The prognostic significance of T-wave inversion according to ECG lead group during long-term follow-up in the general population

Background

Inverted T waves in the electrocardiogram (ECG) have been associated with coronary heart disease (CHD) and mortality. The pathophysiology and prognostic significance of T-wave inversion may differ between different anatomical lead groups, but scientific data related to this issue is scarce.

Methods

A representative sample of Finnish subjects (n = 6,354) aged over 30 years underwent a health examination including a 12-lead ECG in the Health 2000 survey. ECGs with T-wave inversions were divided into three anatomical lead groups (anterior, lateral, and inferior) and were compared to ECGs with no pathological T-wave inversions in multivariable-adjusted Fine–Gray and Cox regression hazard models using CHD and mortality as endpoints.

Results

The follow-up for both CHD and mortality lasted approximately fifteen years (median value with interquartile ranges between 14.9 and 15.3). In multivariate-adjusted models, anterior and lateral (but not inferior) T-wave inversions associated with increased risk of CHD (HR: 2.37 [95% confidence interval 1.20–4.68] and 1.65 [1.27–2.15], respectively). In multivariable analyses, only lateral T-wave inversions associated with increased risk of mortality in the entire study population (HR 1.51 [1.26–1.81]) as well as among individuals with no CHD at baseline (HR 1.59 [1.29–1.96]).

Conclusions

The prognostic information of inverted T waves differs between anatomical lead groups. T-wave inversion in the anterior and lateral lead groups is independently associated with the risk of CHD, and lateral T-wave inversion is also associated with increased risk of mortality. Inverted T wave in the inferior lead group proved to be a benign phenomenon.

     

Nighttime ambulatory pulse pressure predicts cardiovascular and all‐cause mortality among middle‐aged participants in the 21‐year follow‐up

Office pulse pressure (PP) is a predictor for cardiovascular (CV) events and mortality. Our aim was to evaluate ambulatory PP as a long‐term risk factor in a random cohort of middle‐aged participants. The Opera study took place in years 1991–1993, with a 24‐h ambulatory blood pressure measurement (ABPM) performed to 900 participants. The end‐points were non‐fatal and fatal CV events, and deaths of all‐causes. Follow‐up period, until the first event or until the end of the year 2014, was 21.1 years (mean). Of 900 participants, 22.6% died (29.6% of men/15.6% of women, p<.001). A CV event was experienced by 208 participants (23.1%), 68.3% of them were male (p<.001). High nighttime ambulatory PP predicted independently CV mortality (hazard ratio [HR] 2.60; 95% confidence interval [CI 95%] 1.08–6.31, p=.034) and all‐cause mortality in the whole population (HR 1.72; Cl 95% 1.06–2.78, p=.028). In males, both 24‐h PP and nighttime PP associated with CV mortality and all‐cause mortality (24‐h PP HR for CV mortality 2.98; CI 95% 1.11–8.04, p=.031 and all‐cause mortality HR 2.40; CI 95% 1.32–4.37, p=.004). Accordingly, nighttime PP; HR for CV mortality 3.13; CI 95% 1.14–8.56, p=.026, and for all‐cause mortality HR 2.26; CI 95% 1.29–3.96, p=.004. Cox regression analyses were adjusted by sex, CV risk factors, and appropriate ambulatory mean systolic BP. In our study, high ambulatory nighttime PP was detected as a long‐term risk factor for CV and all‐cause mortality in middle‐aged individuals.     

Chronological T‐wave alternation before and after the onset of arrhythmogenic right ventricular cardiomyopathy

Identification of arrhythmogenic right ventricular cardiomyopathy (ARVC) during childhood is challenging due to the lack of specific ECG manifestation. We report chronological ECG alteration before several years of the ARVC onset in two affected children. Their ECG at the age of 6 years was almost normal for their age, and their chronological ECGs exhibited inversion of T wave in inferior leads, which are typical for ARVC, developed at younger age than that in precordial leads. In addition, the leftmost T‐wave inversion in the precordial lead shifted toward the left in our patients, which is a sharp contrast to its physiological transition.     

Association between heart rate and cardiovascular death in patients with coronary heart disease: A NHANES‐based cohort study

BackgroundDue to the lack of research, this study aimed to assess the association between the specific range of heart rate and cardiovascular (CV) death in coronary heart disease (CHD) patients.HypothesisHeart rate of 70–79 bpm may be associated with reduced risk of CV death in CHD patients.MethodsThis retrospective cohort study collected the data of CHD patients from the eight cycles of the Health and Nutrition Examination Survey (NHANES). The included patients were divided into four groups: <60, 60–69, 70–79, and ≥80 bpm. The start of follow‐up date was the mobile examination center date, the last follow‐up date was December 31, 2015. The average follow‐up time was 81.70 months, and the longest follow‐up time was 200 months. Competing risk models were developed to evaluate the association between heart rate and CV death, with hazard ratios (HRs) and 95% confidence intervals (CIs) calculated.ResultsA total of 1648 patients with CHD were included in this study. CHD patients at heart rate of <60 (HR, 1.35; 95% CI, 1.34–1.36), 60–69 (HR, 1.05; 95% CI, 1.04–1.06) or ≥80 (HR, 1.39; 95% CI, 1.38–1.41) bpm had a higher risk of CV death than those at heart rate of 70–79 bpm.ConclusionsHeart rate of <70 or ≥80 bpm was associated with an elevated risk of CV death among CHD patients. Continuous monitoring of heart rate may help to screen for health risks and offer early interventions to corresponding patients.     

Peripheral artery disease and clinical outcomes in patients with atrial fibrillation: A systematic review and meta‐analysis

BackgroundAtrial fibrillation (AF) is the most common cardiac rhythm disturbance and leads to morbidity and mortality. Peripheral artery disease (PAD) is associated with atherosclerotic risk factors and always classified as a vascular disease and deemed to be a bad complication of AF. In patients with AF, the risk and prognostic value of PAD have not been estimated comprehensively.HypothesisPAD is associated with all‐cause mortality, cardiovascular (CV) mortality, and other outcomes in patients with AF.MethodsWe searched PubMed, Embase, and Cochrane Library databases for prospective studies published before April 2021 that provided outcomes data on PAD in confirmed patients with AF. Heterogeneity was estimated using the I ² statistic. The fixed‐effects model was used for low to moderate heterogeneity studies, and the random‐effects model was used for high heterogeneity studies.ResultsEight prospective studies (Newcastle‐Ottawa score range, 7–8) with 39 654 patients were enrolled. We found a significant association between PAD and all‐cause mortality (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.25–1.62; p < .001), CV mortality (HR, 1.64; 95% CI, 1.32–2.05; p < .001) and MACE (HR, 1.75; 95% CI, 1.38–2.22; p < .001) in patients with AF. No significant relationship was found in major bleeding (HR, 1.22; 95% CI, 0.95–1.57; p = 0.118), myocardial infarction (MI) (HR, 2.07; 95% CI, 1.17–3.67; p = .038), and stroke (HR, 1.14; 95% CI, 0.87–1.50, p = 0.351).ConclusionsPAD is associated with an increased risk of all‐cause mortality, CV mortality, and MACE in patients with AF. However, no significant association was found with major bleeding, MI, and stroke.     

Short‐term repeatability of the peguero‐lo presti electrocardiographic left ventricular hypertrophy criteria

BackgroundElectrocardiographic left ventricular hypertrophy (ECG‐LVH) represents preclinical cardiovascular disease and predicts cardiovascular disease morbidity and mortality. While the newly developed Peguero‐Lo Presti ECG‐LVH criteria have greater sensitivity for LVH than the Cornell voltage and Sokolow–Lyon criteria, its short‐term repeatability is unknown. Therefore, we characterized the short‐term repeatability of Peguero‐Lo Presti ECG‐LVH criteria and evaluate its agreement with Cornell voltage and Sokolow–Lyon ECG‐LVH criteria.MethodsParticipants underwent two resting, standard, 12‐lead ECGs at each of two visits one week apart (n = 63). We defined a Peguero‐Lo Presti index as a sum of the deepest S wave amplitude in any single lead and lead V₄ (i.e., S_D + SV₄) and defined Peguero‐Lo Presti LVH index as ≥ 2,300 µV among women and ≥ 2,800 µV among men. We estimated repeatability as an intraclass correlation coefficient (ICC), agreement as a prevalence‐adjusted bias‐adjusted kappa coefficient (κ), and precision using 95% confidence intervals (CIs).ResultsThe Peguero‐Lo Presti index was repeatable: ICC (95% CI) = 0.94 (0.91–0.97). Within‐visit agreement of Peguero‐Lo Presti LVH was high at the first and second visits: κ (95% CI) = 0.97 (0.91–1.00) and 1.00 (1.00–1.00). Between‐visit agreement of the first and second measurements at each visit was comparable: κ (95% CI) = 0.90 (0.80–1.00) and 0.93 (0.85–1.00). Agreement of Peguero‐Lo Presti and Cornell or Sokolow–Lyon LVH on any one of the four ECGs was slightly lower: κ (95% CI) = 0.71 (0.54–0.89).ConclusionThe Peguero‐Lo Presti index and LVH have excellent repeatability and agreement, which support their use in clinical and epidemiological studies.     

Steep repolarization time gradients in pig hearts cause distinct changes in composite electrocardiographic T‐wave parameters

BackgroundThe T wave of the electrocardiogram (ECG) reflects ventricular repolarization. Repolarization heterogeneity is associated with reentrant arrhythmias. Several T‐wave markers (including QT interval) have been associated with ventricular arrhythmias, but studies linking such markers to underlying local repolarization time (RT) inhomogeneities are lacking. We aimed to investigate the relation of several T‐wave markers to controlled drug‐induced regional RT gradients in intact pig hearts.MethodsRepolarization time gradients were created by regional infusion of dofetilide and pinacidil in four atrially paced porcine Langendorff‐perfused hearts placed inside a torso tank. From the 12‐lead ECG on the torso tank, the mean, maximum, and dispersion (max–min) of QT_time, JT_time, T_peak–end, T_width, TQ_ratio, dV/dt_max, T_area, T_amp, and T‐upslope duration were determined, as well as upslope end difference between leads V₁ and V₆.ResultsTemporal T‐wave parameters T_peak–end, T_width, and TQ_ratio show a significant and high correlation with RT gradient, best reflected by mean value. T_area (mean, max and dispersion) and dV/dt_max dispersion show only a moderate significant correlation. T‐upslope duration shows a significant correlation in particular for mean values. Mean, maximum, or dispersion of QT_time and V₁–V₆ upslope end difference were not significantly correlated with RT gradient.ConclusionComposite 12‐lead ECG T‐wave parameters T_peak–end, T_width, TQ_ratio, upslope duration, and T_area show a good correlation with underlying RT heterogeneity, whereas standard clinical metrics such as QT_time do not reflect local RT heterogeneity. The composite T‐wave metrics may thus provide better insights in arrhythmia susceptibility than traditional QT_time metrics.     

Behavioral factors associated with SARS‐CoV‐2 infection in Japan

BackgroundThe relative burden of COVID‐19 has been less severe in Japan. One reason for this may be the uniquely strict restrictions imposed upon bars/restaurants. To assess if this approach was appropriately targeting high‐risk individuals, we examined behavioral factors associated with SARS‐CoV‐2 infection in the community.MethodsThis multicenter case–control study involved individuals receiving SARS‐CoV‐2 testing in June–August 2021. Behavioral exposures in the past 2 weeks were collected via questionnaire. SARS‐CoV‐2 PCR‐positive individuals were cases, while PCR‐negative individuals were controls.ResultsThe analysis included 778 individuals (266 [34.2%] positives; median age [interquartile range] 33 [27–43] years). Attending three or more social gatherings was associated with SARS‐CoV‐2 infection (adjusted odds ratio [aOR] 2.00 [95% CI 1.31–3.05]). Attending gatherings with alcohol (aOR 2.29 [1.53–3.42]), at bars/restaurants (aOR 1.55 [1.04–2.30]), outdoors/at parks (aOR 2.87 [1.01–8.13]), at night (aOR 2.07 [1.40–3.04]), five or more people (aOR 1.81 [1.00–3.30]), 2 hours or longer (aOR 1.76 [1.14–2.71]), not wearing a mask during gatherings (aOR 4.18 [2.29–7.64]), and cloth mask use (aOR 1.77 [1.11–2.83]) were associated with infection. Going to karaoke (aOR 2.53 [1.25–5.09]) and to a gym (aOR 1.87 [1.11–3.16]) were also associated with infection. Factors not associated with infection included visiting a cafe with others, ordering takeout, using food delivery services, eating out by oneself, and work/school/travel‐related exposures including teleworking.ConclusionsWe identified multiple behavioral factors associated with SARS‐CoV‐2 infection, many of which were in line with the policy/risk communication implemented in Japan. Rapid assessment of risk factors can inform decision making.     

T‐wave heterogeneity in standard resting 12‐lead ECGs is associated with 90‐day cardiac mortality in women following emergency department admission: A nested case–control study

BackgroundWe investigated whether T‐wave heterogeneity (TWH) can identify patients who are at risk for near‐term cardiac mortality.MethodsA nested case–control analysis was performed in the 888 patients admitted to the Emergency Department (ED) of our medical center in July through September 2018 who had ≥2 serial troponin measurement tests within 6 hr for acute coronary syndrome evaluation to rule‐in or rule‐out the presence of acute myocardial infarction. Patients who died from cardiac causes during 90 days after ED admission were considered cases (n = 20; 10 women) and were matched 1:4 on sex and age with patients who survived during this period (n = 80, 40 women). TWH, that is, interlead splay of T waves, was automatically assessed from precordial leads by second central moment analysis.ResultsTWH_V4‐6 was significantly elevated at ED admission in 12‐lead resting ECGs of female patients who died of cardiac causes during the following 90 days compared to female survivors (100 ± 14.9 vs. 40 ± 3.6 µV, p < .0001). TWH_V4‐6 generated areas under the receiver‐operating characteristic (ROC) curve (AUC) of 0.933 in women (p < .0001) and 0.573 in men (p = .4). In women, the ROC‐guided 48‐µV TWH_V4‐6 cut point for near‐term cardiac mortality produced an adjusted odds ratio of 121.37 (95% CI: 2.89–6,699.84; p = .02) with 100% sensitivity and 82.5% specificity. In Kaplan–Meier survival analysis, TWH_V4‐6 ≥ 48 µV predicted cardiac mortality in women during 90‐day follow‐up with a hazard ratio of 27.84 (95% CI: 7.29–106.36, p < .0001).ConclusionElevated TWH_V4‐6 is associated with near‐term cardiac mortality among women evaluated for acute coronary syndrome.     

Identifying the culprit artery via 12‐lead electrocardiogram in inferior wall ST‐segment elevation myocardial infarction: A meta‐analysis

BackgroundInferior wall ST‐segment elevation myocardial infarction (STEMI) is mostly caused by acute occlusion of right coronary artery (RCA) and left circumflex artery (LCX). Several methods and algorithms using 12‐lead ECG were developed to localize the lesion in inferior wall STEMI. However, the diagnostic properties of these methods remain under‐recognized.AimsThe aim of this meta‐analysis is to compare the diagnostic properties among the methods of identifying culprit artery in inferior wall STEMI using 12‐lead ECG.MethodsWe performed a meta‐analysis to calculate the pooled sensitive, specificity, area under the curve (AUC) and diagnostic odds ratio (DOR) of each method.ResultsThirty‐three studies with 4414 participants were included in the analysis. Methods using double leads had better diagnostic properties, especially ST‐segment elevation (STE) in III > II [with pooled sensitivity 0.89 (0.84–0.93), specificity 0.68 (0.57–0.79), DOR 17 (9–32), AUC 0.88 (0.85–0.91)], ST‐segment depression (STD) in aVL > I [with pooled sensitivity 0.82 (0.72–0.90), specificity 0.69 (0.48–0.86), DOR 11 (4–29), AUC 0.85 (0.81–0.88)], and STD V3/STE III ≤1.2 [with pooled sensitivity 0.88 (0.78–0.95), specificity 0.59 (0.42–0.75), DOR 12 (5–27), AUC 0.82 (0.78–0.85)]. Diagnostic algorithms, including Jim score[pooled sensitivity 0.70 (0.55–0.85), specificity 0.88 (0.75–0.96)], Fiol''s algorithm [pooled sensitivity 0.54 (0.44–0.62), specificity 0.92 (0.88–0.96)] and Tierala''s algorithm [pooled sensitivity 0.60 (0.49–0.71), specificity 0.91 (0.86–0.96)], were not superior to these simple methods.ConclusionsOur meta‐analysis indicated that diagnostic methods using double leads had better properties. STE in III > II together with STD in aVL > I may be the most ideal method, for its accuracy and convenience.     

Visit‐to‐visit office blood pressure variability combined with Framingham risk score to predict all‐cause mortality: A post hoc analysis of the systolic blood pressure intervention trial

We aim to determine if visit‐to‐visit blood pressure variability (BPV) adds prognostic value for all‐cause mortality independently of the Framingham risk score (FRS) in the systolic blood pressure intervention trial (SPRINT). We defined BPV as variability independent of the mean (VIM) and the difference of maximum minus minimum (MMD) of the systolic blood pressure (SBP). Multivariable Cox proportional hazards models were used to estimate the hazard ratio (HR) and 95% confidence interval (CI). Based on FRS stratification, there were 1035, 2911, and 4050 participants in the low‐, intermediate‐, and high‐risk groups, respectively. During the trial, 230 deaths occurred since the 12th month with an average follow‐up of 2.5 years. In continuous analysis, 1‐SD increase of SBP VIM and MMD were significantly associated with all‐cause mortality (HR 1.18, 95% CI 1.05–1.32, p = .005; and HR 1.21, 95% CI 1.09–1.35, p < .001, respectively). In category analysis, the highest quintile of BPV compared with the lowest quintile had significantly higher risk of all‐cause mortality. Cross‐tabulation analysis showed that the 3rd tertile of SBP VIM in the high‐risk group had the highest HR of all‐cause mortality in total population (HR 4.99; 95% CI 1.57–15.90; p = .007), as well as in intensive‐therapy group (HR 7.48; 95% CI 1.01–55.45; p = .05) analyzed separately. Cross‐tabulation analysis of SBP MMD had the same pattern as VIM showed above. In conclusion, visit‐to‐visit BPV was an independent predictor of all‐cause mortality, when accounting for conventional risk factors or FRS. BPV combined with FRS conferred an increased risk for all‐cause mortality in the SPRINT trial.     

Comparison of electrocardiograms (ECG) waveforms and centralized ECG measurements between a simple 6‐lead mobile ECG device and a standard 12‐lead ECG

BackgroundInterval duration measurements (IDMs) were compared between standard 12‐lead electrocardiograms (ECGs) and 6‐lead ECGs recorded with AliveCor''s KardiaMobile 6L, a hand‐held mobile device designed for use by patients at home.MethodsElectrocardiograms were recorded within, on average, 15 min from 705 patients in Mayo Clinic''s Windland Smith Rice Genetic Heart Rhythm Clinic. Interpretable 12‐lead and 6‐lead recordings were available for 685 out of 705 (97%) eligible patients. The most common diagnosis was congenital long QT syndrome (LQTS, 343/685 [50%]), followed by unaffected relatives and patients (146/685 [21%]), and patients with other genetic heart diseases, including hypertrophic cardiomyopathy (36 [5.2%]), arrhythmogenic cardiomyopathy (23 [3.4%]), and idiopathic ventricular fibrillation (14 [2.0%]). IDMs were performed by a central ECG laboratory using lead II with a semi‐automated technique.ResultsDespite differences in patient position (supine for 12‐lead ECGs and sitting for 6‐lead ECGs), mean IDMs were comparable, with mean values for the 12‐lead and 6‐lead ECGs for QTcF, heart rate, PR, and QRS differing by 2.6 ms, −5.5 beats per minute, 1.0 and 1.2 ms, respectively. Despite a modest difference in heart rate, intervals were close enough to allow a detection of clinically meaningful abnormalities.ConclusionsThe 6‐lead hand‐held device is potentially useful for a clinical follow‐up of remote patients, and for a safety follow‐up of patients participating in clinical trials who cannot visit the investigational site. This technology may extend the use of 12‐lead ECG recordings during the current COVID‐19 pandemic as remote patient monitoring becomes more common in virtual or hybrid‐design clinical studies.     

The prognostic significance of electrocardiography findings in patients with coronavirus disease 2019: A retrospective study

BackgroundCoronavirus disease 2019 (COVID‐19) has reached a pandemic level. Cardiac injury is not uncommon among COVID‐19 patients. We sought to describe the electrocardiographic characteristics and to identify the prognostic significance of electrocardiography (ECG) findings of patients with COVID‐19.HypothesisECG abnormality was associated with higher risk of death.MethodsConsecutive patients with laboratory‐confirmed COVID‐19 and definite in‐hospital outcome were retrospectively included. Demographic characteristics and clinical data were extracted from medical record. Initial ECGs at admission or during hospitalization were reviewed. A point‐based scoring system of abnormal ECG findings was formed, in which 1 point each was assigned for the presence of axis deviation, arrhythmias, atrioventricular block, conduction tissue disease, QTc interval prolongation, pathological Q wave, ST‐segment change, and T‐wave change. The association between abnormal ECG scores and in‐hospital mortality was assessed in multivariable Cox regression models.ResultsA total of 306 patients (mean 62.84 ± 14.69 years old, 48.0% male) were included. T‐wave change (31.7%), QTc interval prolongation (30.1%), and arrhythmias (16.3%) were three most common found ECG abnormalities. 30 (9.80%) patients died during hospitalization. Abnormal ECG scores were significantly higher among non‐survivors (median 2 points vs 1 point, p < 0.001). The risk of in‐hospital death increased by a factor of 1.478 (HR 1.478, 95% CI 1.131–1.933, p = 0.004) after adjusted by age, comorbidities, cardiac injury and treatments.ConclusionsECG abnormality was common in patients admitted for COVID‐19 and was associated with adverse in‐hospital outcome. In‐hospital mortality risk increased with increasing abnormal ECG scores.     

Etiology,risk factors,and prognosis of patients with syncope: A single‐center analysis

ObjectiveTo investigate the main causes, risk factors, and prognosis of patients hospitalized with syncope.MethodsThe patients admitted due to syncope were included. We analyzed the etiology, risk factors, and prognosis of patients with an average follow‐up of 15.3 months.ResultsHigh‐risk factors for cardiogenic syncope included age ≥60, male, hypertension, palpitation, troponin T‐positive, abnormal ECG, CHD history, and syncope‐related trauma. Mortality rate was 4.6%, recurrence rate of syncope was 10.5%, and the rehospitalization rate was 8.5%. Univariate analysis showed that prognosis of syncope was related to age ≥60 years old, hypertension, positive troponin T, abnormal electrocardiogram, and coronary heart disease (p < .05). Multivariate Cox proportional hazard analysis showed that age ≥60 years old (p = .021) and high‐sensitivity troponin‐positive (p = .024) were strongly related to the prognosis of syncope. Kaplan–Meier curve showed statistical difference in the survival rate between the groups divided by age ≥60 years (p = .028), hs‐TnT‐positive (p < .001), abnormal ECG (p = .027), and history of CHD (p = .020).ConclusionHigh‐risk factors for cardiogenic syncope included age ≥60, male, hypertension, palpitation, troponin T‐positive, abnormal ECG, CHD family history, and syncope‐related trauma. Age, hypertension, troponin T‐positive, abnormal ECG, and CHD history were associated with the prognosis of syncope.     

Incidence and risk factors of severe non‐proliferative/proliferative diabetic retinopathy: More than a decade follow up in the Tehran Lipids and Glucose Study

Aims/IntroductionTo examine the incidence rate of severe non‐proliferative and proliferative diabetic retinopathy (severe‐NPDR/PDR) and determine its potential risk factors.Materials and MethodsThe study consisted of 1,169 participants (675 women) with type 2 diabetes mellitus, aged ≥20 years. A trained interviewer collected information about the history of pan‐retinal photocoagulation as a result of diabetic retinopathy. Multivariable Cox proportional hazards regression models were applied.ResultsWe found 187 cases (126 women) of severe‐NPDR/PDR during a median follow‐up period of 12.7 years; the corresponding incidence rate was 13.6 per 1,000 person‐years. Being overweight (hazard ratio [HR], 95% confidence interval [CI] 0.60, 0.39–0.92) and obese (HR 0.48, 95% CI 0.27–0.83) were associated with lower risk, whereas being smoker (HR 1.75, 95% CI 1.12–2.74), having fasting plasma glucose levels 7.22–10.0 mmol/L (HR 2.81, 95% CI 1.70–4.62), fasting plasma glucose ≥10 mmol/L (HR 5.87, 95% CI 3.67–9.41), taking glucose‐lowering medications (HR 2.58, 95% CI 1.87–3.56), prehypertension status (HR 1.65, 95% CI 1.05–2.58) and newly diagnosed hypertension (HR 1.96, 95% CI 1.06–3.65) increased the risk of severe‐NPDR/PDR. Among newly diagnosed diabetes patients, being male was associated with a 59% lower risk of severe‐NPDR/PDR (HR 0.41, 95% CI 0.21–0.79). Furthermore, patients who had an intermediate level of education (6–12 years) had a higher risk of developing PDR (HR 1.86, 95% CI 1.05–3.30) compared with those who had <6 years of education.ConclusionsAmong Iranians with type 2 diabetes mellitus, 1.36% developed severe‐NPDR/PDR annually. Normal bodyweight, being a smoker, out of target fasting plasma glucose level, prehypertension and newly diagnosed hypertension status were independent risk factors of severe‐NPDR/PDR. Regarding the sight‐threatening entity of advanced diabetic retinopathy, the multicomponent strategy to control diabetes, abstinence of smoking and tight control of blood pressure should be considered.     

Prognostic value of the dynamic hepatorenal function on intermediate‐term mortality in TAVI patients with survival to discharge

BackgroundRenal and liver dysfunctions are risk factors for mortality in patients with severe aortic stenosis (AS). Transcatheter aortic valve implantation (TAVI) has the potential to break the vicious cycle between AS and hepatorenal dysfunction by relieving aortic valve obstruction.HypothesisA part of patients can derive hepatorenal function improvement from TAVI, and this noncardiac benefit improves the intermediate‐term outcomes.MethodsWe developed this retrospective cohort study in 439 consecutive patients undergoing TAVI and described the dynamic hepatorenal function assessed by model for end‐stage liver disease model for end‐stage liver disease (MELD)‐XI score in subgroups. The endpoint was 2‐year all‐cause mortality.ResultsReceiver‐operating characteristic analysis showed that the baseline MELD‐XI score of 10.71 was the cutoff point. A high MELD‐XI score (>10.71) at baseline was an independent predictor of the 2‐year mortality hazard ratio (HR: 2.65 [1.29–5.47], p = .008). After TAVI, patients with irreversible high MELD‐XI scores had a higher risk of 2‐year mortality than patients who improved from high to low MELD‐XI scores (HR: 2.50 [1.06–5.91], p = .03). Factors associated with reversible MELD‐XI scores improvement were low baseline MELD‐XI scores (≤12.00, odds ratio [OR]: 2.02 [1.04–3.94], p = .04), high aortic valve peak velocity (≥5 m/s, OR: 2.17 [1.11–4.24], p = .02), and low body mass index (≤25 kg/m², OR: 2.73 [1.25–5.98], p = .01).ConclusionHigh MELD‐XI score at baseline is an independent predictor for 2‐year mortality. Patients with hepatorenal function improvement after TAVI have better outcomes. For patients with irreversible hepatorenal dysfunction after TAVI, further optimization of the subsequent treatment after TAVI is needed to improve the outcomes.     

SARS‐CoV‐2 infection rate in Antananarivo frontline health care workers,Madagascar

BackgroundHealth care workers (HCWs) represent a vulnerable population during epidemic periods. Our cohort study aimed to estimate the risk of infection and associated factors among HCWs during the first wave of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) in Madagascar.MethodsA prospective cohort study was carried out in three hospitals that oversaw the first cases of COVID‐19. Monthly ELISA‐based serological tests were conducted, and nasopharyngeal swabs were collected in the case of symptoms linked to COVID‐19 for RT–PCR analysis. Survival analyses were used to determine factors associated with SARS‐CoV‐2 infection.ResultsThe study lasted 7 months from May 2020. We included 122 HCWs, 61.5% of whom were women. The median age was 31.9 years (IQR: 26.4–42.3). In total, 42 (34.4%) had SARS‐CoV‐2 infections, of which 20 were asymptomatic (47.6%). The incidence of SARS‐CoV‐2 infection was 9.3% (95% CI [6.5–13.2]) person‐months. Sixty‐five HCWs presented symptoms, of which 19 were positive by RT–PCR. When adjusted for exposure to deceased cases, infection was more frequent in HCWs younger than 30 years of age (RR = 4.9, 95% CI [1.4–17.2]).ConclusionOur results indicate a high incidence of infection with SARS‐CoV‐2 among HCWs, with a high proportion of asymptomatic cases. Young HCWs are more likely to be at risk than others. Greater awareness among young people is necessary to reduce the threat of infection among HCWs.     

Impact of P‐wave indices in prediction of atrial fibrillation—Insight from loop recorder analysis

BackgroundSeveral P‐wave indices are associated with the development of atrial fibrillation (AF). However, previous studies have been limited in their ability to reliably diagnose episodes of AF. Implantable loop recorders allow long‐term, continuous, and therefore more reliable detection of AF.HypothesisThe aim of this study is to identify and evaluate ECG parameters for predicting AF by analyzing patients with loop recorders.MethodsThis study included 366 patients (mean age 62 ± 16 years, mean LVEF 61 ± 6%, 175 women) without AF who underwent loop recorder implantation between 2010–2020. Patients were followed up on a 3 monthly outpatient interval.ResultsDuring a follow‐up of 627 ± 409 days, 75 patients (20%) reached the primary study end point (first detection of AF). Independent predictors of AF were as follows: age ≥68 years (hazard risk [HR], 2.66; 95% confidence interval [CI], 1.668–4.235; p < .001), P‐wave amplitude in II <0.1 mV (HR, 2.11; 95% CI, 1.298–3.441; p = .003), P‐wave terminal force in V₁ ≤ −4000 µV × ms (HR, 5.3; 95% CI, 3.249–8.636; p < .001, and advanced interatrial block (HR, 5.01; 95% CI, 2.638–9.528; p < .001). Our risk stratification model based on these independent predictors separated patients into 4 groups with high (70%), intermediate high (41%), intermediate low (18%), and low (4%) rates of AF.ConclusionsOur study indicated that P‐wave indices are suitable for predicting AF episodes. Furthermore, it is possible to stratify patients into risk groups for AF using simple ECG parameters, which is particularly important for patients with cryptogenic stroke.     

Proenkephalin and the risk of new‐onset heart failure: data from prevention of renal and vascular end‐stage disease

BackgroundEnkephalins of the opioid system exert several cardiorenal effects. Proenkephalin (PENK), a stable surrogate, is associated with heart failure (HF) development after myocardial infarction and worse cardiorenal function and prognosis in patients with HF. The association between plasma PENK concentrations and new‐onset HF in the general population remains to be established.HypothesisWe hypothesized that plasma PENK concentrations are associated with new‐onset HF in the general population.MethodsWe included 6677 participants from the prevention of renal and vascular end‐stage disease study and investigated determinants of PENK concentrations and their association with new‐onset HF (both reduced [HFrEF] and preserved ejection fraction [HFpEF]).ResultsMedian PENK concentrations were 52.7 (45.1–61.9) pmol/L. Higher PENK concentrations were associated with poorer renal function and higher NT‐proBNP concentrations. The main determinants of higher PENK concentrations were lower estimated glomerular filtration rate (eGFR), lower urinary creatinine excretion, and lower body mass index (all p < .001). After a median 8.3 (7.8–8.8) years follow‐up, 221 participants developed HF; 127 HFrEF and 94 HFpEF. PENK concentrations were higher in subjects who developed HF compared with those who did not, 56.2 (45.2–67.6) versus 52.7 (45.1–61.6) pmol/L, respectively (p = .003). In competing‐risk analyses, higher PENK concentrations were associated with higher risk of new‐onset HF (hazard ratio [HR] = 2.09[1.47–2.97], p < .001), including both HFrEF (HR = 2.31[1.48–3.61], p < .001) and HFpEF (HR = 1.74[1.02–2.96], p = .042). These associations were, however, lost after adjustment for eGFR.ConclusionsIn the general population, higher PENK concentrations were associated with lower eGFR and higher NT‐proBNP concentrations. Higher PENK concentrations were not independently associated with new‐onset HFrEF and HFpEF and mainly confounded by eGFR.     

The value of ECG changes in risk stratification of COVID‐19 patients

BackgroundThere is growing evidence of cardiac injury in COVID‐19. Our purpose was to assess the prognostic value of serial electrocardiograms in COVID‐19 patients.MethodsWe evaluated 269 consecutive patients admitted to our center with confirmed SARS‐CoV‐2 infection. ECGs available at admission and after 1 week from hospitalization were assessed. We evaluated the correlation between ECGs findings and major adverse events (MAE) as the composite of intra‐hospital all‐cause mortality or need for invasive mechanical ventilation. Abnormal ECGs were defined if primary ST‐T segment alterations, left ventricular hypertrophy, tachy or bradyarrhythmias and any new AV, bundle blocks or significant morphology alterations (e.g., new Q pathological waves) were present.ResultsAbnormal ECG at admission (106/216) and elevated baseline troponin values were more common in patients who developed MAE (p = .04 and p = .02, respectively). Concerning ECGs recorded after 7 days (159), abnormal findings were reported in 53.5% of patients and they were more frequent in those with MAE (p = .001). Among abnormal ECGs, ischemic alterations and left ventricular hypertrophy were significantly associated with a higher MAE rate. The multivariable analysis showed that the presence of abnormal ECG at 7 days of hospitalization was an independent predictor of MAE (HR 3.2; 95% CI 1.2–8.7; p = .02). Furthermore, patients with abnormal ECG at 7 days more often required transfer to the intensive care unit (p = .01) or renal replacement therapy (p = .04).ConclusionsPatients with COVID‐19 should receive ECG at admission but also during their hospital stay. Indeed, electrocardiographic alterations during hospitalization are associated with MAE and infection severity.