Citations

Background: Early diagnosis of heart failure with reduced ejection fraction (HFrEF) can lead to reduced healthcare costs and improved outcomes. In this study, we evaluated the economic effectiveness of an AI algorithm for detecting low ejection fraction using 12-lead ECG data. Aims: The primary aim was to estimate the health economic impact of the AI-ECG algorithm intervention to detect low ejection fraction. Methods: The study population consisted of 113,719 individuals without a prior history of HFrEF who visited a multistate health system between 2010-2018 with 12-lead ECG data and an echocardiogram within 1 year. The AI-ECG algorithm was run retrospectively, and projected costs were estimated assuming each patient incurred the average cost based on their age group and AI-detected heart failure stage. Hospitalization costs were estimated using Medicare reimbursement rates, and economic benefits from increased survival were estimated using a willingness to pay of $50,000 per quality-adjusted life year (QALY) gained. Results: At the optimal model threshold, the total cost savings per patient (including benefits from QALYs gained) for the AI-ECG algorithm vs. standard-of-care on the overall study population were projected to be $79.11 (95% CI: [$53.77, $104.44]) and $124.93 (95% CI: [$83.99, $165.88]) for the 2 and 4 year periods, respectively. For patients over 50 years old, the projected total cost savings were $85.56 (95% CI: [$56.35, $114.78]) and $135.28 (95% CI: [$88.18, $182.38]) per patient for the 2 and 4 year periods, respectively. See Figure. Conclusions: The AI-ECG algorithm to detect low ejection fraction is a cost-effective early screening tool for HFrEF.

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.

Background: Fasciculoventricular pathway (FVP) is a rare form of preexcitation without known clinical tachycardia. As it is connected to the His bundle, they conduct whenever it is engaged. Conduction through the His Bundle but block at FVP has not been reported. Case presentation: We present a case of a 42-year-old male with a history of Wolff-Parkinson-White syndrome (WPWS), supraventricular tachycardia (SVT), syncope, embolic stroke, paroxysmal atrial fibrillation, hypertension, hypothyroidism, Sjogren's syndrome and prior unsuccessful attempts at elimination of the preexcitation. He underwent electrophysiology (EP) study for presumed SVT ablation. The EP study identified an FVP as the cause of preexcitation, and the planned accessory pathway ablation was deemed unnecessary. Atrial tachycardia originating from the right superior pulmonary vein (PV) was induced, eventually degenerating into atrial fibrillation, and the patient successfully underwent pulmonary vein isolation with the resolution of symptoms. Discussion: FVP is usually an incidental finding when patients with symptomatic preexcitation are studied. If tachycardia is induced, it is unrelated to the preexcitation. The FVP is connected to the His bundle and invariably conducts if the impulse engages the His Bundle. We are unaware of a case when the His bundle conducts, but the impulse loses preexcitation due to a block in the FVP. This unusual finding was noted in our case. To further confirm the location of the accessory pathway, IV adenosine was given with a complete heart block suggesting the preexcitation is beyond the level of the AV node and within the conduction system. It is not at the annulus with independent atrial and ventricular insertion, typical of an accessory pathway. Conclusions: This case demonstrates an FV pathway's unusual conduction block and physiological characteristics.

Background: Gaps in ECG interpretation competency among medical professionals exist, with a need for practical, evidence-based, and accessible learning solutions. We conducted an international, prospective, randomized controlled trial to assess the effectiveness of web-based, self-directed ECG learning. Methods: A total of 1206 diverse medical learners and professionals underwent an initial test, followed by random assignment to one of four groups: (i) online question-bank (questions), (ii) online lectures (lectures), (iii) online, question-bank and lectures (hybrid), or (iv) no resources (control). After 4 months, a post-test was administered to evaluate the overall change in performance. Results: Of all participants, 863 (72%) completed the trial. After the 4-month follow-up, all three online, self-directed intervention groups (questions, lectures, and hybrid) showed significant improvement in overall performance (P<0.001), while the control group did not (P=0.544). The questions, lectures, and hybrid interventions demonstrated score improvements of +11.4% (95% CI, 9.1-13.7; P<0.001), +9.8% (95% CI, 7.8-11.9; P<0.001), and +11.0% (95% CI, 9.2-12.9; P<0.001) respectively, compared to +0.8% (95% CI, -1.2-2.8; P=0.544) for the control group. These improvements were consistent across medical professional groups (Figure 1) . Conclusions: Web-based, self-directed learning resources effectively improved ECG interpretation proficiency for diverse medical learners and professionals.

Introduction: Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been developed as a new class of anti-diabetic drug, and shown cardio- and renal-protective effects in patients with diabetes, heart failure, and chronic kidney diseases. SGLT2 inhibitor also has effect to expand lifespan in aged mice, suggesting anti-aging effect. But the detailed machinery of these protective effects is still to be clarified. Here we demonstrate that canagliflozin has a effect to eliminate senescent cells from pathological tissues, so-called "senolysis" in murine aging or age-related disease models. Methods: Canagliflozin mixed in food at 0.03% (w/w) was administered for up to 4 weeks to high-fat-fed diabetic mice, for 2 weeks to ApoE-knockout atherosclerotic mice model, for 20 weeks for chronological aged mice, and for lifetime to Zmpste-knockout progeroid mice. Burden of senescent cell accumilation as well as pathological or aged phenotype were measured in each mice model. Results: Canagliflozin reduced senescent cells in visceral adipose tissue within 1 week. Also, we found that senolytic effect of canagliflozin was provided through enhancing endogenous senolytic function by immune cells such as CD8+T cells. This machinery was mediated by enhanced AMPK signaling through incrase of endogenous AICAR production, which leads to the downregulation of PD-L1 expression on senescent cells. Oppositely, inhibition of AMPK signaling with Compound C administration (10mg/kg ip daily) resulted in abolishing senolytic effect of canagliflozin. Furthermore, canagliflozin reduced their senescent cell burden and alleviated atherosclerosis in ApoE-knockout mice, extended lifespan in progeroid mice, and altered physical function in aged mice. Conclusions: Our results showed new aspect of protective efficacy of SGLT2 inhibitors and would be promising evidence that SGLT2 inhibitors can be used as not only cardio- or renal-protective drugs but also anti-aging drugs.

Background: Thoracic aortic aneurysms (TAAs) can be found in 1-2/1000 individuals in the general population and are commonly associated with genetic disorders of connective tissue and bicuspid aortic valve (BAV). Larger size, distal aneurysms, high DBP and presence of BAV are some factors that can accelerate aneurysm growth. Case: A 37-year-old male without a history of recent trauma or stimulant use presented to the emergency room with 2 days of chest tightness. He had acute worsening overnight and awoke with chest pain, discomfort in the suprasternal notch and between the shoulder blades. He had no other medical history, however, was treated with a 10-day course of Ciprofloxacin for epididymitis 3 weeks prior. On presentation, the patient had active pleuritic chest pain, tachycardia and tachypnea with no abnormalities on cardiac auscultation. EKG showed sinus tachycardia, PVCs, and nonspecific ST elevations in leads II, III and aVF with normal troponins and chest X-ray. CT chest angiogram revealed a 60 mm ascending aortic aneurysm ( Fig. 1a ). Doming of the right cusp of the aortic valve in the parasternal view ( Fig. 1b ) raised suspicion for BAV which was confirmed with the classic fish mouth appearance on the TEE ( Fig. 1c ). The patient underwent successful aortic repair with graft placement. First degree relatives were offered screening for BAV. Ciprofloxacin was replaced with Sulfamethoxazole-Trimethoprim for treating his residual epididymal infection. Discussion: TAA rupture is associated with a >90% mortality rate. It is important to be aware of echocardiographic features of BAV as this can predispose to accelerated aneurysm growth. Additionally, fluoroquinolones (FQs) are a commonly prescribed class of antibiotics that may affect the structural integrity of the aorta, associated with aneurysm enlargement and rupture. This case offers an important example to highlight why the FDA recommends against the use of FQs in patients with known TAA or risk factors for it.

Background: Cardiovascular disease is the leading cause of death worldwide, with a notable impact on postmenopausal women. However, contemporary large-scale population-based data for the burden and disparities of Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) in this population remains limited. Methods: The National Inpatient Sample (2020, ICD10 codes, age>55 years) was queried to identify postmenopausal women's hospitalizations. Socio-demographics, racial subgroups, comorbidities, and MACCE rates were retrieved with a more granular comparative analysis in postmenopausal women. A p<0.05 was considered statistically significant. Results: Of the total 8435195 postmenopausal women hospitalizations (median age 75 years), 1021375 (12.1%) were identified with MACCE. MACCE cohort, in comparison to non-MACCE cohort, had significantly higher prevalence of hypertension (77.1% vs 71.3), diabetes (39.8% vs 34.0%), hyperlipidemia (53.7% vs 48.4%), PVD (9.8% vs 7.1%), prior MI (8.3 vs 5.7%), prior TIA/stroke (10.5 vs 9%) and CKD (29.4 vs 23.4%). Significant clinical predictors for all-cause mortality were found to be race Asian/PI vs white ( 1.31 [1.09-1.18]), median household income national quartile (1.16 [1.13-1.20]), hypertension (1.18[1.16-1.20]) diabetes (1.20 [1.19-1.22]), hyperlipidemia (1.12[1.11-1.14]), prior MI (1.37[1.34-1.40]) and prior TIA stroke (1.0 5 [1.03-1.07] (all p<0.05). Conclusion: Among hospitalizations, Asian/Pacific Islanders, patients from the lowermost income quartile with co-existent hypertension, diabetes, hyperlipidemia, CKD, and cardiovascular comorbidities independently revealed the highest MACCE rates. Special emphasis needs to be laid on socio-demographics, comorbidities, and racial differences for CVD disease prevention, and risk factor modification in postmenopausal women.

Background: Choosing either a mechanical or a bioprosthetic valve during surgical aortic valve replacement (AVR) in middle-aged patients is still controversial, especially with contemporary advancements in valve technology. Aims: To evaluate long-term survival and major morbidity in patients aged 50-70 years undergoing AVR using contemporary mechanical and bioprosthetic valves. Methods: A retrospective study was performed using the TriNetX global database to identify patients aged 50 to 70 years who had primary isolated surgical AVR from 2014 to 2020. Patients who had transcatheter AVR, concomitant, or prior cardiac surgery were excluded. Patients were stratified into 2 groups: mechanical and bioprosthetic. A 1:1 propensity-score matching was performed to control for baseline differences between the two cohorts. The primary endpoint was all-cause mortality and secondary endpoints were stroke, major bleeding, and reoperation over a follow-up period of 8 years. Results: A total of 1,138 propensity-matched patients were included in each group. There was no significant difference in survival, stroke, or reoperation rates between the two groups. Survival probability at the end of the follow-up period was 76.6% in the mechanical group and 80.1% in the bioprosthetic group (HR, 0.946 [95% CI, 0.702, 1.276]) (Figure 1). A total of 137(12%) vs 119 (10.4%) patients had stroke in the mechanical vs the bioprosthetic group, respectively (HR, 1.08 [95% CI, 0.851-1.392]). A total of 19 (1.7%) vs 17 (1.5%) patients had reoperation in the mechanical, and the bioprosthetic valve group, respectively (HR, 1.01 [95% CI, 0.526, 1.951]). There were higher major bleeding events in the mechanical group, 266 (23.4%) vs 163 (14.3%) in the bioprosthetic group, (HR, 1.64 [95% CI, 1.353, 1.999]). Conclusion: Contemporary bioprosthetic valves could be a reasonable option for AVR in patients aged 50 to 70 years with less major bleeding risk and similar survival, stroke, and reoperation rates.

Background: Guidelines are still unclear regarding whether mechanical or bioprosthetic valves should be selected for mitral valve replacement (MVR) in patients aged 50-70 years. Aims: To assess long-term outcomes in patients aged 50-70 years undergoing MVR using contemporary mechanical and bioprosthetic valves. Methods: We performed a retrospective study using the TriNetX global database to identify patients aged 50 to 70 years who had primary isolated surgical MVR from 2014 to 2020. Patients who had concomitant or prior cardiac surgeries were excluded. Patients were stratified into 2 groups: mechanical and bioprosthetic, and a 1:1 propensity-score matching to control for baseline differences between the two groups was performed. The primary endpoint was all-cause mortality and secondary endpoints were stroke, major bleeding, and reoperation over a follow-up period of 8 years. Results: Propensity-score matching yielded 1,130 patients in each group. There were significantly higher rates of all-cause mortality, stroke, and major bleeding events in the mechanical group compared to the bioprosthetic valve. There was no significant difference between the two groups regarding reoperation (Table 1 and Figure 1). Conclusion: At an 8-year follow-up, the use of contemporary bioprosthetic valves for MVR in patients aged 50-70 years shows favorable all-cause mortality and lower rates of strokes and major bleeding with similar reoperation rates compared to mechanical valves.