Occurrence of Transient Myocardial Ischemic Events among Non-ST Segment Elevation Acute Coronary Syndrome Patients Before or After Invasive Coronary Angiography.

BACKGROUND: The occurrence of transient myocardial ischemia (TMI) is an important pathology in patients with non-ST elevation acute coronary syndrome (NSTE-ACS), yet studies are scarce regarding when TMI occurs during hospitalization, particularly in relation to invasive coronary angiography (ICA). This study examined: (1) TMI before or after ICA; (2) patient characteristics and ischemic burden by TMI group (before or after ICA); and (3) major in-hospital complications (transfer to critical care, death) and length of stay (LOS) by TMI group (before or after ICA). METHODS: Secondary data analysis in hospitalized NSTE-ACS patients with TMI event(s) identified from 12-lead electrocardiographic (ECG) Holter. Patient records were reviewed to assess ischemic burden (TMI time [minutes] ÷ hours recording duration), outcomes and TMI timing, before or after ICA. RESULTS: In 38 patients, 3 (8%) had TMI before and after ICA. Of the remaining 35 patients (92%), TMI occurred before ICA (16; 46%), and after ICA (9; 26%), and 10 (28%) did not have ICA. Patient characteristics, untoward outcomes, and TMI duration (minutes) did not differ by group. Ischemic burden was higher in patients with TMI after ICA (7.29±8.82 min/hr) compared to before ICA (2.54±2.11 min/hr), p=0.039. Hospital LOS by TMI group was 113±113 (before), 226±244 (after), and 85±65 hr (no ICA); p=0.172. CONCLUSION: Almost half of the sample had TMI before ICA; one-third had TMI but did not have ICA. Patients with TMI after an ICA had higher ischemic burden. Future studies with larger sample sizes are needed to investigate further the short- and long-term clinical significance of TMI among NSTE-ACS patients.

Estimating Ejection Fraction from the 12 Lead ECG among Patients with Acute Heart Failure.

Background: Identifying patients with low left ventricular ejection fraction (LVEF) in the emergency department using an electrocardiogram (ECG) may optimize acute heart failure (AHF) management. We aimed to assess the efficacy of 527 automated 12-lead ECG features for estimating LVEF among patients with AHF. Method: Medical records of patients >18 years old and AHF-related ICD codes, demographics, LVEF %, comorbidities, and medication were analyzed. Least Absolute Shrinkage and Selection Operator (LASSO) identified important ECG features and evaluated performance. Results: Among 851 patients, the mean age was 74 years (IQR:11), male 56% (n=478), and the median body mass index was 29 kg/m2 (IQR:1.8). A total of 914 echocardiograms and ECGs were matched; the time between ECG-Echocardiogram was 9 hours (IQR of 9 hours); ≤30% LVEF (16.45%, n=140). Lasso demonstrated 42 ECG features important for estimating LVEF ≤30%. The predictive model of LVEF ≤30% demonstrated an area under the curve (AUC) of 0.86, a 95% confidence interval (CI) of 0.83 to 0.89, a specificity of 54% (50% to 57%), and a sensitivity of 91 (95% CI: 88% to 96%), accuracy 60% (95% CI:60 % to 63%) and, negative predictive value of 95%. Conclusions: An explainable machine learning model with physiologically feasible predictors may be useful in screening patients with low LVEF in AHF.

Work outcomes in public safety personnel after potentially traumatic events: A systematic review.

BACKGROUND: It is well documented that public safety personnel are exposed to potentially traumatic events (PTEs) at elevated frequency and demonstrate higher prevalence of trauma-related symptoms compared to the general population. Lesser studied to date are the organizational consequences of workplace PTE exposure and associated mental health outcomes such as acute/posttraumatic stress disorder (ASD/PTSD), depression, and anxiety. METHODS: The present review synthesizes international literature on work outcomes in public safety personnel (PSP) to explore whether and how PTE and trauma-related symptoms relate to workplace outcomes. A total of N = 55 eligible articles examining PTE or trauma-related symptoms in relation to work outcomes were systematically reviewed using best-evidence narrative synthesis. RESULTS: Three primary work outcomes emerged across the literature: absenteeism, productivity/performance, and costs to organization. Across n = 21 studies of absenteeism, there was strong evidence that PTE or trauma-related symptoms are associated with increased sickness absence. N = 27 studies on productivity/performance demonstrated overall strong evidence of negative impacts in the workplace. N = 7 studies on cost to organizations demonstrated weak evidence that PTE exposure or trauma-related mental health outcomes are associated with increased cost to organization. CONCLUSIONS: Based on available evidence, the experience of workplace PTE or trauma-related symptoms is associated with negative impact on PSP occupational functioning, though important potential confounds (e.g., organizational strain and individual risk factors) remain to be more extensively investigated.

Disparities in 30-Day Readmission Between Medicare/Medicaid and Private Insurance Among Patients With Heart Failure Screened for Cognitive Impairment.

BACKGROUND: Racial disparities exist among patients with heart failure (HF). HF is often comorbid with cognitive impairment. Appropriate self-care can prevent HF hospital readmissions but requires access to resources through insurance. Racial differences exist between insurance types, and this may influence the disparity between races and patients with HF and cognitive impairment. OBJECTIVE: The objectives of this study were to examine the relationships between insurance type and self-care stratified by race and to assess for differences in time-to-30-day readmission among patients with HF with cognitive impairment. METHODS: This is a secondary analysis of data collected among hospitalized patients with HF with cognitive impairment. Patients completed surveys on self-care (Self-Care of Heart Failure Index), HF knowledge (Dutch Heart Failure Knowledge Scale), depression (Geriatric Depression Scale), and social support (Enhancing Recovery in Coronary Heart Disease Social Support Inventory). Socioeconomic data were collected. Linear models were created to examine the relationships between insurance type and self-care by race. Kaplan-Meier curves and Cox regression were used to assess readmission. RESULTS: The sample of 125 patients with HF with cognitive impairment was predominantly Black (68%, n = 85) and male (53%, n = 66). The sample had either Medicare/Medicaid (62%, n = 78) or private insurance (38%, n = 47). Black patients with HF with cognitive impairment and private insurance reported higher self-care confidence compared with Black patients with HF with cognitive impairment and Medicare/Medicaid (P < .05). Medicare/Medicaid was associated with a higher frequency of 30-day readmission and a faster time-to-readmission. CONCLUSIONS: Patients with HF with cognitive impairment and Medicare/Medicaid insurance reported lower self-care confidence and more likely to be readmitted within 30 days.

Trends in NIH-funding to schools of nursing in the last 17 years.

BACKGROUND: Growing clinical demands, faculty retirements, fewer PhD-prepared graduates, and funding instability are challenges for nursing science. PURPOSE: The purpose of this analysis was to investigate National Institutes of Health (NIH) funding patterns in schools of nursing (SONs). METHODS: Data were extracted from the Blue Ridge Institute for Medical Research between 2006 and 2022. Growth modeling examined changes in funding over time between private and public SONs. DISCUSSION: In the last 17 years, NIH funding for SONs has risen nearly 25% but remains only 1% of the total NIH budget for extramural research. Overall, 109 (75%) of the SONs were public and 36 (25%) were private institutions. Regarding geography, 90% of the States received NIH funding except six: ID, ME, MS, NH, VT, and WY. Private SONs consistently received more funding than public SONs but the difference was only statistically significant in 2022. CONCLUSION: NIH funding has significantly increased to SONs, there is better geographic distribution but a funding disparity exists between public and private SONs.

The Effect of Mandatory Fitness Requirements on Cardiovascular Events: A State-by-State Analysis Using a National Database.

BACKGROUND: Cardiovascular events are known to be the leading cause of death among on-duty firefighters. Implementing fitness standards may help reduce the incidence of cardiovascular deaths; however, standards vary between firefighter type and states. We aimed to investigate the rate of cardiovascular events among firefighters across states. METHODS: Using publicly available data from the United States Fire Administration, we explored the rates of cardiovascular deaths between firefighter type (e.g., career, volunteer, and wildland) and state. Specifically, we examined rates of cardiovascular deaths between California and Tennessee, which have fitness standards for all firefighters, and New York, which does not have fitness standards for volunteer firefighters. We used descriptive statistics and trend analysis to examine the data. FINDINGS: Most cardiovascular events occur among volunteer firefighters (60.6%, n = 877). Volunteer firefighters had 7.5 (95% CI = [4.8, 11.7], p < .001) greater odds of cardiovascular events compared to wildland firefighters, who had the lowest incidence of cardiovascular events (1.7%, n = 24). New York reported the most cardiovascular events (n = 161), primarily among volunteer firefighters (73.9%, n = 119). After the passage of legislation mandating fitness standards in California, a downtrend in the number of volunteer firefighter fatalities is observed. However, a null effect was observed in Tennessee after the passage of similar fitness standards as in California. CONCLUSIONS/APPLICATIONS TO PRACTICE: Volunteer firefighters are significantly more likely to die of a cardiovascular event than career and wildland firefighters, both of which have stricter fitness standards. However, the effect of legislation mandating stricter fitness standards among volunteers did not produce a clear benefit for preventing fatalities. Nurses need to promote cardiovascular health among volunteer firefighters.

Signs and Symptoms Clusters Among Patients With Acute Heart Failure: A Correlational Study.

BACKGROUND: Patients with acute heart failure present to the emergency department with a myriad of signs and symptoms. Symptoms evaluated in clusters may be more meaningful than those evaluated individually by clinicians. OBJECTIVE: Among emergency department patients, we aimed to identify signs and symptoms correlations, clusters, and differences in clinical variables between clusters. METHODS: Medical record data included adults older than 18 years, International Classification of Diseases, Tenth Revisions codes , and positive Framingham Heart Failure Diagnostic Criteria. Exclusion criteria included medical records with a ventricular assist device and dialysis. For analysis, correlation, and the Gower distance, the independent t test, Mann-Whitney U test, χ 2 test, and regression were performed. RESULTS: A secondary analysis was conducted from the data set to evaluate door-to-diuretic time among patients with acute heart failure in the emergency department. A total of 218 patients were included, with an average age of 69 ± 15 years and predominantly White (74%, n = 161). Two distinct symptom clusters were identified: severe and mild congestion. The severe congestion cluster had a more comorbidity burden compared with the mild congestion cluster, as measured by the Charlson Comorbidity index (cluster 1 vs cluster 2, 6 [5-7] vs 5 [4-6]; P = .0019). Heart failure with preserved ejection fraction was associated with the severe congestion symptom cluster ( P = .009), and heart failure with mildly reduced ejection fraction was associated with the mild congestion cluster ( P = .019). CONCLUSIONS: In conclusion, 2 distinct symptom clusters were identified among patients with acute heart failure. Symptom clusters may be related to ejection fraction or overall cardiac output and comorbidity burden.

Integrative review of electrocardiographic characteristics in patients with reduced, mildly reduced, and preserved heart failure.

INTRODUCTION: Electrocardiographic (ECG) changes in heart failure with reduced, mildly reduced, and preserved ejection fractions can be critical in clinical assessment while waiting to perform echocardiograms or when it is unavailable. This integrative review aimed to identify ECG characteristics among hospitalized patients demonstrating three types of heart failure during acute decompensation. METHODS: We searched an electronic database of PubMed, Web of Science, EMBASE, Scopus, Google Scholar, and ClinicalTrials.gov using medical subject headings (MeSH) terms and keywords. Sixteen studies were synthesized and reported. RESULTS: Heart failure with reduced ejection fraction (HFrEF) was more common in men, comorbid with coronary artery diseases and diabetes mellitus, higher BNP/Pro-BNP, wide QRS, and left bundle branch block on ECG. On average, clients with heart failure with preserved ejection fraction (HFpEF) were older and more likely to have a history of atrial fibrillation, valvular heart diseases, hypertension, chronic obstructive pulmonary, and atrial fibrillation (AF) on ECG. Patients with mildly reduced (HFmrEF) were more similar to HFpEF in older patients, comorbid with hypertension, AF and valvular diseases, and AF on ECG. CONCLUSIONS: ECG characteristics might be related to left ventricular ejection fraction. Demographics, BNP/Pro-BNP, and ECG changes might help differentiate different heart failure types. Therefore, ECG might be a prognostic tool while caring for heart failure patients when highly skilled resources are unavailable. These identified ECG characteristics help generate research hypotheses and warrant validation in future research.

Ventricular tachycardia and in-hospital mortality in the intensive care unit.

Background: Continuous electrocardiographic (ECG) monitoring is used to identify ventricular tachycardia (VT), but false alarms occur frequently. Objective: The purpose of this study was to assess the rate of 30-day in-hospital mortality associated with VT alerts generated from bedside ECG monitors to those from a new algorithm among intensive care unit (ICU) patients. Methods: We conducted a retrospective cohort study in consecutive adult ICU patients at an urban academic medical center and compared current bedside monitor VT alerts, VT alerts from a new-unannotated algorithm, and true-annotated VT. We used survival analysis to explore the association between VT alerts and mortality. Results: We included 5679 ICU admissions (mean age 58 ± 17 years; 48% women), 503 (8.9%) experienced 30-day in-hospital mortality. A total of 30.1% had at least 1 current bedside monitor VT alert, 14.3% had a new-unannotated algorithm VT alert, and 11.6% had true-annotated VT. Bedside monitor VT alert was not associated with increased rate of 30-day mortality (adjusted hazard ratio [aHR] 1.06; 95% confidence interval [CI] 0.88-1.27), but there was an association for VT alerts from our new-unannotated algorithm (aHR 1.38; 95% CI 1.12-1.69) and true-annotated VT(aHR 1.39; 95% CI 1.12-1.73). Conclusion: Unannotated and annotated-true VT were associated with increased rate of 30-day in-hospital mortality, whereas current bedside monitor VT was not. Our new algorithm may accurately identify high-risk VT; however, prospective validation is needed.

Secondary electrocardiographic stratification of NSTEMI to identify an acutely occluded culprit artery.

In the United States, approximately 720 000 adults will experience a myocardial infarction (MI) every year. The 12-lead electrocardiogram (ECG) is quintessential for the classification of a MI. About 30% of all MIs exhibit ST-segment elevation on the 12-lead ECG and is therefore classified as an ST-Elevation Myocardial Infarction (STEMI), which is treated emergently with percutaneous coronary intervention to restore blood flow. However, in the remaining 70% of MIs, the 12-lead ECG lacks ST-segment elevation and instead exhibits a motley of changes, including ST-segment depression, T-wave inversion, or, in up to 20% of patients, have no changes whatsoever; as such, these MIs are classified as a Non-ST Elevation Myocardial Infarction (NSTEMI). Of this larger classification of MIs, 33% of NSTEMI actually have an occlusion of the culprit artery consistent with a Type I MI . This is a serious clinical problem because NSTEMI with an occluded culprit artery have similar myocardial damage like STEMI and are more likely to suffer from adverse outcomes compared to NSTEMI without an occluded culprit artery. In this review article, we review the extant literature on NSTEMI with an occluded culprit artery. Afterward, we generate and discuss hypotheses for the absence of ST-segment elevation on the 12-lead ECG: (1) transient occlusion (2) collateral blood flow and chronically occluded artery and (3) ECG-silent myocardial regions. Lastly, we describe and define novel ECG features that are associated with an occluded culprit artery in NSTEMI which include T-wave morphology abnormalities and novel markers of ventricular repolarization heterogeneity.

An annotated ventricular tachycardia (VT) alarm database: Toward a uniform standard for optimizing automated VT identification in hospitalized patients.

BACKGROUND: False ventricular tachycardia (VT) alarms are common during in-hospital electrocardiographic (ECG) monitoring. Prior research shows that the majority of false VT can be attributed to algorithm deficiencies. PURPOSE: The purpose of this study was: (1) to describe the creation of a VT database annotated by ECG experts and (2) to determine true vs. false VT using a new VT algorithm created by our group. METHODS: The VT algorithm was processed in 5320 consecutive ICU patients with 572,574 h of ECG and physiologic monitoring. A search algorithm identified potential VT, defined as: heart rate >100 beats/min, QRSs > 120 ms, and change in QRS morphology in >6 consecutive beats compared to the preceding native rhythm. Seven ECG channels, SpO2 , and arterial blood pressure waveforms were processed and loaded into a web-based annotation software program. Five PhD-prepared nurse scientists performed the annotations. RESULTS: Of the 5320 ICU patients, 858 (16.13%) had 22,325 VTs. After three levels of iterative annotations, a total of 11,970 (53.62%) were adjudicated as true, 6485 (29.05%) as false, and 3870 (17.33%) were unresolved. The unresolved VTs were concentrated in 17 patients (1.98%). Of the 3870 unresolved VTs, 85.7% (n = 3281) were confounded by ventricular paced rhythm, 10.8% (n = 414) by underlying BBB, and 3.5% (n = 133) had a combination of both. CONCLUSIONS: The database described here represents the single largest human-annotated database to date. The database includes consecutive ICU patients, with true, false, and challenging VTs (unresolved) and could serve as a gold standard database to develop and test new VT algorithms.

The Use of Interactive Technology to Improve Student Accuracy on Electrocardiographic Interpretation.

ABSTRACT: Electrocardiography (ECG) instruction relies heavily on memorization of interpretation rules and lacks opportunities for hands-on practice. Consequently, nursing students struggle with ECG interpretation. In an online undergradute nursing course, we implemented interactive technology to facilitate kinesthetic pedagogy. Accuracy was evaluated at midterm and during final assessments by two experts using a standardized rubric. Students who engaged with interactive technology at both assessments demonstrated consistent accuracy of ECG interpretation; students who did not failed to demonstrate consistent accuracy with ECG interpretation. Incorporating interactive technology to facilitate psychomotor learning may be essential in improving the accuracy of ECG interpretation.

Correlates of Autonomic Function, Hemodynamics, and Physical Activity Performance During Exercise Stress Testing Among Firefighters.

BACKGROUND: Autonomic dysfunction is an important propagator of cardiometabolic disease and can be measured using multiple metrics such as heart rate variability (HRV) and heart rate recovery (HRR). The relationships between HRV and HRR have not been fully examined, nor have the relationships between HRV, HRR, and other physiological measures linked to cardiometabolic disease (e.g., blood pressure recovery). Evaluation of these additional relationships may provide new insights into the association between autonomic function and cardiometabolic disease especially among high-risk groups like firefighters. METHODS: 92 firefighters (96% male, 81% white) without overt cardiovascular disease underwent exercise testing with continuous heart rate (HR) and blood pressure (BP) monitoring. HRR was the difference between maximal HR and HR 1-minute post-exercise; BP recovery (BPR) was the difference between maximal BP and BP 2-minute post-exercise. Afterwards, participants underwent 24-hour electrocardiographic monitoring to measure HRV. Unadjusted Spearman correlations and adjusted partial Spearman correlations were computed. Between group analyses were also conducted with Kruskal-Wallis test. RESULTS: Associations between HRV and HRR poorly converged (RMSSD and HRR, unadjusted = 0.235; adjusted = 0.144). SDNN Index exhibited the strongest association with parasympathetic tone exhibited by overall lower HRs (unadjusted = -0.600; adjusted = -0.631). HRR demonstrated stronger associations with systolic and diastolic BP responses during exercise (SBP Recovery unadjusted = 0.267; adjusted = 0.297; DBP Recovery unadjusted = -0.276; adjusted = -0.232). CONCLUSIONS: Overall, while HRV metrics converged and were associated with lower resting heart rates, HRV and HRR poorly converged. Interestingly, HRR was related with measures of hemodynamics indicating a potential relationship with vascular function during both maximal exercise and exercise recovery.

Methodological correlates of variability in the prevalence of posttraumatic stress disorder in high-risk occupational groups: A systematic review and meta-regression.

BACKGROUND: Although numerous studies have reported on PTSD prevalence in high-risk occupational samples, previous meta-analytic work has been severely limited by the extreme variability in prevalence outcomes. METHODS: The present systematic review and meta-regression examined methodological sources of variability in PTSD outcomes across the literature on high-risk personnel with a specific focus on measurement tool selection. RESULTS: The pooled global prevalence of PTSD in high-risk personnel was 12.1% [6.5%, 23.5%], and was similar to estimates obtained in other meta-analytic work. However, meta-regression revealed that PTSD prevalence differed significantly as a function of measurement tool selection, study inclusion criteria related to previous traumatic exposure, sample size, and study quality. PTSD prevalence estimates also differed significantly by occupational group and over time, as has also been reported in previous work, though exploratory examination of trends in measurement selection across these factors suggests that measurement strategy may partially explain some of these previously reported differences. CONCLUSIONS: Our results highlight a pressing need to better understand the role of measurement strategies and other methodological choices in characterizing variable prevalence outcomes. Understanding the role of methodological variance will be critical for work attempting to reliably characterize prevalence as well as risk and protective factors for PTSD.