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Electrocardiogram-Based Deep Learning to Predict Mortality in Repaired Tetralogy of Fallot. 基于心电图的深度学习预测法洛氏四联症修复后的死亡率
IF 8 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-09-04 DOI: 10.1016/j.jacep.2024.07.015
Joshua Mayourian, Juul P A van Boxtel, Lynn A Sleeper, Vedang Diwanji, Alon Geva, Edward T O'Leary, John K Triedman, Sunil J Ghelani, Rachel M Wald, Anne Marie Valente, Tal Geva

Background: Artificial intelligence-enhanced electrocardiogram (AI-ECG) analysis shows promise to predict mortality in adults with acquired cardiovascular diseases. However, its application to the growing repaired tetralogy of Fallot (rTOF) population remains unexplored.

Objectives: This study aimed to develop and externally validate an AI-ECG model to predict 5-year mortality in rTOF.

Methods: A convolutional neural network was trained on electrocardiograms (ECGs) obtained at Boston Children's Hospital and tested on Boston (internal testing) and Toronto (external validation) INDICATOR (International Multicenter TOF Registry) cohorts to predict 5-year mortality. Model performance was evaluated on single ECGs per patient using area under the receiver operating (AUROC) and precision recall (AUPRC) curves.

Results: The internal testing and external validation cohorts comprised of 1,054 patients (13,077 ECGs at median age 17.8 [Q1-Q3: 7.9-30.5] years; 54% male; 6.1% mortality) and 335 patients (5,014 ECGs at median age 38.3 [Q1-Q3: 29.1-48.7] years; 57% male; 8.4% mortality), respectively. Model performance was similar during internal testing (AUROC 0.83, AUPRC 0.18) and external validation (AUROC 0.81, AUPRC 0.21). AI-ECG performed similarly to the biventricular global function index (an imaging biomarker) and outperformed QRS duration. AI-ECG 5-year mortality prediction, but not QRS duration, was a significant independent predictor when added into a Cox regression model with biventricular global function index to predict shorter time-to-death on internal and external cohorts. Saliency mapping identified QRS fragmentation, wide and low amplitude QRS complexes, and flattened T waves as high-risk features.

Conclusions: This externally validated AI-ECG model may complement imaging biomarkers to improve risk stratification in patients with rTOF.

背景:人工智能增强心电图(AI-ECG)分析有望预测成人后天性心血管疾病患者的死亡率。然而,其在日益增长的法洛氏四联症(rTOF)修复人群中的应用仍有待探索:本研究旨在开发并从外部验证一个人工智能心电图模型,以预测法洛氏四联症患者的 5 年死亡率:在波士顿儿童医院获得的心电图(ECG)上训练了一个卷积神经网络,并在波士顿(内部测试)和多伦多(外部验证)INDICATOR(国际多中心TOF注册)队列中进行了测试,以预测5年死亡率。使用接收者操作(AUROC)和精确召回(AUPRC)曲线对每位患者的单张心电图进行了模型性能评估:内部测试组和外部验证组分别包括 1,054 名患者(13,077 张心电图,中位年龄为 17.8 [Q1-Q3: 7.9-30.5] 岁;54% 为男性;死亡率为 6.1%)和 335 名患者(5,014 张心电图,中位年龄为 38.3 [Q1-Q3: 29.1-48.7] 岁;57% 为男性;死亡率为 8.4%)。模型在内部测试(AUROC 0.83,AUPRC 0.18)和外部验证(AUROC 0.81,AUPRC 0.21)中的表现相似。AI-ECG的表现与双心室整体功能指数(成像生物标志物)相似,而优于QRS持续时间。当将 AI-ECG 与双心室整体功能指数一起加入 Cox 回归模型以预测内部和外部队列的较短死亡时间时,AI-ECG(而非 QRS 持续时间)是一个重要的独立预测因子。Saliency mapping确定QRS片段、宽而低振幅的QRS波群和平坦的T波为高风险特征:这一经外部验证的人工智能-心电图模型可与影像生物标志物互补,从而改善 rTOF 患者的风险分层。
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引用次数: 0
Modeling Idiopathic Ventricular Fibrillation Using iPSC Cardiomyocytes and Computational Approaches: A Proof-of-Concept Study. 利用 iPSC 心肌细胞和计算方法模拟特发性室颤:概念验证研究
IF 8 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-09-03 DOI: 10.1016/j.jacep.2024.07.014
Louise Reilly, Mitchell Josvai, Manasa Kalluri, Corey L Anderson, Haibo Ni, Kate M Orland, Di Lang, Alexey V Glukhov, Eleonora Grandi, Lee L Eckhardt

Idiopathic ventricular fibrillation (IVF) is an unrefined diagnosis representing a heterogeneous patient group without a structural or genetic definition. IVF treatment is not mechanistic-based due to the lack of experimental patient-models. We sought to create a methodology to assess cellular arrhythmia mechanisms for IVF as a proof-of-concept study. Using IVF patient-specific induced pluripotent stem cell-derived cardiomyocytes, we integrate electrophysiological optical mapping with computational modeling to characterize the cellular phenotype. This approach flips the traditional paradigm using a biophysically detailed computational model to solve the problem inversely. Insight into the cellular mechanisms of this patient's IVF phenotype could also serve as a therapeutic testbed.

特发性心室颤动(IVF)是一种未经细化的诊断,代表了一个没有结构或基因定义的异质性患者群体。由于缺乏实验性患者模型,IVF 的治疗并非基于机理。我们试图创建一种方法来评估试管婴儿的细胞心律失常机制,作为概念验证研究。利用试管婴儿患者特异性诱导多能干细胞衍生的心肌细胞,我们将电生理学光学绘图与计算建模相结合,以表征细胞表型。这种方法颠覆了使用生物物理详细计算模型反向解决问题的传统范式。深入了解该患者体外受精表型的细胞机制也可作为治疗试验平台。
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引用次数: 0
Ventricular Tachycardia Substrates in Children and Young Adults With Repaired Tetralogy of Fallot. 患有法洛氏四联症修复术的儿童和青少年的室性心动过速基质。
IF 8 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-09-02 DOI: 10.1016/j.jacep.2024.07.016
Justin Wallet, Yoshitaka Kimura, Nico A Blom, Monique R M Jongbloed, Robin A Bertels, Mark G Hazekamp, Katja Zeppenfeld

Background: Patients with repaired tetralogy of Fallot (rTOF) have a time-dependent increased risk of ventricular tachycardia (VT). Slow conducting anatomical isthmuses (SCAIs) are the dominant VT substrates in adults with rTOF. It is unknown if they are present at younger age.

Objectives: This study aimed to characterize VT substrates in patients with rTOF <30 years of age.

Methods: Data of consecutive patients with rTOF aged <30 years who underwent electroanatomical mapping and programmed electrical stimulation between 2005 and 2022 were analyzed.

Results: Fifty-five patients were included (median age: 15.8 years, IQR: 13.8-21.8 years; 15 repaired via ventriculotomy; 13 complex TOF variants). Twelve patients had right ventricle-to-pulmonary artery conduits inserted during initial repair or had early pulmonary valve replacement (PVR) (<1 year after repair). Indications for electroanatomical mapping and programmed electrical stimulation were spontaneous VT, before PVR, and risk stratification in 5, 40, and 10 patients, respectively. In 16 patients (29%), SCAI 3 was identified; no other SCAI was present. Monomorphic VT was inducible in 8 and related to SCAI 3 in 7 patients. Identified VT substrates were targeted by ablation. Right ventricle-to-pulmonary artery conduit/early PVR, ventriculotomy, and complex TOF were associated with SCAI 3 in univariable analysis. During a median follow-up of 5.3 years, VT recurred in 2 patients. No patients died.

Conclusions: In young patients with rTOF, SCAI 3 is the dominant substrate for VT. Complex TOF and interrelated type and timing of (re-)operation may contribute to the development of SCAI 3 already at a young age.

背景:经修复的法洛氏四联症(rTOF)患者发生室速(VT)的风险随时间而增加。慢传导解剖峡部(SCAI)是成年法洛氏四联症患者室速的主要基质。目前尚不清楚它们是否存在于更年轻的患者中:本研究旨在确定 rTOF 患者 VT 基底的特征:结果:共纳入 55 名患者(年龄在 15 岁以下):共纳入 55 例患者(中位年龄:15.8 岁,IQR:13.8-21.8 岁;15 例经脑室切开术修复;13 例复杂 TOF 变异型)。12名患者在初次修复时植入了右心室至肺动脉导管,或进行了早期肺动脉瓣置换术(PVR)(结论:在年轻的 rTOF 患者中,SCAI 3 是 VT 的主要基质。复杂的TOF与(再)手术的类型和时间相互关联,可能会导致年轻患者就出现SCAI 3。
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引用次数: 0
Biatrial Resynchronization With Electrogram-Guided Bachmann Bundle Pacing 电图引导巴赫曼束起搏的心房再同步化技术
IF 8 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-09-01 DOI: 10.1016/j.jacep.2024.04.030
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引用次数: 0
Cardiac MRI Oversampling in Heart Digital Twins Improves Preprocedure Ventricular Tachycardia Identification in Postinfarction Patients 心脏核磁共振成像在心脏数字化双胞胎中的过度取样可提高梗死后患者术前室性心动过速的识别能力。
IF 8 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-09-01 DOI: 10.1016/j.jacep.2024.04.032

Background

Ventricular tachycardia (VT), which can lead to sudden cardiac death, occurs frequently in patients after myocardial infarction. Radiofrequency catheter ablation (RFA) is a modestly effective treatment of VT, but it has limitations and risks. Cardiac magnetic resonance (CMR)–based heart digital twins have emerged as a useful tool for identifying VT circuits for RFA treatment planning. However, the CMR resolution used to reconstruct these digital twins may impact VT circuit predictions, leading to incorrect RFA treatment planning.

Objectives

This study sought to predict RFA targets in the arrhythmogenic substrate using heart digital twins reconstructed from both clinical and high-resolution 2-dimensional CMR datasets and compare the predictions.

Methods

High-resolution (1.35 × 1.35 × 3 mm), or oversampled resolution (Ov-Res), short-axis late gadolinium–enhanced CMR was acquired by combining 2 subsequent clinical resolution (Clin-Res) (1.35 × 1.35 × 6 mm) short-axis late gadolinium–enhanced CMR scans from 6 post–myocardial infarction patients undergoing VT ablation and used to reconstruct a total of 3 digital twins (1 Ov-Res, 2 Clin-Res) for each patient. Rapid pacing was used to assess VT circuits and identify the optimal ablation targets in each digital twin. VT circuits predicted by the digital twins were compared with intraprocedural electroanatomic mapping data and used to identify emergent VT.

Results

The Ov-Res digital twins reduced partial volume effects and better predicted unique VT circuits compared with the Clin-Res digital twins (66.6% vs 54.5%; P < 0.01). Only the Ov-Res digital twin successfully identified emergent VT after a failed initial ablation.

Conclusions

Digital twin infarct geometry and VT circuit predictions depend on the magnetic resonance resolution. Ov-Res digital twins better predict VT circuits and emergent VT, which may improve RFA outcomes.
背景:室性心动过速(VT)可导致心脏性猝死,经常发生在心肌梗死后的患者身上。射频导管消融术(RFA)是一种治疗室性心动过速的有效方法,但也存在局限性和风险。基于心脏磁共振(CMR)的心脏数字孪缩已成为一种有用的工具,可用于识别VT回路以制定RFA治疗计划。然而,用于重建这些数字双胞胎的 CMR 分辨率可能会影响 VT 回路预测,从而导致不正确的 RFA 治疗计划:本研究试图利用从临床和高分辨率二维 CMR 数据集重建的心脏数字孪生来预测心律失常基质中的 RFA 靶点,并对预测结果进行比较。方法:高分辨率(1.35 × 1.35 × 3 毫米)或超采样分辨率(Ov-Res)短轴晚期钆增强 CMR 是通过合并 6 名接受 VT 消融术的心肌梗死后患者的 2 个后续临床分辨率(Clin-Res)(1.35 × 1.35 × 6 毫米)短轴晚期钆增强 CMR 扫描获得的,用于为每名患者重建共 3 个数字双胞胎(1 个 Ov-Res,2 个 Clin-Res)。快速起搏用于评估 VT 回路,并确定每个数字孪生中的最佳消融目标。将数字孪生预测的 VT 电路与术中电解剖图数据进行比较,并用于识别突发 VT:结果:与 Clin-Res 数字双胞胎相比,Ov-Res 数字双胞胎减少了部分容积效应,更好地预测了独特的 VT 回路(66.6% vs 54.5%;P < 0.01)。只有Ov-Res数字双胞胎成功识别了初始消融失败后出现的VT:结论:数字孪生心肌梗死的几何形状和VT回路预测取决于磁共振的分辨率。结论:数字孪生子梗死几何形状和 VT 回路预测取决于磁共振分辨率,Ov-Res 数字孪生子能更好地预测 VT 回路和突发 VT,从而改善 RFA 治疗效果。
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引用次数: 0
Long-Term Changes in Atrial Arrhythmia Burden After Renal Denervation Combined With Pulmonary Vein Isolation 肾去神经联合肺静脉隔离术后房性心律失常负担的长期变化SYMPLICITY-AF.
IF 8 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-09-01 DOI: 10.1016/j.jacep.2024.04.035

Background

The autonomic nervous system plays an important role in atrial fibrillation (AF) and hypertension. Renal denervation (RDN) lowers blood pressure (BP), but its role in AF is poorly understood.

Objectives

The purpose of this study was to investigate whether RDN reduces AF recurrence after pulmonary vein isolation (PVI).

Methods

This study randomized patients from 8 centers (United States, Germany) with drug-refractory AF for treatment with PVI+RDN vs PVI alone. A multielectrode radiofrequency Spyral catheter system was used for RDN. Insertable cardiac monitors were used for continuous rhythm monitoring. The primary efficacy endpoint was ≥2 minutes of AF recurrence or repeat ablation during all follow-up. The secondary endpoints included atrial arrhythmia (AA) burden, discontinuation of class I/III antiarrhythmic drugs, and BP changes from baseline.

Results

A total of 70 patients with AF (52 paroxysmal, 18 persistent) and uncontrolled hypertension were randomized (RDN+PVI, n = 34; PVI, n = 36). At 3.5 years, 26.2% and 21.4% of patients in RDN+PVI and PVI groups, respectively, were free from the primary efficacy endpoint (log rank P = 0.73). Patients with mean ≥1 h/d AA had less daily AA burden after RDN+PVI vs PVI (4.1 hours vs 9.2 hours; P = 0.016). More patients discontinued class I/III antiarrhythmic drugs after RDN+PVI vs PVI (45% vs 14%; P = 0.040). At 1 year, systolic BP changed by −17.8 ± 12.8 mm Hg and −13.7 ± 18.8 mm Hg after RDN+PVI and PVI, respectively (P = 0.43). The composite safety endpoint was not significantly different between groups.

Conclusions

In patients with AF and uncontrolled BP, RDN+PVI did not prevent AF recurrence more than PVI alone. However, RDN+PVI may reduce AF burden and antiarrhythmic drug usage, but this needs further prospective validation.
背景:自律神经系统在心房颤动(AF)和高血压中发挥着重要作用。肾脏神经支配(RDN)可降低血压(BP),但其在房颤中的作用却鲜为人知:本研究旨在探讨 RDN 是否能减少肺静脉隔离术(PVI)后房颤的复发:这项研究对来自 8 个中心(美国、德国)的药物难治性房颤患者进行了随机分组,让他们接受 PVI+RDN 与单纯 PVI 的治疗。RDN 采用多电极射频 Spyral 导管系统。插入式心脏监护仪用于连续心律监测。主要疗效终点是在所有随访期间房颤复发或重复消融时间≥2分钟。次要终点包括房性心律失常(AA)负荷、停用 I/III 类抗心律失常药物和血压与基线相比的变化:共有 70 名房颤患者(阵发性 52 人,持续性 18 人)和未控制的高血压患者接受了随机治疗(RDN+PVI,34 人;PVI,36 人)。3.5年后,RDN+PVI组和PVI组分别有26.2%和21.4%的患者未达到主要疗效终点(对数秩P = 0.73)。RDN+PVI组与PVI组相比,平均每日AA时间≥1小时的患者每日AA负担较轻(4.1小时 vs 9.2小时;P = 0.016)。RDN+PVI与PVI相比,停用I/III类抗心律失常药物的患者更多(45% vs 14%; P = 0.040)。1 年后,RDN+PVI 和 PVI 的收缩压变化分别为 -17.8 ± 12.8 mm Hg 和 -13.7 ± 18.8 mm Hg(P = 0.43)。各组间的复合安全性终点无明显差异:结论:对于房颤且血压未得到控制的患者,RDN+PVI 比单独使用 PVI 更能预防房颤复发。然而,RDN+PVI 可减少房颤负担和抗心律失常药物的使用,但这还需要进一步的前瞻性验证。
{"title":"Long-Term Changes in Atrial Arrhythmia Burden After Renal Denervation Combined With Pulmonary Vein Isolation","authors":"","doi":"10.1016/j.jacep.2024.04.035","DOIUrl":"10.1016/j.jacep.2024.04.035","url":null,"abstract":"<div><h3>Background</h3><div>The autonomic nervous system plays an important role in atrial fibrillation<span> (AF) and hypertension. Renal denervation (RDN) lowers blood pressure (BP), but its role in AF is poorly understood.</span></div></div><div><h3>Objectives</h3><div>The purpose of this study was to investigate whether RDN reduces AF recurrence after pulmonary vein isolation (PVI).</div></div><div><h3>Methods</h3><div>This study randomized patients from 8 centers (United States, Germany) with drug-refractory AF for treatment with PVI+RDN vs PVI alone. A multielectrode radiofrequency Spyral catheter system was used for RDN. Insertable cardiac monitors were used for continuous rhythm monitoring. The primary efficacy endpoint was ≥2 minutes of AF recurrence or repeat ablation during all follow-up. The secondary endpoints included atrial arrhythmia<span> (AA) burden, discontinuation of class I/III antiarrhythmic drugs, and BP changes from baseline.</span></div></div><div><h3>Results</h3><div>A total of 70 patients with AF (52 paroxysmal, 18 persistent) and uncontrolled hypertension were randomized (RDN+PVI, n = 34; PVI, n = 36). At 3.5 years, 26.2% and 21.4% of patients in RDN+PVI and PVI groups, respectively, were free from the primary efficacy endpoint (log rank <em>P =</em> 0.73). Patients with mean ≥1 h/d AA had less daily AA burden after RDN+PVI vs PVI (4.1 hours vs 9.2 hours; <em>P =</em><span> 0.016). More patients discontinued class I/III antiarrhythmic drugs after RDN+PVI vs PVI (45% vs 14%; </span><em>P =</em><span> 0.040). At 1 year, systolic BP changed by −17.8 ± 12.8 mm Hg and −13.7 ± 18.8 mm Hg after RDN+PVI and PVI, respectively </span><em>(P =</em> 0.43). The composite safety endpoint was not significantly different between groups.</div></div><div><h3>Conclusions</h3><div>In patients with AF and uncontrolled BP, RDN+PVI did not prevent AF recurrence more than PVI alone. However, RDN+PVI may reduce AF burden and antiarrhythmic drug usage, but this needs further prospective validation.</div></div>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141456953","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Obstructive Sleep Apnea and Atrial Fibrillation 阻塞性睡眠呼吸暂停和心房颤动:从布尔逻辑到模糊推理!
IF 8 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-09-01 DOI: 10.1016/j.jacep.2024.06.022
{"title":"Obstructive Sleep Apnea and Atrial Fibrillation","authors":"","doi":"10.1016/j.jacep.2024.06.022","DOIUrl":"10.1016/j.jacep.2024.06.022","url":null,"abstract":"","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141995738","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Novel Sleep Phenotypic Profiles Associated With Incident Atrial Fibrillation in a Large Clinical Cohort 大型临床队列中与心房颤动发病相关的新型睡眠表型特征
IF 8 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-09-01 DOI: 10.1016/j.jacep.2024.05.027

Background

While sleep disorders are implicated in atrial fibrillation (AF), the interplay of physiologic alterations and symptoms remains unclear. Sleep-based phenotypes can account for this complexity and translate to actionable approaches to identify at-risk patients and therapeutic interventions.

Objectives

This study hypothesized discrete phenotypes of symptoms and polysomnography (PSG)-based data differ in relation to incident AF.

Methods

Data from the STARLIT (sleep Signals, Testing, And Reports LInked to patient Traits) registry on Cleveland Clinic patients (≥18 years of age) who underwent PSG from November 27, 2004, to December 30,2015, were retrospectively examined. Phenotypes were identified using latent class analysis of symptoms and PSG-based measures of sleep-disordered breathing and sleep architecture. Phenotypes were included as the primary predictor in a multivariable-adjusted Cox proportional hazard models for incident AF.

Results

In our cohort (N = 43,433, age 51.8 ± 14.5 years, 51.9% male, 74.9% White), 7.3% (n = 3,166) had baseline AF. Over a 7.6- ± 3.4-year follow-up period, 8.9% (n = 3,595) developed incident AF. Five phenotypes were identified. The hypoxia subtype (n = 3,245) had 48% increased incident AF (HR: 1.48; 95% CI: 1.34-1.64), the apneas + arousals subtype (n = 4,592) had 22% increased incident AF (HR: 1.22; 95% CI: 1.10-1.35), and the short sleep + nonrapid eye movement subtype (n = 6,126) had 11% increased incident AF (HR: 1.11; 95% CI: 1.01-1.22) compared with long sleep + rapid eye movement (n = 26,809), the reference group. The hypopneas subtype (n = 2,661) did not differ from reference (HR: 0.89; 95% CI: 0.77-1.03).

Conclusions

Consistent with prior evidence supporting hypoxia as an AF driver and cardiac risk of the sleepy phenotype, this constellation of symptoms and physiologic alterations illustrates vulnerability for AF development, providing potential value in enhancing our understanding of integrated sleep-specific symptoms and physiologic risk of atrial arrhythmogenesis.
背景:虽然睡眠障碍与心房颤动(房颤)有关,但生理改变和症状之间的相互作用仍不清楚。基于睡眠的表型可以解释这种复杂性,并转化为识别高危患者和治疗干预的可行方法:本研究假设症状的离散表型和基于多导睡眠图(PSG)的数据与房颤事件的关系有所不同:方法:对克利夫兰诊所患者(≥18 岁)在 2004 年 11 月 27 日至 2015 年 12 月 30 日期间接受 PSG 检查的 STARLIT(与患者特征相关的睡眠信号、测试和报告)登记数据进行了回顾性研究。通过对症状和基于 PSG 的睡眠呼吸障碍和睡眠结构测量进行潜类分析,确定了表型。表型被作为主要预测因素纳入了房颤事件的多变量调整 Cox 比例危险模型:在我们的队列中(N = 43,433 人,年龄 51.8 ± 14.5 岁,51.9% 为男性,74.9% 为白人),7.3%(n = 3,166 人)有基线房颤。在 7.6 ± 3.4 年的随访期间,8.9% 的患者(n = 3,595 例)发展为偶发性房颤。研究发现了五种表型。缺氧亚型(n = 3,245)的房颤发病率增加了 48%(HR:1.48;95% CI:1.34-1.64),呼吸暂停+唤醒亚型(n = 4,592)的房颤发病率增加了 22%(HR:1.22;95% CI:1.10-1.35),睡眠时间短+唤醒亚型(n = 4,592)的房颤发病率增加了 22%(HR:1.22;95% CI:1.10-1.35)。35),短睡眠+非快速眼动亚型(n = 6 126)与参照组长睡眠+快速眼动(n = 26 809)相比,房颤发生率增加了 11%(HR:1.11;95% CI:1.01-1.22)。低通气亚型(n = 2,661)与参照组没有差异(HR:0.89;95% CI:0.77-1.03):与之前支持缺氧作为房颤驱动因素和嗜睡表型的心脏风险的证据一致,这种症状和生理改变的组合说明了房颤发展的脆弱性,为增强我们对综合睡眠特异性症状和房性心律失常发生的生理风险的理解提供了潜在价值。
{"title":"Novel Sleep Phenotypic Profiles Associated With Incident Atrial Fibrillation in a Large Clinical Cohort","authors":"","doi":"10.1016/j.jacep.2024.05.027","DOIUrl":"10.1016/j.jacep.2024.05.027","url":null,"abstract":"<div><h3>Background</h3><div>While sleep disorders are implicated in atrial fibrillation (AF), the interplay of physiologic alterations and symptoms remains unclear. Sleep-based phenotypes can account for this complexity and translate to actionable approaches to identify at-risk patients and therapeutic interventions.</div></div><div><h3>Objectives</h3><div>This study hypothesized discrete phenotypes of symptoms and polysomnography (PSG)-based data differ in relation to incident AF.</div></div><div><h3>Methods</h3><div>Data from the STARLIT (sleep Signals, Testing, And Reports LInked to patient Traits) registry on Cleveland Clinic patients (≥18 years of age) who underwent PSG from November 27, 2004, to December 30,2015, were retrospectively examined. Phenotypes were identified using latent class analysis<span> of symptoms and PSG-based measures of sleep-disordered breathing and sleep architecture. Phenotypes were included as the primary predictor in a multivariable-adjusted Cox proportional hazard models for incident AF.</span></div></div><div><h3>Results</h3><div>In our cohort (N = 43,433, age 51.8 ± 14.5 years, 51.9% male, 74.9% White), 7.3% (n = 3,166) had baseline AF. Over a 7.6- ± 3.4-year follow-up period, 8.9% (n = 3,595) developed incident AF. Five phenotypes were identified. The hypoxia<span> subtype (n = 3,245) had 48% increased incident AF (HR: 1.48; 95% CI: 1.34-1.64), the apneas + arousals subtype (n = 4,592) had 22% increased incident AF (HR: 1.22; 95% CI: 1.10-1.35), and the short sleep + nonrapid eye movement<span> subtype (n = 6,126) had 11% increased incident AF (HR: 1.11; 95% CI: 1.01-1.22) compared with long sleep + rapid eye movement (n = 26,809), the reference group. The hypopneas subtype (n = 2,661) did not differ from reference (HR: 0.89; 95% CI: 0.77-1.03).</span></span></div></div><div><h3>Conclusions</h3><div><span>Consistent with prior evidence supporting hypoxia as an AF driver and cardiac risk of the sleepy phenotype, this constellation of symptoms and physiologic alterations illustrates vulnerability for AF development, providing potential value in enhancing our understanding of integrated sleep-specific symptoms and physiologic risk of atrial </span>arrhythmogenesis.</div></div>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141633498","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Distinct Substrates of Idiopathic Ventricular Fibrillation Revealed by Arrhythmia Characteristics on Implantable Cardioverter-Defibrillator 植入式心律转复除颤器的心律失常特征揭示特发性室颤的不同基质
IF 8 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-09-01 DOI: 10.1016/j.jacep.2024.04.028

Background

Idiopathic ventricular fibrillation (IVF) can be associated with undetected distinct conditions such as microstructural cardiomyopathic alterations (MiCM) or Purkinje (Purk) activities with structurally normal hearts.

Objectives

This study sought to evaluate the characteristics of recurrent VF recorded on implantable defibrillator electrograms, associated with these substrates.

Methods

This was a multicenter collaboration study. At 32 centers, we selected patients with an initial diagnosis of IVF and recurrent arrhythmia at follow-up without antiarrhythmic drugs, in whom mapping demonstrated Purk or MiCM substrate. We analyzed variables related to previous ectopy, sinus rate preceding VF, trigger, and initial VF cycle lengths. Logistic regression with cross validation was used to evaluate the performance of criteria to discriminate Purk or MiCM substrates.

Results

Among 95 patients (35 women, age 35 ± 11 years) meeting the inclusion criteria, IVF was associated with MiCM in 41 and Purk in 54 patients. A total of 117 arrhythmia recurrences including 91% VF were recorded on defibrillator. Three variables were mostly discriminant. Sinus tachycardia (≤570 ms) was more frequent in MiCM (35.9% vs 13.4%, P = 0.014) whereas short-coupled (<350 ms) triggers were most frequent in Purk-related VF (95.5% vs 23.1%, P = 0.001), which also had shorter VFCLs (182 ± 15 ms vs 215 ± 24 ms, P < 0.001).The multivariable combination provided the highest prediction (accuracy = 0.93 ± 0.05, range 0.833-1.000), discriminating 81% of IVF substrates with a high probability (>80%). Ectopy were inconsistently present before VF.

Conclusions

Characteristics of arrhythmia recurrences on implantable cardioverter- defibrillator provide phenotypic markers of the distinct and hidden substrates underlying IVF. These findings have significant clinical and genetic implications.
背景:特发性心室颤动(IVF)可能与未被发现的不同情况有关,例如微结构心肌病变(MiCM)或心脏结构正常的普金杰(Purk)活动:本研究旨在评估植入式除颤器电图记录到的复发性室颤与这些基质相关的特征:这是一项多中心合作研究。我们在 32 个中心选择了初步诊断为 IVF 且在随访时复发心律失常且未服用抗心律失常药物的患者,这些患者的心电图显示其基底为 Purk 或 MiCM。我们分析了与既往异位、VF 前窦性心率、触发和初始 VF 周期长度相关的变量。交叉验证的逻辑回归用于评估区分 Purk 或 MiCM 基底的标准的性能:在 95 名符合纳入标准的患者(35 名女性,年龄为 35 ± 11 岁)中,41 名患者的 IVF 与 MiCM 相关,54 名患者的 IVF 与 Purk 相关。除颤器共记录到 117 次心律失常复发,其中 91% 为室颤。有三个变量具有很强的判别能力。窦性心动过速(≤570 毫秒)在 MiCM 中更为常见(35.9% 对 13.4%,P = 0.014),而短耦合(80%)。结论:心律失常复发的特征与其他心律失常相似:结论:植入式心律转复除颤器上心律失常复发的特征提供了表型标记,显示了IVF背后独特而隐蔽的基质。这些发现具有重要的临床和遗传意义。
{"title":"Distinct Substrates of Idiopathic Ventricular Fibrillation Revealed by Arrhythmia Characteristics on Implantable Cardioverter-Defibrillator","authors":"","doi":"10.1016/j.jacep.2024.04.028","DOIUrl":"10.1016/j.jacep.2024.04.028","url":null,"abstract":"<div><h3>Background</h3><div>Idiopathic ventricular fibrillation (IVF) can be associated with undetected distinct conditions such as microstructural cardiomyopathic alterations (MiCM) or Purkinje (Purk) activities with structurally normal hearts.</div></div><div><h3>Objectives</h3><div><span>This study sought to evaluate the characteristics of recurrent VF<span> recorded on implantable defibrillator </span></span>electrograms, associated with these substrates.</div></div><div><h3>Methods</h3><div><span><span><span>This was a multicenter collaboration study. At 32 centers, we selected patients with an initial diagnosis of IVF and recurrent arrhythmia at follow-up without </span>antiarrhythmic drugs, in whom mapping demonstrated Purk or MiCM substrate. We analyzed variables related to previous ectopy, sinus rate preceding VF, trigger, and initial VF cycle lengths. </span>Logistic regression with cross validation was used to evaluate the performance of criteria to discriminate Purk or MiCM substrates</span><strong>.</strong></div></div><div><h3>Results</h3><div><span>Among 95 patients (35 women, age 35 ± 11 years) meeting the inclusion criteria, IVF was associated with MiCM in 41 and Purk in 54 patients. A total of 117 arrhythmia recurrences including 91% VF were recorded on defibrillator. Three variables were mostly discriminant. Sinus tachycardia (≤570 ms) was more frequent in MiCM (35.9% vs 13.4%, </span><em>P</em> = 0.014) whereas short-coupled (&lt;350 ms) triggers were most frequent in Purk-related VF (95.5% vs 23.1%, <em>P</em> = 0.001), which also had shorter VFCLs (182 ± 15 ms vs 215 ± 24 ms, <em>P</em> &lt; 0.001).The multivariable combination provided the highest prediction (accuracy = 0.93 ± 0.05, range 0.833-1.000), discriminating 81% of IVF substrates with a high probability (&gt;80%). Ectopy were inconsistently present before VF.</div></div><div><h3>Conclusions</h3><div>Characteristics of arrhythmia recurrences on implantable cardioverter- defibrillator provide phenotypic markers of the distinct and hidden substrates underlying IVF. These findings have significant clinical and genetic implications.</div></div>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":null,"pages":null},"PeriodicalIF":8.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141544829","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Prediction of Sudden Cardiac Death With Ultra-Short-Term Heart Rate Fluctuations 利用超短期心率波动预测心脏性猝死
IF 8 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-09-01 DOI: 10.1016/j.jacep.2024.04.018

Background

Conventional measures of heart rate variability (HRV) have shown only modest associations with sudden cardiac death (SCD). Detrended fluctuation analysis (DFA), with novel methodological developments to evaluate the short-term scaling exponent, is a potentially superior method compared to conventional HRV tools.

Objectives

In this study, the authors studied the analysis of the association between DFA and SCD.

Methods

The investigators studied the predictive value of ultra-short-term heart rate fluctuations (1-minute electrocardiogram samples) with DFA at rest and during different stages of physical exertion for incident SCD among 2,794 participants undergoing clinical exercise testing in the prospective FINCAVAS (Finnish Cardiovascular Study). The novel key DFA measure, the short-scale scaling exponent computed with second-order detrending (DFA2 α1), was the main exposure variable. SCDs were defined by American Heart Association/European Society of Cardiology criteria using death certificates with written accounts of the events.

Results

During a median follow-up of 8.3 years (Q1-Q3: 6.4-10.5), 83 SCDs occurred. DFA2 α1 measured at rest (but not in exercise) associated highly significantly with the risk of SCD, with 1-SD lower values associating with a 2.4-fold (Q1-Q3: 2.0-3.0) risk (P < 0.001). The results persisted when adjusting for other major risk factors for SCD, including age, cardiovascular morbidities, cardiorespiratory fitness, heart rate reduction, and left ventricular ejection fraction. Associations between conventional HRV parameters (measured at any stage of exercise or at rest) and SCD were substantially weaker and statistically nonsignificant after adjusting for other risk factors.

Conclusions

Ultra-short-term DFA2 α1, when measured at rest, is a powerful and independent predictor of SCD. The association between DFA2 α1 and SCD is modified by physical exertion.
背景:传统的心率变异性(HRV)测量与心脏性猝死(SCD)的关系不大。与传统的心率变异工具相比,去趋势波动分析(DFA)在评估短期缩放指数的方法上有了新的发展,可能是一种更优越的方法:在这项研究中,作者研究了 DFA 与 SCD 之间的关联分析:研究人员在前瞻性 FINCAVAS(芬兰心血管研究)中对 2794 名接受临床运动测试的参与者进行了研究,研究了超短期心率波动(1 分钟心电图样本)与 DFA 在静息和不同体力消耗阶段对 SCD 事件的预测价值。新的关键DFA测量指标--用二阶去趋势计算的短尺度缩放指数(DFA2 α1)是主要的暴露变量。SCD按照美国心脏协会/欧洲心脏病学会的标准进行定义,使用附有事件书面记录的死亡证明:在中位随访 8.3 年(Q1-Q3:6.4-10.5)期间,共发生 83 例 SCD。静息时(而非运动时)测量的 DFA2 α1 与 SCD 风险有非常显著的相关性,低 1-SD 的值与 2.4 倍(Q1-Q3:2.0-3.0)的风险相关(P < 0.001)。在调整了 SCD 的其他主要风险因素(包括年龄、心血管疾病、心肺功能、心率降低和左心室射血分数)后,上述结果依然存在。常规心率变异参数(在运动的任何阶段或静息时测量)与SCD之间的关系要弱得多,而且在调整其他风险因素后,两者之间的关系在统计学上并不显著:结论:在静息状态下测量的超短期 DFA2 α1,是预测 SCD 的强有力的独立指标。DFA2 α1与SCD之间的关系会因体力消耗而改变。
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JACC. Clinical electrophysiology
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