Shapiro, Brian P.

Apply It! By reading this article, you will: • Understand how commonly used cardiorespiratory fitness prediction equations can misclassify fitness in both high-performance and clinical populations. • Learn how common prediction equations were developed and why the population of prediction equation studies matters when interpreting estimated cardiorespiratory fitness and percent-predicted values. • Recognize how to critically assess the suitability of a given cardiorespiratory fitness equation based on your client’s or patient’s characteristics.

Purpose: Despite the 2022 American Heart Association/American College of Cardiology guidelines recommending cardiac rehabilitation (CR) after aortic dissection repair, both patient participation in CR and the associated clinical outcomes remain poorly understood. Methods: Adults (≥18 years of age) discharged alive following thoracic aortic dissection surgery across the Mayo Clinic Enterprise (January 2012 to November 2022), with follow-up until May 2024, were included (IRB #24-001141). Data were presented using summary statistics and logistic regression modeling. Results: A total of 186 patients were referred; 37% were female, and the median age was 64 (51, 73) years. Dissections were classified as type A (43%), type B (18%), or a combination, and 55% had residual dissection. Over half (53%) did not start CR, with older age (aOR = 0.97: 95% CI, 0.94 - 0.99; P = .003), family history of aortic dissections and/or aneurysms (aOR = 0.17: 95% CI, 0.04 - 0.54; P = .005), and tobacco use (aOR = 0.35: 95% CI, 0.13 - 0.91; P = .037) being associated with lower odds of enrollment. Of the 87 who enrolled, 34 did so at a Mayo Clinic facility. There were no complications, with no difference in adverse outcomes. Among those with evaluations at graduation from CR (n = 21), quality of life (Dartmouth index 16 [14, 19] vs 25 [22, 30]; P = .002) and 6-minute walk distance (488 [375, 531] vs 302 [235, 398] m; P = .001) improved. Conclusions: Following thoracic aortic dissection repair, CR significantly improved quality of life and functional capacity without adverse events. Further work is needed to improve enrollment and establish data-driven safety margins for exercise.

Introduction: Cardiovascular risks following SARS-CoV-2 infection are incompletely defined. We evaluated evolving cardiovascular outcomes across COVID-19 variant eras using a large community-based cohort to inform risk stratification and clinical care. Methods: We conducted a retrospective cohort study of 162,471 adults with COVID-19 between March 2020 and December 2023 using the Rochester Epidemiology Project. Patients were stratified by variant era (Pre-Delta, Delta, and Omicron). Cardiovascular outcomes included major adverse cardiovascular events (MACE: myocardial infarction, stroke, death), ischemic and inflammatory heart disease, thrombotic events, and dysrhythmias. Diagnoses were identified using ICD-10 codes and validated in a subset. Cumulative incidence was estimated using Kaplan-Meier and competing risk models. Cox proportional hazards regression was used to assess differences by era and age. Results: MACE occurred in 4,922 patients, primarily in those ≥80 (2-year incidence: 17%). Event rates peaked within 30 days post-infection, with marked variation by variant. In patients ≥80, 30-day MACE risk was highest in the Pre-Delta (HR 3.85; 95% CI, 3.14–4.71) and Delta (HR 2.72; 95% CI, 2.13–3.47) eras versus Omicron. After 30 days, event rates fell and era differences narrowed. Thrombotic events (n=2,090; 1.4%) decreased across eras. Ischemic and inflammatory heart disease rates were stable. Myocarditis/pericarditis were rare (0.1%) without age trends. Dysrhythmias affected 6,765 patients (2-year incidence: 4.9%) and rose with age (2.0% in <40 vs. 19.9% in ≥80). Within 30 days, risk was higher in the Pre-Delta and Delta eras for age ≥40, especially ≥80 (Delta HR 3.08; 95% CI, 2.08–4.56) and 60–79 (HR 2.23; 95% CI, 1.75–2.85). Among those 40–59, Delta posed the highest risk (HR 2.74; 95% CI, 1.94–3.86 vs. Pre-Delta HR 1.77; 95% CI, 1.26–2.49). No differences were observed in <40. Beyond 30 days, risk converged across variants. Conclusion: Cardiovascular risk after SARS-CoV-2 infection was concentrated in the first 30 days, with attenuation thereafter. While MACE and thrombotic event rates declined over time, early dysrhythmia risk varied by variant and age, especially in older adults. These findings define a time-sensitive, variant-specific risk window and support short-term, risk-stratified post-COVID monitoring. This work informs targeted follow-up protocols by infection era and age, with implications for quality improvement, resource use, and equitable care.

Background Pilots face significant occupational risks affecting cardiometabolic health and are subject to regulatory health screenings. Cardiometabolic risk factors, cardiac screening findings and outcomes among pilots have not been well reported. Objectives This study aimed to investigate cardiac evaluations of asymptomatic aircraft pilots and the association between clinical risk factors and outcomes. Methods Asymptomatic aircraft pilots referred for cardiac assessment between January 1991 and May 2023 were studied. Baseline characteristics, cardiac test findings and outcomes were evaluated. Major adverse clinical event (MACE) was defined as death, myocardial infarction, stroke, major arrhythmia, heart failure event or cardiac-related hospitalisation and estimated using Kaplan-Meier methods. Significant valvular disease by echocardiography was defined as stenosis, regurgitation or prolapse of moderate severity or greater. Aortic dilation by transthoracic echocardiogram (TTE) was defined as measuring ≥40 mm in diameter. Results 212 pilots met eligibility criteria for the study. The majority were white (92.9%) and male (91%) with a mean age of 58.5±10.9 years. Mean body mass index was 27.8±4.8 with comorbid hyperlipidaemia (48%), hypertension (32%), prior cancer (27%), sleep apnoea (15%), arrhythmia (12%) and known coronary artery disease (6%). Imaging revealed significant valvular disease (2.4%) and dilated aortas (16%) based on TTEs. Functional cardiac testing performed showed mean functional aerobic capacity of 109±24.6% reaching 11.89±2.65 metabolic equivalents with <8% showing positive findings per EKG or wall motion abnormalities on exercise TTE. Six patients received coronary angiography based on clinical evaluation, with two undergoing percutaneous coronary intervention. Over a 32-year period with a median (range) follow-up of 5.15 (0.1, 31.82) years, MACE incidence was 15%. Conclusions Asymptomatic aircraft pilots have underlying cardiovascular risk factors but good overall functional capacity, long-term outcomes and life expectancy. Prevalence of cardiac structural findings like aortic dilatation warrants increased attention during examination of these patients.

Background: Despite expert opinion recommending patient-tailored cardiac rehabilitation (CR) after acute aortic dissection, both patient participation in CR and the associated risk factor modification after CR following aortic dissection repair are poorly understood. Objectives: To describe the characteristics of patients referred to CR, as well as the enrollment rate and outcomes of those referred to CR following thoracic aortic dissection. Methods: We reviewed electronic health records of adults (≥18) discharged alive following thoracic aortic dissection surgery across the Mayo Clinic Enterprise (01/01/2020-11/15/2022) with follow-up to 05/15/2024 (IRB #24-001141). Data are presented using summary statistics. Results: During the study period, 85 patients were included (median [IQR] age: 65 [50-75] years; 40% female; Table 1 ). Across 84% (N=71) who were referred to CR at discharge, 55% (N=39) enrolled. In those patients referred versus not referred to CR, the prevalence of type A dissection (75% vs. 43%), end-organ involvement (27% vs. 0%), and underlying CAD (54% vs. 21%) were greater while current tobacco use (9% vs. 29%) was lower. Of those enrolled at Mayo Clinic (N=16), CR was started 35 (28-65) days following surgery. These patients completed 21 (13-30) CR sessions at an exercise intensity of 59% (50-65%) maximum predicted heart rate. CR was discontinued in 44% (N=7) due to non-cardiac reasons ( Table 2 ). Of the 9 patients who completed CR, general health status (Dartmouth index: 19 [17-21] vs. 26 [22-34]), depressive symptoms (PHQ-9: 1 [0-1] vs. 4 [1-4]), and exercise capacity (6MWT: 214 [196-244] vs. 384 [305-597] meters) improved ( Table 2 ). There were no reported complications or deaths, with stable aortic sizes reported at 18 months. Conclusions: CR improves functional capacity and well-being without complications in patients after thoracic aortic dissection surgery. Further investigation is needed to better assess CR efficacy and usage in this population.

Introduction: Clinical outcomes of FFR-guided PCI have been superior to those of angiographically guided PCI, with or without prior cardiac stress testing. Based on these findings, we hypothesized that the accuracy of stress testing is inferior to that of FFR in determining the physiologic significance of angiographic coronary artery disease. Method: To that end, we studied 243 consecutive patients who underwent coronary angiography and FFR assessment between September 2010 and April 2013 at Mayo Clinic, Florida. Out of this group, we excluded 143 patients due to absence of stress testing in the preceding 6 months. We assessed demographics, coronary risk factors, symptoms, stress test variables, angiographic data, and FFR measurements. FFR values ≤0.80 were considered to be positive for ischemia. We evaluated the diagnostic performance of stress testing vs. FFR. Result: Out of the 100 patients included in the study, FFR was measured in the Left Main coronary artery in 3(3%), in the Left Anterior Descending artery (LAD) in 67(67%), in the left circumflex territory in 11(11%), in the Right Coronary Artery (RCA) in 18(18%). The diagnostic performance of stress testing vs. FFR is summarized in the table, with regards to presence of ischemia in any vascular territory and with regards to a specific vascular territory. Conclusion: Compared to FFR, cardiac stress testing has reasonable NPV but poor PPV in determining the presence of absence of overall ischemia in a given patient. Most concerning, however, is that stress testing has poor PPV and NPV when used to determine the site of ischemia in a specific vascular territory.

Background: The impact of computer ECG interpretation (CEI) on medical professionals’ performance is understudied. This study aims to assess the interpretation proficiency of diverse medical professionals with and without access to CEI reports. Methods: Medical professionals from diverse backgrounds interpreted 60 12-lead ECGs with urgent and non-urgent findings. The interpretation process involved two interpretation phases: (i) 30 ECGs with clinical statements and (ii) the same 30 ECGs and clinical statements in random order along with a CEI report. Diagnostic performance was evaluated based on interpretation accuracy, time per ECG, and self-reported confidence (rated 0 [not confident], 1 [somewhat confident], or 2 [confident]). Results: Among 892 participants, there were 44 (4.9%) primary care physicians, 123 (13.8%) cardiology fellows-in-training, 259 (29.0%) resident physicians, 137 (15.4%) medical students, 56 (6.3%) advanced practice providers, 82 (9.2%) nurses, and 191 (21.4%) allied health professionals. The inclusion of the CEI significantly improved interpretation accuracy by 15.1% (95% CI, 14.3 to 16.0; P<0.001), reduced interpretation time by 52 seconds (95% CI, -56 to -48; P<0.001), and increased confidence by 0.06 (95% CI, 0.03 to 0.09; P=0.003) (Table 1) . Conclusions: CEI integration improves ECG interpretation accuracy, efficiency, and confidence across medical professionals. Nevertheless, even with CEI, significant gaps in ECG interpretation proficiency remain.

Background: Accurate ECG interpretation is vital, but variations in skills exist among healthcare professionals. This study aims to identify factors contributing to ECG interpretation proficiency. Methods: Survey data and ECG test scores from participants in the EDUCATE Trial were analyzed. The dependent variable was the test score for interpreting 30 12-lead ECGs. Independent variables included non-modifiable factors (physician status, clinical experience, patient care impact) and modifiable factors (weekly interpretations, training hours, expert supervision frequency). Bivariate and multivariate analyses generated the Comprehensive Model (all factors) and Actionable Model (modifiable factors only). Results: Among 1206 participants, there were 72 (6.0%) primary care physicians, 146 (12.1%) cardiology fellows-in-training, 353 (29.3%) resident physicians, 182 (15.1%) medical students, 84 (7.0%) advanced practice providers, 120 (9.9%) nurses, and 249 (20.7%) allied health professionals. Physicians accounted for 571 (47.3%) of participants, while 453 (37.6%) were non-physicians. Bivariate analysis showed associations between test scores and multiple variables (Table 1) . In the Comprehensive Model, scores were independently associated with weekly interpretations (9.9 score increase; 95% CI 7.9-11.8; P<0.001), physician status (9.0 score increase; 95% CI 7.2-10.8; P<0.001), and training hours (5.7 score increase; 95% CI 3.7-7.6; P<0.001). In the Actionable Model, scores were independently associated with weekly interpretations (12.0 score increase; 95% CI, 10.0-14.0; P<0.001) and training hours (4.7 score increase; 95% CI 2.6-6.7; P<0.001). The Comprehensive and Actionable Models accounted for 18.7% and 12.3% of the variance in test scores, respectively. Conclusions: Being a physician is a non-modifiable predictor, while training and regular practice are modifiable predictors of ECG interpretation performance.