Can 24 h of ambulatory ECG be used to triage patients to extended monitoring?

BACKGROUND: Access to long-term ambulatory recording to detect atrial fibrillation (AF) is limited for economical and practical reasons. We aimed to determine whether 24 h ECG (24hECG) data can predict AF detection on extended cardiac monitoring. METHODS: We included all US patients from 2020, aged 17-100 years, who were monitored for 2-30 days using the PocketECG device (MEDICALgorithmics), without AF ≥30 s on the first day (n = 18,220, mean age 64.4 years, 42.4% male). The population was randomly split into equal training and testing datasets. A Lasso model was used to predict AF episodes ≥30 s occurring on days 2-30. RESULTS: The final model included maximum heart rate, number of premature atrial complexes (PACs), fastest rate during PAC couplets and triplets, fastest rate during premature ventricular couplets and number of ventricular tachycardia runs ≥4 beats, and had good discrimination (ROC statistic 0.7497, 95% CI 0.7336-0.7659) in the testing dataset. Inclusion of age and sex did not improve discrimination. A model based only on age and sex had substantially poorer discrimination, ROC statistic 0.6542 (95% CI 0.6364-0.6720). The prevalence of observed AF in the testing dataset increased by quintile of predicted risk: 0.4% in Q1, 2.7% in Q2, 6.2% in Q3, 11.4% in Q4, and 15.9% in Q5. In Q1, the negative predictive value for AF was 99.6%. CONCLUSION: By using 24hECG data, long-term monitoring for AF can safely be avoided in 20% of an unselected patient population whereas an overall risk of 9% in the remaining 80% of the population warrants repeated or extended monitoring.

Diagnostic yield of ambulatory cardiac monitoring in pediatric patients with palpitations.

Background: Palpitations are a frequent reason for referral to pediatric cardiology providers and diagnostic workup includes ambulatory cardiac monitoring. While common practice, the diagnostic yield is unknown in the pediatric population. The objective is to evaluate the diagnostic yield of 24-h Holter and extended ambulatory cardiac monitoring in pediatric patients with palpitations. Methods and Results: All pediatric patients aged 10-18 years who had ambulatory cardiac monitoring (1-30 days) through the Pocket Electrocardiogram (PocketECG™) system (Medi-Lynx) between January 2016 and July 2020 were included. Patients with an International Classification of Diseases-10 diagnosis code of palpitations (R00.2) during enrollment were evaluated separately. Tachyarrhythmia diagnoses included atrial fibrillation (AF), nonsustained supraventricular tachycardia (nSVT), supraventricular tachycardia (SVT), nonsustained ventricular tachycardia (nVT), and ventricular tachycardia (VT). Age, heart rates, arrhythmia type, and symptomatic transmission data were collected and analyzed. A total of 2388 patients (mean age 11.6 years, 58% F) with the R00.2 code had ambulatory cardiac monitoring (28% 24-h Holter, 72% extended) performed during the study period and there were 6287 total patients (mean age 13.9 years, 54% F) that underwent ambulatory cardiac monitoring (42% 24-h Holter, 58% extended) during that time. Of 2388 patients, 321 (13%) were diagnosed with tachyarrhythmia: AF (9), nSVT (192), SVT (59), and nVT (61). In the overall cohort, 764 (12%) patients were diagnosed with tachyarrhythmia: AF (22), nSVT (478), SVT (85), nVT (177), and VT (2). Symptomatic transmissions with normal cardiac rhythm were common in the R00.2 (n = 1697, 71%) and overall (n = 3848, 61%) groups. No episodes of nSVT, SVT, nVT, or VT were associated with symptomatic transmissions. Conclusion: Ambulatory cardiac monitors are an integral part of the diagnostic workup for pediatric palpitations patients and have demonstrated a high yield of combined positive arrhythmia diagnoses and symptomatic normal transmissions. Further prospective study of this population with the integration of clinical information is warranted.

Ventricular tachycardia risk prediction with an abbreviated duration mobile cardiac telemetry.

Background: Ventricular tachycardia (VT) occurs intermittently, unpredictably, and has potentially lethal consequences. Objective: Our aim was to derive a risk prediction model for VT episodes ≥10 beats detected on 30-day mobile cardiac telemetry based on the first 24 hours of the recording. Methods: We included patients who were monitored for 2 to 30 days in the United States using full-disclosure mobile cardiac telemetry, without any VT episode ≥10 beats on the first full recording day. An elastic net prediction model was derived for the outcome of VT ≥10 beats on monitoring days 2 to 30. Potential predictors included age, sex, and electrocardiographic data from the first 24 hours: heart rate; premature atrial and ventricular complexes occurring as singlets, couplets, triplets, and runs; and the fastest rate for each event. The population was randomly split into training (70%) and testing (30%) samples. Results: In a population of 19,781 patients (mean age 65.3 ± 17.1 years, 43.5% men), with a median recording time of 18.6 ± 9.6 days, 1510 patients had at least 1 VT ≥10 beats. The prediction model had good discrimination in the testing sample (area under the receiver-operating characteristic curve 0.7584, 95% confidence interval 0.7340-0.7829). A model excluding age and sex had an equally good discrimination (area under the receiver-operating characteristic curve 0.7579, 95% confidence interval 0.7332-0.7825). In the top quintile of the score, more than 1 in 5 patients had a VT ≥10 beats, while the bottom quintile had a 98.2% negative predictive value. Conclusion: Our model can predict risk of VT ≥10 beats in the near term using variables derived from 24-hour electrocardiography, and could be used to triage patients to extended monitoring.

Ambulatory Cardiac Monitoring in Infants with Supraventricular Tachycardia.

Supraventricular tachycardia (SVT) is a frequent cause of tachyarrhythmia in infants < 1 year of age and ambulatory cardiac monitoring is an important tool for diagnosis and follow-up of these patients. We retrospectively reviewed 594 infants (mean age 4.05 months, SD 3.55; 54% M) who underwent ambulatory cardiac monitoring (69% 24 h Holter, 31% extended monitor) through the Pocket ECG system (MediLynx) between January 2016 and July 2020. 170 patients who had the ICD-10 code I47.1 for SVT used at enrollment were analyzed separately. 49 (8.3%) patients had sustained SVT or non-sustained SVT (nSVT) during the study period, including 20 patients (11.8%) who had the ICD-10 code I47.1 at enrollment. Extended ambulatory cardiac monitors detected 61% of all patients with nSVT or SVT and was superior when compared to 24 h Holter (p < 0.0001). In the overall group, the first episode of SVT or nSVT was detected within 24 h of monitoring in 40/49 patients (82%). 48/49 patients (98%) were diagnosed within a week of monitoring and the single remaining patient was diagnosed with nSVT at day 15 of monitoring. There was no significant difference in minimal, maximal, and average heart rate between patients with and without ICD-10 code I47.1 at enrollment or between patients with and without SVT or nSVT. Despite their low yield, ambulatory cardiac monitors are an important diagnostic tool. The ideal length of monitoring in patients with known or suspected SVT has yet to be defined, although all patients in our cohort were identified by day 15 of monitoring.

Diagnostic yield is dependent on monitoring duration. Insights from a full-disclosure mobile cardiac telemetry system.

BACKGROUND: Despite the advancement of electrocardiogram (ECG) monitoring methods, the most important factor influencing diagnostic yield (DY) may still be monitoring duration. Ambulatory ECG monitoring, typically with 24-48 hours duration, is widely used but may result in underdiagnosis of rare arrhythmias. AIMS: This study aimed to examine the relationship between the DY and monitoring duration in a large patient cohort and investigate sex and age differences in the presentation of arrhythmias. METHODS: The study population consisted of 25 151 patients (57.8% women; median [interquartile range, IQR], 71 [64-78] years), who were examined with mobile cardiac telemetry during 2017 in the United States, using the PocketECGTM that continuously transmits a signal on a beat-to-beat basis. We investigated the occurrence of atrial fibrillation at a burden of both ≤1% (atrial fibrillation [AF], ≤1%) and ≤10% (AF ≤10%), premature ventricular contractions (PVC; >10 000 per 24 hours), non-sustained ventricular tachycardias (nsVT), sustained ventricular tachycardias (VT ≥30 seconds), atrioventricular blocks (AVB), pauses of >3 seconds duration, and bradycardia (heart rate <40 beats per minute for ≥60 seconds). RESULTS: The median (IQR) recording duration was 15.4, 8.2-28.2) days. The DY increased gradually with monitoring duration for all types of investigated arrhythmias. Compared to DY after up to 30 days of monitoring, a standard 24 hours monitoring resulted in DY for males/females of 20%/18% for AF ≤1%, 29%/28% for AF ≤10%, 45%/40% for PVCs, 17%/11% for nsVT, 17%/11% for VT ≥30 seconds, 49%/42 for AVB, 27%/20% for pauses, 36%/29% for bradycardia. CONCLUSION: A substantial number of patients suffering from arrhythmias may remain undiagnosed due to insufficient ECG monitoring time.

Sex differences in presentation of atrial fibrillation: Findings from 30-day ambulatory monitoring in real-world practice.

Background: Women are less likely to receive oral anticoagulation or ablation for treatment of atrial fibrillation (AF). Identification of sex differences in arrhythmia characteristics and symptoms may lead to a better understanding of potential reasons for these differences. Objectives: To determine sex differences in AF with respect to heart rate, duration, burden, and symptoms in patients undergoing mobile cardiac telemetry (MCT) monitoring. Methods: All patients who registered for ≤30-day MCT using PocketECG (MediLynx) in the USA in 2017 were included (n = 27,512, 58 % women). PocketECG records and transmits a three-lead ambulatory electrocardiogram (ECG) with real-time beat-to-beat analysis. Sex-related differences were analyzed with Chi2 and Spearmans rho. Results: Fewer women than men were diagnosed with AF lasting ≥30s (13.7 % versus [vs] 19.0 %, p < 0.001). AF burden was lower in women in all age groups <90 years (all p < 0.01). Women were older at the time of AF diagnosis (median 76 vs 73 years, p < 0.001), had faster heart rate during AF (mean: 104.7 ± 26.0 vs 96.7 ± 26.7 bpm, p < 0.001), and shorter AF duration (mean: 96.2 ± 176.0 vs 121.6 ± 189.9 min, p < 0.001). There was a non-significant trend toward more symptoms (such as dizziness, racing heart, fatigue, or palpitations) during AF in women compared to men (46.5 % vs 43.7 %, p = 0.062). Conclusions: AF was less prevalent and occurred at lower burdens in women than men in each age strata. Despite faster heart rates in AF in women, there were no significant sex differences in reported symptoms during AF. Sex differences in therapy cannot be explained by differences in symptoms or rates in AF. Condensed abstract: Real-world data on sex differences in AF using a 30-day MCT monitoring device remain scarce. We aim to determine the sex differences in AF with respect to prevalence, burden, heart rate, and symptom in patients undergoing ≤30-day MCT monitoring. Our data analysis suggests that fewer women than men had AF, women were older at diagnosis of AF, and women with AF had higher mean heart rate, shorter mean AF duration, and lower mean AF burden than men. Further studies are needed to examine reasons for sex differences, specifically in relation to AF therapy and its impact on clinical outcomes.

Rheological properties of kuzu starch pastes with galactomannans.

The paper describes the effects of galactomannans on viscoelastic properties of commercial Japanese white kuzu starch pastes. The study included morphological, thermal and rheological analyses of the biopolymer. The results obtained in the form of storage modulus G'(ω) and loss modulus G″(ω) were described by the modified fractional Kelvin-Voigt model with two springpot-type elements, created on the basis of differential calculus of fractional order and Fourier transform. It allowed to determine 17 material parameters providing a lot of additional information about structure and viscoelastic properties of the biopolymer in comparison to the classical analysis of oscillatory and creep tests. The study led to the conclusion that commercial Japanese white kuzu starch was so-called type II starch with a high pasting temperature of 75 °C and an average granule diameter equal to 10.9 µm. Rheological properties of the pastes depended on the galactose-to-mannose ratio in galactomannan molecule. The larger substitution degree, the higher viscosity, characteristic relaxation times, polydispersity index, gel stiffness, and the lower cross-linking density and average molecular weights. The presence of galactose side groups favored the hydration and immobilization of water molecules.

Rheo-Kinetic Study of Sol-Gel Phase Transition of Chitosan Colloidal Systems.

Chitosan colloidal systems, created by dispersing in aqueous solutions of hydrochloric acid, with and without the addition of disodium ß-glycerophosphate (ß-NaGP), were prepared for the investigation of forming mechanisms of chitosan hydrogels. Three types of chitosan were used in varying molecular weights. The impacts of the charge and shape of the macromolecules on the phase transition process were assessed. The chitosan system without the addition of ß-NaGP was characterized by stiff and entangled molecules, in contrast to the chitosan system with the addition of ß-NaGP, wherein the molecules adopt a more flexible and disentangled form. Differences in molecules shapes were confirmed using the Zeta potential and thixotropy experiments. The chitosan system without ß-NaGP revealed a rapid nature of phase transition-consistent with diffusion-limited aggregation (DLA). The chitosan system with ß-NaGP revealed a two-step nature of phase transition, wherein the first step was consistent with reaction-limited aggregation (RLA), while the second step complied with diffusion-limited aggregation (DLA).

The Application of Small-Angle Light Scattering for Rheo-Optical Characterization of Chitosan Colloidal Solutions.

In the recent studies on chitosan hydrogels, it was found that understanding both rheological and structural properties plays an important role in their application. Therefore, a combination of two independent techniques was applied to investigate micro- and macroscopic properties of chitosan colloidal system. Studies on viscous properties, as well as the sol-gel phase transition process, were performed using rheological methods coupled with the small angle light scattering (SALS) technique. Based on the anisotropy of scattering patterns obtained during rotational shear tests, it was found that the chitosan solution reveals two different behaviors delimited by the critical value of the shear rate. Below a critical value, chitosan clusters are deformed without breaking up aggregates, whereas after exceeding a critical value, chitosan clusters apart from deformation also breakup into smaller aggregates. The values of the radius of gyration determined by applying the Debye function allow one to state that with an increase of chitosan concentration, molecule size decreases. An analysis of the light scattering data from the temperature ramp test showed that with an increase of temperature, the level of polymer coil swelling increases. Simultaneously, the supply of thermal energy leads to a neutralization of the charge of chitosan chains. As a consequence, the formation of intermolecular links occurs and a gel structure is formed.

The effect of structural properties on rheological behaviour of starches in binary dimethyl sulfoxide-water solutions.

This research study analysed the rheological properties of potato amylose and potato amylopectin in binary solutions of the following water and dimethyl sulfoxide concentrations: 90% DMSO (1), 80% DMSO (2) and 50% DMSO (3), with preparation methodology involving the dissolution at the temperature of 98°C. The studies of dynamic light scattering on the biopolymer coils and the determination of main relaxation times of the solutions were carried out. For the amylose solutions, the fast relaxation phenomena are predominant. The results of the quality tests of the hysteresis loop showed, that the amylose solutions in the solvents (1) and (2) are rheologically stable and shear-thickened. The amylose solutions in solvents (3) reveal oscillatory alterations of viscosity in the time. Amylopectin solutions are characterized by 80% share of slow relaxation phenomena, very low diffusion coefficients and hydrodynamic radii in the range of 2000 nm. The amylopectin solutions are rheologically unstable.

Fractional Generalizations of Maxwell and Kelvin-Voigt Models for Biopolymer Characterization.

The paper proposes a fractional generalization of the Maxwell and Kelvin-Voigt rheological models for a description of dynamic behavior of biopolymer materials. It was found that the rheological models of Maxwell-type do not work in the case of modeling of viscoelastic solids, and the model which significantly better describes the nature of changes in rheological properties of such media is the modified fractional Kelvin-Voigt model with two built-in springpots (MFKVM2). The proposed model was used to describe the experimental data from the oscillatory and creep tests of 3% (w/v) kuzu starch pastes, and to determine the values of their rheological parameters as a function of pasting time. These parameters provide a lot of additional information about structure and viscoelastic properties of the medium in comparison to the classical analysis of dynamic curves G' and G" and shear creep compliance J(t). It allowed for a comprehensive description of a wide range of properties of kuzu starch pastes, depending on the conditions of pasting process.

Viscoelastic properties of soft materials on a basis of starch mixtures.

UNLABELLED: The effect of concentration of carbohydrates on viscoelastic properties of corn and rice starch is discussed in this paper. The texture of starch pastes was estimated using a fractional rheological linear standard solid model. Rheological parameters of the model were identified and their changes for different values of sugar concentrations in the 2 tested starches were discussed. PRACTICAL APPLICATION: The fractional rheological models can be very useful to control the biomaterial texture for the needs of final product, which is particularly significant from the point of view of materials engineering. The proposed method for interpretation of the results of rheological measurements of these pastes allows for a comprehensive estimation of the analyzed biomaterial texture.

PocketECG: a new continuous and real-time ambulatory arrhythmia diagnostic method.

This article presents a new approach to ambulatory arrhythmia monitoring, one which can be viewed as a natural evolution of the existing non-invasive methods for diagnosing heart rhythm abnormalities. This new method combines the real-time capabilities of modern mobile cardiovascular telemetry systems with a quantitative way of reporting measured findings and continuous storage of the ECG data typical of Holter monitoring systems. It further combines this with a symptom-reporting capability typical of event monitoring applications. Combining all these features produces a single device which could be described as the ultimate arrhythmia diagnostic tool.