Mitral annular disjunction in surgical mitral valve prolapse: prevalence, characteristics and outcomes.

BACKGROUND: There is a paucity of literature regarding outcomes of patients with mitral valve prolapse (MVP) and mitral annular disjunction (MAD) after mitral surgery, with many unanswered questions including the post-surgical persistence of MAD, effect of MAD on mitral valve reparability, and incidence of arrhythmia after mitral valve surgery. We aimed to examine the prevalence, imaging characteristics and clinical associations of mitral annular disjunction among patients undergoing mitral valve surgery for mitral valve prolapse, as well as outcomes after surgery including the persistence of MAD, arrhythmic events and excess mortality. RESULTS: A retrospective analysis of 111 consecutive patients who underwent mitral valve surgery for MVP was performed. A total of 32 patients (28.8%) had MAD. Patients with MAD were younger (64 vs 67 yrs, p = 0.04), with lower rates of hypertension (21.9% vs 50.6%, p = 0.01) and hyperlipidaemia (25% vs 50.6%; p = 0.01) and were more likely to be female (43.8% vs 21.4%, p = 0.04) with myxomatous leaflets > 5mm (90.6% vs 15.2%, p = < 0.01) and bileaflet prolapse (31.3% vs 10.1%, p = 0.02). Mitral valve repair was performed in 29/32 patients (90.6%) in the MAD positive group, and no patients had the persistence of MAD post-surgery. Post-operative ventricular arrhythmia was higher in the MAD positive group (28.13% vs 11.69%, p = 0.04) with no difference in mortality, 30-day hospital re-admission, or post-operative mitral regurgitation between patients with and without MAD over 3.91 years of follow up. CONCLUSION: In this study of consecutive patients with MVP undergoing surgery, MAD was a common finding (almost 1 in 3). MAD does not compromise mitral valve surgical reparability, and both repair and replacement are effective at correcting disjunction. Our data suggest that concurrent MAD in MVP patients undergoing surgery has no significant effect on post surgical outcomes. Further research as to whether this patient cohort requires post-surgical arrhythmia monitoring is warranted.

Summary and Comparison of the 2022 ACC/AHA/HFSA and 2021 ESC Heart Failure Guidelines.

The guidelines released by the American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) in 2022 and those released in 2021 by the European Society of Cardiology (ESC) play a crucial role in offering evidence-based recommendations for the diagnosis and management of heart failure (HF). This comprehensive review aims to provide an overview of these guidelines, incorporating insights from relevant clinical trials. While there is considerable alignment between the two sets of guidelines, certain notable differences arise due to variations in publication timelines, which we will outline. By presenting this summary, our objective is to empower clinicians to make informed decisions regarding HF management in their own practice, and facilitate the development of more harmonized guidelines in the future.

Diuretics in the management of chronic heart failure: when and how.

Heart failure is an increasingly prevalent condition resulting in recurrent hospitalisations and significant mortality and morbidity. The management of heart failure has evolved, and multiple drugs have an established mortality benefit in heart failure with reduced ejection fraction. Although the focus should be on ensuring that patients are treated with the maximum tolerated doses of these guideline-directed therapies, diuretics continue to play a key role in the management of clinical congestion in all forms of heart failure. Clinicians play a key role in heart failure management. Familiarity with the role of diuretics and their dosing and monitoring is critical.

Aspirin and Statin Therapy for Nonobstructive Coronary Artery Disease: Five-year Outcomes from the CONFIRM Registry.

Purpose: In this cohort study, 5-year data from the Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry (ie, CONFIRM) were examined to identify associations of baseline aspirin and statin use with mortality, major adverse cardiovascular events (MACE), and myocardial infarction (MI) in individuals without substantial (≥50%) stenosis. Materials and Methods: In this prospective cohort study, all participants in the registry underwent coronary CT angiography and were classified as having no detectable coronary plaque or having nonobstructive coronary artery disease (CAD) (1%-49% stenosis). Participants with obstructive (≥50%) stenosis were excluded from analysis. The study commenced in June 2003 and was completed in March 2016. All unadjusted and risk-adjusted analyses utilized the Cox proportional hazard model with hospital sites modeled using shared frailty. Results: A total of 6386 participants with no detectable plaque or with nonobstructive CAD were included (mean age, 56.0 years ± 13.3 [SD], 52% men). The mean follow-up period was 5.66 years ± 1.10. Nonobstructive CAD (n = 2815, 44% of all participants included in the study) was associated with a greater risk of all-cause mortality (10.6% [298 of 2815] vs 4.8% [170 of 3571], P < .001) compared to those without CAD (n = 3571, 56%). Baseline aspirin and statin use was documented for 1415 and 1429 participants, respectively, with nonobstructive CAD, and for 1560 and 1565 participants without detectable plaque, respectively. In individuals with nonobstructive CAD, baseline aspirin use was not associated with a reduction in MACE (10.9% [102 of 936] vs 14.7% [52 of 355], P = .06), all-cause mortality (9.6% [95 of 991] vs 10.9% [46 of 424], P = .468), or MI (4.4% [41 of 936] vs 6.2% [22 of 355], P = .18). On multivariate risk-adjusted analysis, baseline statin use was associated with a lower rate of MACE (hazard ratio, 0.59; 95% CI: 0.40, 0.87; P = .007). Neither therapy improved clinical outcomes for participants with no detectable plaque. Conclusion: In participants with nonobstructive CAD, baseline use of statins, but not of aspirin, was associated with improved clinical outcomes. Neither therapy was associated with benefit in participants without plaque.Keywords: Aspirin, Statin, Coronary Artery Disease, CT Angiography, Nonobstructive Coronary Artery DiseaseClinical trial registration no. NCT01443637 Supplemental material is available for this article. © RSNA, 2022See also the commentary by Canan and Navar in this issue.

Bluetooth-Enabled Implantable Cardiac Monitors and Two-Way Smartphone Communication for Patients With Hypertrophic Cardiomyopathy.

Background: Sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM) currently relies on arrhythmic burden quantification by 24 or 48-hour Holter monitoring. Whether this approach adequately captures arrhythmic burden, compared with longer-term continuous monitoring, is unclear. We sought to assess the long-term incidence of nonsustained ventricular tachycardia (NSVT) in HCM patients at low or moderate SCD risk, using implantable cardiac monitors (ICMs) paired with a novel Bluetooth-enabled 2-way communication platform. Methods: This prospective, single-arm, observational study enrolled 33 HCM patients. Patients were implanted with an Abbott (Chicago, IL) Confirm Rx ICM and monitored using a protocolized care pathway. Results: A total of 20 patients (60.6%) had ≥ 1 episode of NSVT recorded on the ICM, the majority of whom had previous Holter monitors that did not identify NSVT (60%, n = 12). A total of 71 episodes of NSVT were detected. Median time to first NSVT detection was 76.5 days (range: 0-553 days). A total of 19 patients underwent primary prevention implantable cardioverter defibrillator implantation during an average follow-up of 544 days (range: 42-925 days). A total of 172,112 automatic transmissions were received, and 65 (0.04%) required clinical follow-up. A total of 325 manual transmissions were received and managed. A total of 14 manual transmissions (4.3%) required follow-up, whereas 311 (95.7%) were managed solely with a text message. Conclusions: Surveillance and reporting systems utilizing 2-way communication enabled by novel ICMs are feasible and allow remote management of patients with HCM. Prolonged monitoring with ICMs identified more patients with nonsustained arrythmias than did standard Holter monitoring. In many cases, this information impacted both SCD risk stratification and patient management.

Contexte: La stratification du risque de mort cardiaque subite (MCS) dans la cardiomyopathie hypertrophique (CMH) dépend actuellement de la quantification de la charge arythmique par une surveillance Holter de 24 ou 48 heures. Il n'est pas clair si cette approche permet d'évaluer adéquatement la charge arythmique, comparativement à une surveillance continue à plus long terme. Nous avons cherché à évaluer la fréquence à long terme de la tachycardie ventriculaire non soutenue (TVNS) chez des patients atteints de CMH à risque faible ou modéré de MCS, au moyen de moniteurs cardiaques implantables (MCI) couplés à une nouvelle plate-forme de communication bidirectionnelle utilisable avec Bluetooth. Méthodologie: Cette étude par observation prospective comportant un seul groupe a été menée auprès de 33 patients atteints de CMH. Les patients ont reçu un MCI Confirm Rx d'Abbott (Chicago, États-Unis) et ont été surveillés dans le cadre d'un parcours de soins reposant sur un protocole. Résultats: Au total, 20 patients (60,6 %) ont eu au moins un épisode de TVNS enregistré par le MCI. La majorité de ces patients portaient déjà un moniteur Holter qui n'a pas décelé de TVNS (60 %, n = 12). Au total, 71 épisodes de TVNS ont été détectés. Le temps médian écoulé avant la première détection de TVNS était de 76,5 jours (fourchette : 0-553 jours). Au total, 19 patients se sont fait poser un défibrillateur cardioverteur implantable en prévention primaire pendant un suivi moyen de 544 jours (fourchette : 42-925 jours). En tout, 172 112 transmissions automatiques ont été reçues, et 65 (0,04 %) ont nécessité un suivi clinique. Par ailleurs, 325 transmissions manuelles ont été reçues et traitées. De ce nombre, 14 transmissions (4,3 %) ont nécessité un suivi, tandis que 311 (95,7 %) ont été traitées uniquement au moyen d'un message texte. Conclusions: Les systèmes de surveillance et de signalement utilisant une communication bidirectionnelle rendue possible grâce aux nouveaux MCI sont réalisables et permettent une prise en charge à distance des patients atteints d'un CMH. La surveillance prolongée par un MCI a permis de déceler plus d'arythmies non soutenues que la surveillance Holter type. Dans de nombreux cas, ces renseignements ont eu un effet positif tant sur la stratification du risque de MCS que sur la prise en charge des patients.

A Smartphone-Based Model of Care to Support Patients With Cardiac Disease Transitioning From Hospital to the Community (TeleClinical Care): Pilot Randomized Controlled Trial.

BACKGROUND: Patients hospitalized with acute coronary syndrome (ACS) or heart failure (HF) are frequently readmitted. This is the first randomized controlled trial of a mobile health intervention that combines telemonitoring and education for inpatients with ACS or HF to prevent readmission. OBJECTIVE: This study aims to investigate the feasibility, efficacy, and cost-effectiveness of a smartphone app-based model of care (TeleClinical Care [TCC]) in patients discharged after ACS or HF admission. METHODS: In this pilot, 2-center randomized controlled trial, TCC was applied at discharge along with usual care to intervention arm participants. Control arm participants received usual care alone. Inclusion criteria were current admission with ACS or HF, ownership of a compatible smartphone, age ≥18 years, and provision of informed consent. The primary end point was the incidence of unplanned 30-day readmissions. Secondary end points included all-cause readmissions, cardiac readmissions, cardiac rehabilitation completion, medication adherence, cost-effectiveness, and user satisfaction. Intervention arm participants received the app and Bluetooth-enabled devices for measuring weight, blood pressure, and physical activity daily plus usual care. The devices automatically transmitted recordings to the patients' smartphones and a central server. Thresholds for blood pressure, heart rate, and weight were determined by the treating cardiologists. Readings outside these thresholds were flagged to a monitoring team, who discussed salient abnormalities with the patients' usual care providers (cardiologists, general practitioners, or HF outreach nurses), who were responsible for further management. The app also provided educational push notifications. Participants were followed up after 6 months. RESULTS: Overall, 164 inpatients were randomized (TCC: 81/164, 49.4%; control: 83/164, 50.6%; mean age 61.5, SD 12.3 years; 130/164, 79.3% men; 128/164, 78% admitted with ACS). There were 11 unplanned 30-day readmissions in both groups (P=.97). Over a mean follow-up of 193 days, the intervention was associated with a significant reduction in unplanned hospital readmissions (21 in TCC vs 41 in the control arm; P=.02), including cardiac readmissions (11 in TCC vs 25 in the control arm; P=.03), and higher rates of cardiac rehabilitation completion (20/51, 39% vs 9/49, 18%; P=.03) and medication adherence (57/76, 75% vs 37/74, 50%; P=.002). The average usability rating for the app was 4.5/5. The intervention cost Aus $6028 (US $4342.26) per cardiac readmission saved. When modeled in a mainstream clinical setting, enrollment of 237 patients was projected to have the same expenditure compared with usual care, and enrollment of 500 patients was projected to save approximately Aus $100,000 (approximately US $70,000) annually. CONCLUSIONS: TCC was feasible and safe for inpatients with either ACS or HF. The incidence of 30-day readmissions was similar; however, long-term benefits were demonstrated, including fewer readmissions over 6 months, improved medication adherence, and improved cardiac rehabilitation completion. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618001547235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375945.

Digital health technology in the prevention of heart failure and coronary artery disease.

Coronary artery disease and heart failure are leading causes of morbidly and mortality, resulting in a substantial economic burden globally. Guidelines from the European Society of Cardiology and American Heart Association place adherence to medication and healthy lifestyle behaviors at the core of cardiovascular disease primary and secondary prevention strategies. The growing collective burden of cardiovascular disease is likely to eventually outgrow the available resources allocated for traditional care provision, such as nurse-led outreach services. Novel strategies are required to address this growing need. Worldwide, more than 6.5 billion people own smartphones and opportunities to deliver healthcare digitally for patients with cardiac conditions are expanding exponentially. Multiple randomized controlled trials have now demonstrated that various modes of noninvasive digital health technology, including teleconsultations, smartphone applications (apps), wearables, remote monitoring, and predictive analytics can influence patient behaviors in both the primary and secondary prevention of coronary artery disease and prevention and management of heart failure. The purpose of this narrative review is to critically analyze pivotal trials and discuss examples of successfully deployed mobile digital technology in the prevention of heart failure hospitalizations, and in the primary and secondary prevention of coronary artery disease.

Plaque progression: Where, why, and how fast? A review of what we have learned from the analysis of patient data from the PARADIGM registry.

Ischemic heart disease is the most common cause of mortality worldwide. The pathophysiology of myocardial infarction relates to temporal changes of atherosclerotic plaque culminating in plaque rupture, erosion or hemorrhage and the subsequent thrombotic response. Coronary computed tomographic angiography (CCTA) provides the ability to visualize and quantify plaque, and plaque progression can be measured on a per-patient basis by comparing findings of serial CCTA. The Progression of AtheRosclerotic PlAque DetermIned by Computed TomoGraphic Angiography IMaging (PARADIGM) registry was established with the objective of identifying patterns of plaque progression in a large population. The registry comprises over 2000 patients with multiple CCTA scans performed at least two years apart. Unlike previous CCTA registries, a semi-automated plaque quantification technique permitting detailed analysis of plaque progression was performed on all patients with interpretable studies. Since the registry was established, 19 peer-reviewed publications were identified, and all are reviewed and summarized in this article.

Arrhythmic Mitral Valve Prolapse and Mitral Annulus Disjunction in Heritable Aortic Disease.

Patients with heritable aortic disease (HAD) have an increased risk of ventricular arrhythmias and sudden cardiac death. Although mitral valve prolapse is common in HAD, mitral annulus disjunction (MAD) has only recently been described in these patients. This under-recognized condition may be a contributing factor to otherwise unexplained ventricular arrhythmias and sudden cardiac death in patients with HAD. This case series describes 3 patients in an adult HAD clinic who have concomitant mitral valve prolapse, MAD, and malignant arrhythmias. These cases may represent a unique disease entity or overlap syndrome, and they introduce MAD as a potential arrhythmogenic risk marker in HAD.

Les patients atteints de maladie aortique héréditaire (MAH) présentent un risque accru d'arythmie ventriculaire et de mort subite d'origine cardiaque. Bien que le prolapsus valvulaire mitral soit fréquent dans les cas de MAH, la disjonction annulaire mitrale (DAM) n'a été décrite que récemment chez ces patients. Cet état méconnu peut être un facteur contribuant à des arythmies ventriculaires autrement inexpliquées et à la mort subite d'origine cardiaque chez les patients atteints de MAH. Cette série de cas décrit trois patients d'une clinique de MAH pour adultes qui présentent un prolapsus valvulaire mitral, une DAM et des arythmies malignes en concomitance. Ces cas peuvent représenter une entité morbide unique ou un syndrome de chevauchement, et laissent entendre que la DAM pourrait être un nouveau marqueur du risque arythmogène associé à la MAH.

Association of Tube Voltage With Plaque Composition on Coronary CT Angiography: Results From PARADIGM Registry.

OBJECTIVES: This study sought to investigate the impact of low tube voltage scanning heterogeneity of coronary luminal attenuation on plaque quantification and characterization with coronary computed tomography angiography (CCTA). BACKGROUND: The impact of low tube voltage and coronary luminal attenuation on quantitative coronary plaque remains uncertain. METHODS: A total of 1,236 consecutive patients (age: 60 ± 9 years; 41% female) who underwent serial CCTA at an interval of ≥2 years were included from an international registry. Patients with prior revascularization or nonanalyzable coronary CTAs were excluded. Total coronary plaque volume was assessed and subclassified based on specific Hounsfield unit (HU) threshold: necrotic core, fibrofatty plaque, and fibrous plaque and dense calcium. Luminal attenuation was measured in the aorta. RESULTS: With increasing luminal HU (<350, 350-500, and >500 HU), percent calcified plaque was increased (16%, 27%, and 40% in the median; P < 0.001), and fibrofatty plaque (26%, 13%, and 4%; P < 0.001) and necrotic core (1.6%, 0.3%, and 0.0%; P < 0.001) were decreased. Higher tube voltage scanning (80, 100, and 120 kV) resulted in decreasing luminal attenuation (689 ± 135, 497 ± 89, and 391 ± 73 HU; P < 0.001) and calcified plaque volume (59%, 34%, and 23%; P < 0.001) and increased fibrofatty plaque (3%, 9%, and 18%; P < 0.001) and necrotic core (0.2%, 0.1%, and 0.6%; P < 0.001). Mediation analysis showed that the impact of 100 kV on plaque composition, compared with 120 kV, was primarily caused by an indirect effect through blood pool attenuation. Tube voltage scanning of 80 kV maintained a direct effect on fibrofatty plaque and necrotic core in addition to an indirect effect through the luminal attenuation. CONCLUSIONS: Low tube voltage usage affected plaque morphology, mainly through an increase in luminal HU with a resultant increase in calcified plaque and a reduction in fibrofatty and necrotic core. These findings should be considered as CCTA-based plaque measures are being used to guide medical management and, in particular, when being used as a measure of treatment response. (Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging [PARADIGM]; NCT02803411).

Trials and Tribulations: mHealth Clinical Trials in the COVID-19 Pandemic.

INTRODUCTION: Mobile phone-based interventions in cardiovascular disease are growing in popularity. A randomised control trial (RCT) for a novel smartphone app-based model of care, named TeleClinical Care - Cardiac (TCC-Cardiac), commenced in February 2019, targeted at patients being discharged after care for an acute coronary syndrome or episode of decompensated heart failure. The app was paired to a digital sphygmomanometer, weighing scale and a wearable fitness band, all loaned to the patient, and allowed clinicians to respond to abnormal readings. The onset of the COVID-19 pandemic necessitated several modifications to the trial in order to protect participants from potential exposure to infection. The use of TCC-Cardiac during the pandemic inspired the development of a similar model of care (TCC-COVID), targeted at patients being managed at home with a diagnosis of COVID-19. METHODS: Recruitment for the TCC-Cardiac trial was terminated shortly after the World Health Organization announced COVID-19 as a global pandemic. Telephone follow-up was commenced, in order to protect patients from unnecessary exposure to hospital staff and patients. Equipment was returned or collected by a 'no-contact' method. The TCC-COVID app and model of care had similar functionality to the original TCC-Cardiac app. Participants were enrolled exclusively by remote methods. Oxygen saturation and pulse rate were measured by a pulse oximeter, and symptomatology measured by questionnaire. Measurement results were manually entered into the app and transmitted to an online server for medical staff to review. RESULTS: A total of 164 patients were involved in the TCC-Cardiac trial, with 102 patients involved after the onset of the pandemic. There were no hospitalisations due to COVID-19 in this cohort. The study was successfully completed, with only three participants lost to follow-up. During the pandemic, 5 of 49 (10%) of patients in the intervention arm were readmitted compared to 12 of 53 (23%) in the control arm. Also, in this period, 28 of 29 (97%) of all clinically significant alerts received by the monitoring team were managed successfully in the outpatient setting, avoiding hospitalisation. Patients found the user experience largely positive, with the average rating for the app being 4.56 out of 5. 26 patients have currently been enrolled for TCC-COVID. Recruitment is ongoing. All patients have been safely and effectively monitored, with no major adverse clinical events or technical malfunctions. Patient satisfaction has been high. CONCLUSION: The TCC-Cardiac RCT was successfully completed despite the challenges posed by COVID-19. Use of the app had an added benefit during the pandemic as participants could be monitored safely from home. The model of care inspired the development of an app with similar functionality designed for use with patients diagnosed with COVID-19.

Process Evaluation of a Randomised Controlled Trial for TeleClinical Care, a Smartphone-App Based Model of Care.

BACKGROUND: A novel smartphone app-based model of care (TeleClinical Care - TCC) for patients with acute coronary syndrome (ACS) and heart failure (HF) was evaluated in a two-site, pilot randomised control trial of 164 participants in Sydney, Australia. The program included a telemonitoring system whereby abnormal blood pressure, weight and heart rate readings were monitored by a central clinical team, who subsequently referred clinically significant alerts to the patients' usual general practitioner (GP, also known as primary care physician in the United States), HF nurse or cardiologist. While the primary endpoint, 30-day readmissions, was neutral, intervention arm participants demonstrated improvements in readmission rates over 6 months, cardiac rehabilitation (CR) completion and medication compliance. A process evaluation was designed to identify contextual factors and mechanisms that influenced the results, as well as strategies of improving site and participant recruitment and the delivery of the intervention, for a planned larger effectiveness trial of over 1,000 patients across the state of New South Wales, Australia (TCC-Cardiac). METHODS: Multiple data sources were used in this mixed-methods process evaluation, including interviews with four TCC team members, three GPs and three cardiologists. CR completion rates, HF outreach service (HFOS) referrals and cardiologist follow-up appointments were audited. A patient questionnaire was also analysed for evidence of improved self-care as a hypothesised mechanism of the TCC app. An implementation research logic model was used to synthesise our findings. RESULTS: Rates of HFOS referral (83 vs. 72%) and cardiologist follow-up (96 vs. 93%) were similarly high in the intervention and control arms, respectively. Team members were largely positive towards their orientation and training, but highlighted several implementation strategies that could be optimised for TCC-Cardiac: streamlining of the enrolment process, improving the reach of the trial by screening patients in non-cardiac wards, and ensuring team members had adequate time to recruit (>15 h per week). GPs and cardiologists viewed the intervention acceptably regarding potential benefit of closely monitoring, and responding to abnormalities for their patients, though there were concerns of the potential additional workload generated by alerts that did not merit clinical intervention. Clear delineation of which clinician (GP or cardiologist) was primarily responsible for alert management was also recommended, as well as a preference to receive regular summary data. Several patients commented on the mechanisms of improved self-management because of TCC, which could have led to the outcome of improved medication compliance. DISCUSSION: Use of TCC was associated with several benefits, including higher patient engagement and completion rates with CR. The conduct and delivery of TCC-Cardiac will be improved by the findings of this process evaluation to optimise recruitment, and establishing the roles of GPs and cardiologists as part of the model.

A case report of isolated right ventricular lymphocytic myocarditis.

BACKGROUND: Lymphocytic myocarditis is an uncommon condition with a variety of clinical presentations. Isolated involvement of the right ventricle (RV) is very rare. We present a case of a young woman who developed right ventricular dysfunction and arrhythmias as a consequence of this condition, which appeared to be chronic at diagnosis. CASE SUMMARY: A 26-year-old lady was admitted to hospital following routine echocardiography, requested for screening of pulmonary hypertension in the context of known hypersensitivity pneumonitis. This echocardiogram demonstrated severe right ventricular dilatation and impairment. She was also experiencing atrial fibrillation and non-sustained, symptomatic episodes of ventricular tachycardia. Endomyocardial biopsy revealed lymphocytic myocarditis. She was managed with azathioprine and prednisone, as well as sotalol and apixaban for her atrial fibrillation, and has had no complications in the 12 months since discharge. DISCUSSION: Lymphocytic myocarditis isolated to the RV has only been reported in two previous cases, both of which were acute, dramatic presentations. This is the first report of a chronic example of this disease process. Due to her intercurrent immunosuppression, this patient may have been pre-disposed to the condition either by re-activation of a latent viral infection or partial treatment of a true autoimmune lymphocytic myocarditis.

Mobile Phone Technologies in the Management of Ischemic Heart Disease, Heart Failure, and Hypertension: Systematic Review and Meta-Analysis.

BACKGROUND: Cardiovascular disease (CVD) remains the leading cause of death worldwide. Mobile phones have become ubiquitous in most developed societies. Smartphone apps, telemonitoring, and clinician-driven SMS allow for novel opportunities and methods in managing chronic CVD, such as ischemic heart disease, heart failure, and hypertension, and in the conduct and support of cardiac rehabilitation. OBJECTIVE: A systematic review was conducted using seven electronic databases, identifying all relevant randomized control trials (RCTs) featuring a mobile phone intervention (MPI) used in the management of chronic CVD. Outcomes assessed included mortality, hospitalizations, blood pressure (BP), and BMI. METHODS: Electronic data searches were performed using seven databases from January 2000 to June 2019. Relevant articles were reviewed and analyzed. Meta-analysis was performed using standard techniques. The odds ratio (OR) was used as a summary statistic for dichotomous variables. A random effect model was used. RESULTS: A total of 26 RCTs including 6713 patients were identified and are described in this review, and 12 RCTs were included in the meta-analysis. In patients with heart failure, MPIs were associated with a significantly lower rate of hospitalizations (244/792, 30.8% vs 287/803, 35.7%; n=1595; OR 0.77, 95% CI 0.62 to 0.97; P=.03; I2=0%). In patients with hypertension, patients exposed to MPIs had a significantly lower systolic BP (mean difference 4.3 mm Hg; 95% CI -7.8 to -0.78 mm Hg; n=2023; P=.02). CONCLUSIONS: The available data suggest that MPIs may have a role as a valuable adjunct in the management of chronic CVD.

Measurement and Management of QT Interval Prolongation for General Physicians.

One of the more challenging aspects of ECG interpretation is measurement and interpretation of the QT interval. This interval represents the time taken for the ventricles to completely repolarise after activation. Abnormal prolongation of the QT interval can lead to torsades de pointes, a form of potentially life-threatening polymorphic ventricular tachycardia (VT). Detection of a prolonged QT interval is essential as this can be a reversible problem, particularly in the context of the use of a variety of commonly prescribed medications in the hospital setting. Automated ECG printouts cannot be relied upon to diagnose QT interval prolongation; thus, the onus is on the clinician to identify it. This is a difficult task, as the normal QT interval is typically measured relative to the heart rate. Therefore, the QT interval often requires "correction" for the current heart rate, in order to correctly stratify the risk of torsades de pointes. A wealth of correctional formulae have been derived, but none has proven superior. We present an approach to the ECG in this context, and a step-by-step guide to manually measuring and correcting the QT interval, and an approach to management in common hospital-based clinical scenarios.

High-intensity interval training for patients with coronary artery disease: Finding the optimal balance.

BACKGROUND: The optimal characteristics of high-intensity interval training (HIIT) for patients with coronary artery disease (CAD) within cardiac rehabilitation (CR) are unclear. We assessed a HIIT protocol designed to balance patient safety, efficacy and enjoyment. METHODS: Twenty-nine patients with CAD completed 6-weeks (× 2 sessions per week) of HIIT within outpatient (phase 2) CR. HIIT comprised 15 repetitions × 30-seconds cycling at ∼85-90% maximum heart rate, interspersed with 30-seconds of active recovery. Key outcomes covered patient safety, efficacy (peak aerobic capacity, body composition, blood pressure and vascular function), and patient adherence and enjoyment. RESULTS: No cardiovascular-related adverse events were reported in relation to HIIT sessions. Patients showed significant improvement in peak aerobic capacity (mean +12%, p < 0.001, effect size d = 0.38), blood pressure (brachial systolic -7mmHg, p < 0.001, d = -0.59) and total body fat (-4%, p < 0.001, d = -0.49). Central adaptations were prominent (aortic systolic BP -5mmHg, p = 0.001, d = -0.50; visceral fat -10%, p = 0.001, d = -0.41). Patient enjoyment of training was high (5.5 out of 7 using the Exercise Enjoyment Scale) and measures of affective state improved following training (assorted p < 0.018). CONCLUSIONS: This HIIT protocol appears safe, effective and enjoyable for patients with CAD within CR. Improved aerobic fitness, blood pressure and body fat levels were observed indicating improved cardiovascular-risk. High patient enjoyment and improved mood suggest the HIIT could be sustainable for patients in the longer-term.

Safety and efficacy of aerobic exercise commenced early after cardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Aerobic exercise is a critical component of cardiac rehabilitation following cardiac surgery. Aerobic exercise is traditionally commenced 2-6 weeks following hospital discharge and most commonly includes stationary cycling or treadmill walking. The initiation of aerobic exercise within this early postoperative period not only introduces the benefits associated with aerobic activity sooner, but also ameliorates the negative effects of immobilization associated with the early postoperative period. METHODS: A systematic review identified all studies reporting safety and efficacy outcomes of aerobic exercise commenced within two weeks of cardiac surgery. A meta-analysis was performed comparing functional, aerobic and safety outcomes in patients receiving early postoperative aerobic exercise compared with usual postoperative care. RESULTS: Six-minute walk test distance at hospital discharge was 419 ± 88 m in early aerobic exercise patients versus 341 ± 81 m in those receiving usual care (mean difference 69.5 m, 95% confidence interval (CI) 39.2-99.7 m, p < 0.00001). Peak aerobic power was 18.6 ± 3.8 ml·kg-1·min-1 in those receiving early exercise versus 15.0 ± 2.1 ml·kg-1·min-1 in usual care (mean difference 3.20 ml·kg-1·min-1, 95% CI 1.45-4.95, p = 0.0003). There was no significant difference in adverse events rates between the two groups (odds ratio 0.41, 95% CI 0.12-1.42, p = 0.16). CONCLUSION: Aerobic exercise commenced early after cardiac surgery significantly improves functional and aerobic capacity following cardiac surgery. While adverse event rates did not differ significantly, patients included were very low risk. Further studies are required to adequately assess safety outcomes of aerobic exercise commenced early after cardiac surgery.

Use of colchicine in pregnancy: a systematic review and meta-analysis.

OBJECTIVES: Colchicine is an anti-inflammatory agent used in the treatment of several rheumatological conditions. The use of colchicine in pregnancy is controversial. The current study aimed to systematically review and meta-analyse the existing data in the literature regarding the safety of colchicine in pregnancy. METHODS: A systematic review was carried out using six electronic databases, identifying all relevant studies where colchicine was administered to pregnant women, and where pregnancy-related outcomes were measured. The primary endpoints were miscarriage and major foetal malformation. Secondary endpoints included birthweight and gestational age at birth. RESULTS: Four studies were included for meta-analysis. Use of colchicine throughout pregnancy was not associated with an increased incidence of miscarriage or major foetal malformations. The incidence of miscarriage was significantly lower in women who took colchicine compared with those that did not. In women with FMF who took colchicine throughout the pregnancy, there was no significant difference in birthweight or gestational age compared with those who did not take colchicine. When not limited to FMF, colchicine use was associated with a significantly lower birthweight and gestational age compared with a control group including healthy women who did not take colchicine. CONCLUSIONS: Colchicine therapy did not significantly increase the incidence of foetal malformations or miscarriage when taken during pregnancy. Colchicine therapy for FMF should not be withheld on this basis during pregnancy.