antiplatelet status at follow-up and various procedural characteristics. The post-procedural hsTnT was much higher in those who suffered MACE than those who did not (156 v.s. 43 ng/L, p<0.001). CONCLUSION: PMI as defined by the current Universal Definition using hsTnT is an independent predictor of adverse clinical outcome at 12 months in patients undergoing PCI. Accordingly, PMI remains a clinically relevant factor in current practice and should be considered a key outcome measure in clinical trials and a potential target for therapy.

Predictive analytics for cardiovascular patient readmission and mortality: An explainable approach.

BACKGROUND: Cardiovascular patients experience high rates of adverse outcomes following discharge from hospital, which may be preventable through early identification and targeted action. This study aimed to investigate the effectiveness and explainability of machine learning algorithms in predicting unplanned readmission and death in cardiovascular patients at 30 days and 180 days from discharge. METHODS: Gradient boosting machines were trained and evaluated using data from hospital electronic medical records linked to hospital administrative and mortality data for 39,255 patients admitted to four hospitals in New South Wales, Australia between 2017 and 2021. Sociodemographic variables, admission history, and clinical information were used as potential predictors. The performance was compared to LASSO regression, as well as the HOSPITAL and LACE risk score indices. Important risk factors identified by the gradient-boosting machine model were explored using Shapley values. RESULTS: The models performed well, especially for the mortality outcomes. Area under the receiver operating characteristic curve values were 0.70 for readmission and 0.87-0.90 for mortality using the full gradient boosting machine algorithms. Among the top predictors for 30-day and 180-day readmission were increased red cell distribution width, old age (especially above 80 years), high measured troponin and urea levels, not being married or in a relationship, and low albumin levels. For mortality, these included increased red cell distribution width, old age (especially older than 70 years), high measured troponin and urea levels, high neutrophil and monocyte counts, and low eosinophil and lymphocyte counts. The Shapley values gave clear insight into the dynamics of decision-tree-based models. CONCLUSIONS: We demonstrated an explainable predictive algorithm to identify cardiovascular patients who are at high risk of readmission or death at discharge from the hospital and identified key risk factors.

Trends and Outcomes for Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in New South Wales from 2008 to 2019.

Risk profiles are changing for patients who undergo percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). In Australia, little is known of the nature of these changes in contemporary practice and of the impact on patient outcomes. We identified all CABG (n = 40,805) and PCI (n = 142,399) procedures in patients aged ≥18 years in New South Wales, Australia, during 2008 to 2019. Between 2008 and 2019, the age- and gender-standardized revascularization rate increased by 20% (from 267/100,000 to 320/100,000 population) for all revascularizations. The increase in revascularization was particularly driven by a 35% increase (from 194/100,000 to 261/100,000) in PCI, whereas the rate of CABG decreased by 20% (from 73/100,000 to 59/100,000). Mean age and the prevalence of co-morbidities (especially diabetes and atrial fibrillation) increased for patients with PCI in more recent years but remained consistently lower than for patients with CABG. CABGs performed in patients presenting with a non-ST-segment-elevation acute coronary syndrome halved from 34.3% to 18.7% during the study period, whereas PCIs in this group decreased from 36.5% to 29.6%. Risk-adjusted in-hospital mortality decreased by 7.5 deaths/1,000 procedures per month for CABG but remained unchanged for PCI. Risk-adjusted readmission rates were consistently higher for CABG than for PCI and did not change significantly over time. In conclusion, we observed a dramatic shift over time from CABG to PCI as the revascularization procedure of choice, with the patient base for PCI extending to older and sicker patients. There was a large decrease in mortality after CABG, whereas mortality after PCI remained unchanged.

Assessing the Generalizability of a Deep Learning-based Automated Atrial Fibrillation Algorithm.

Automated detection of atrial fibrillation (AF) from electrocardiogram (ECG) traces remains a challenging task and is crucial for telemonitoring of patients after stroke. This study aimed to quantify the generalizability of a deep learning (DL)-based automated ECG classification algorithm. We first developed a novel hybrid DL (HDL) model using the PhysioNet/CinC Challenge 2017 (CinC2017) dataset (publicly available) that can classify the ECG recordings as one of four classes: normal sinus rhythm (NSR), AF, other rhythms (OR), and too noisy (TN) recordings. The (pre)trained HDL was then used to classify 636 ECG samples collected by our research team using a handheld ECG device, CONTEC PM10 Portable ECG Monitor, from 102 (age: 68 ± 15 years, 74 male) outpatients of the Eastern Heart Clinic and inpatients in the Cardiology ward of Prince of Wales Hospital, Sydney, Australia. The proposed HDL model achieved average test F1-score of 0.892 for NSR, AF, and OR, relative to the reference values, on the CinC2017 dataset. The HDL model also achieved an average F1-score of 0.722 (AF: 0.905, NSR: 0.791, OR: 0.471 and TN: 0.342) on the dataset created by our research team. After retraining the HDL model on this dataset using a 5-fold cross validation method, the average F1-score increased to 0.961. We finally conclude that the generalizability of the HDL-based algorithm developed for AF detection from short-term single-lead ECG traces is acceptable. However, the accuracy of the pre-trained DL model was significantly improved by retraining the model parameters on the new dataset of ECG traces.

Telehealth and Health Equity in Older Adults With Heart Failure: A Scientific Statement From the American Heart Association.

Enhancing access to care using telehealth is a priority for improving outcomes among older adults with heart failure, increasing quality of care, and decreasing costs. Telehealth has the potential to increase access to care for patients who live in underresourced geographic regions, have physical disabilities or poor access to transportation, and may not otherwise have access to cardiologists with expertise in heart failure. During the COVID-19 pandemic, access to telehealth expanded, and yet barriers to access, including broadband inequality, low digital literacy, and structural barriers, prevented many of the disadvantaged patients from getting equitable access. Using a health equity lens, this scientific statement reviews the literature on telehealth for older adults with heart failure; provides an overview of structural, organizational, and personal barriers to telehealth; and presents novel interventions that pair telemedicine with in-person services to mitigate existing barriers and structural inequities.

Is there attenuation of benefit of invasive therapy in patients with chronic kidney disease? Results from randomized trials and registry data.

Chronic kidney disease (CKD) is not only a common comorbidity among patients presenting with acute coronary syndrome (ACS), it is also an entity that portends worse short- and long-term prognosis. Differences in the pathophysiology of arterial atherosclerosis and calcification, chronic inflammation, platelet reactivity, and thrombogenicity in patients with and without CKD underpin the increased vulnerability of CKD patients with ACS to subsequent ischemic and bleeding complications. These differences, as well as the frequent exclusion of CKD patients from randomized control trials, create uncertainty regarding the benefit of invasive treatment for ACS in patients with CKD. The limited evidence from randomized trials suggests a benefit with invasive treatment in CKD patients with ACS. However, some data from registry studies suggest no benefit or even harm with invasive therapy. Thus, the optimal management of ACS in patients with CKD, in particular end-stage CKD, remains uncertain. In this article we review the characteristics of coronary artery disease in patients with CKD, the available evidence pertaining to the outcomes of CKD patients with ACS with invasive versus conservative therapy, and potential areas for reducing complications of invasive therapy in this high-risk subset of patients.