Short-Time Estimation of Fractionation in Atrial Fibrillation with Coarse-Grained Correlation Dimension for Mapping the Atrial Substrate

[EN] Atrial ¿brillation (AF) is currently the most common cardiac arrhythmia, with catheter ablation (CA) of the pulmonary veins (PV) being its ¿rst line therapy. Ablation of complex fractionated atrial electrograms (CFAEs) outside the PVs has demonstrated improved long-term results, but their identi¿cation requires a reliable electrogram (EGM) fractionation estimator. This study proposes a technique aimed to assist CA procedures under real-time settings. The method has been tested on three groups of recordings: Group 1 consisted of 24 highly representative EGMs, eight of each belonging to a different AF Type. Group 2 contained the entire dataset of 119 EGMs, whereas Group 3 contained 20 pseudo-real EGMs of the special Type IV AF. Coarse-grained correlation dimension (CGCD) was computed at epochs of 1 s duration, obtaining a classi¿cation accuracy of 100% in Group 1 and 84.0¿85.7% in Group 2, using 10-fold cross-validation. The receiver operating characteristics (ROC) analysis for highly fractionated EGMs, showed 100% speci¿city and sensitivity in Group 1 and 87.5% speci¿city and 93.6% sensitivity in Group 2. In addition, 100% of the pseudo-real EGMs were correctly identi¿ed as Type IV AF. This method can consistently express the fractionation level of AF EGMs and provides better performance than previous works. Its ability to compute fractionation in short-time can agilely detect sudden changes of AF Types and could be used for mapping the atrial substrate, thus assisting CA procedures under real-time settings for atrial substrate modi¿cation.This research has been supported by grants DPI2017-83952-C3 from MINECO/AEI/FEDER EU, SBPLY/17/180501/000411 from JCCM and AICO/2019/036 from GVA.Vraka, A.; Hornero, F.; Bertomeu-Gonzalez, V.; Osca, J.; Alcaraz, R.; Rieta, JJ. (2020). Short-Time Estimation of Fractionation in Atrial Fibrillation with Coarse-Grained Correlation Dimension for Mapping the Atrial Substrate. Entropy. 22(2):1-20. https://doi.org/10.3390/e22020232S120222Go, A. S., Hylek, E. M., Phillips, K. A., Chang, Y., Henault, L. E., Selby, J. V., & Singer, D. E. (2001). Prevalence of Diagnosed Atrial Fibrillation in Adults. JAMA, 285(18), 2370. doi:10.1001/jama.285.18.2370Goette, A., Honeycutt, C., & Langberg, J. J. (1996). Electrical Remodeling in Atrial Fibrillation. Circulation, 94(11), 2968-2974. doi:10.1161/01.cir.94.11.2968Chugh, S. S., Roth, G. A., Gillum, R. F., & Mensah, G. A. (2014). Global Burden of Atrial Fibrillation in Developed and Developing Nations. Global Heart, 9(1), 113. doi:10.1016/j.gheart.2014.01.004Cappato, R., Calkins, H., Chen, S.-A., Davies, W., Iesaka, Y., Kalman, J., … Biganzoli, E. (2010). Updated Worldwide Survey on the Methods, Efficacy, and Safety of Catheter Ablation for Human Atrial Fibrillation. 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The relationship between complex fractionated electrograms and atrial low-voltage zones during atrial fibrillation and paced rhythm. Europace, 13(12), 1709-1716. doi:10.1093/europace/eur197Lin, Y.-J., Lo, M.-T., Chang, S.-L., Lo, L.-W., Hu, Y.-F., Chao, T.-F., … Chen, S.-A. (2016). Benefits of Atrial Substrate Modification Guided by Electrogram Similarity and Phase Mapping Techniques to Eliminate Rotors and Focal Sources Versus Conventional Defragmentation in Persistent Atrial Fibrillation. JACC: Clinical Electrophysiology, 2(6), 667-678. doi:10.1016/j.jacep.2016.08.005Verma, A., Jiang, C., Betts, T. R., Chen, J., Deisenhofer, I., Mantovan, R., … Sanders, P. (2015). Approaches to Catheter Ablation for Persistent Atrial Fibrillation. New England Journal of Medicine, 372(19), 1812-1822. doi:10.1056/nejmoa1408288Ammar-Busch, S., Reents, T., Knecht, S., Rostock, T., Arentz, T., Duytschaever, M., … Deisenhofer, I. (2018). Correlation between atrial fibrillation driver locations and complex fractionated atrial electrograms in patients with persistent atrial fibrillation. Pacing and Clinical Electrophysiology, 41(10), 1279-1285. doi:10.1111/pace.13483Almeida, T. P., Chu, G. S., Salinet, J. L., Vanheusden, F. J., Li, X., Tuan, J. H., … Schlindwein, F. S. (2016). Minimizing discordances in automated classification of fractionated electrograms in human persistent atrial fibrillation. Medical & Biological Engineering & Computing, 54(11), 1695-1706. doi:10.1007/s11517-016-1456-2De Bakker, J. M. T., & Wittkampf, F. H. M. (2010). The Pathophysiologic Basis of Fractionated and Complex Electrograms and the Impact of Recording Techniques on Their Detection and Interpretation. Circulation: Arrhythmia and Electrophysiology, 3(2), 204-213. doi:10.1161/circep.109.904763Luca, A., Buttu, A., Pruvot, E., Pascale, P., Bisch, L., & Vesin, J.-M. (2016). Nonlinear analysis of right atrial electrograms predicts termination of persistent atrial fibrillation within the left atrium by catheter ablation. Physiological Measurement, 37(3), 347-359. doi:10.1088/0967-3334/37/3/347Corana, A., Casaleggio, A., Rolando, C., & Ridella, S. (1991). Efficient computation of the correlation dimension from a time series on a LIW computer. Parallel Computing, 17(6-7), 809-820. doi:10.1016/s0167-8191(05)80068-7Fraser, A. M., & Swinney, H. L. (1986). Independent coordinates for strange attractors from mutual information. Physical Review A, 33(2), 1134-1140. doi:10.1103/physreva.33.1134Martínez-Iniesta, M., Ródenas, J., Alcaraz, R., & Rieta, J. J. (2017). Waveform Integrity in Atrial Fibrillation: The Forgotten Issue of Cardiac Electrophysiology. Annals of Biomedical Engineering, 45(8), 1890-1907. doi:10.1007/s10439-017-1832-6Theiler, J., Eubank, S., Longtin, A., Galdrikian, B., & Doyne Farmer, J. (1992). 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The Annals of Mathematical Statistics, 18(1), 50-60. doi:10.1214/aoms/1177730491Křemen, V., Lhotská, L., Macaš, M., Čihák, R., Vančura, V., Kautzner, J., & Wichterle, D. (2008). A new approach to automated assessment of fractionation of endocardial electrograms during atrial fibrillation. Physiological Measurement, 29(12), 1371-1381. doi:10.1088/0967-3334/29/12/002Haley, C. L., Gula, L. J., Miranda, R., Michael, K. A., Baranchuk, A. M., Simpson, C. S., … Redfearn, D. P. (2012). Validation of a novel algorithm for quantification of the percentage of signal fractionation in atrial fibrillation. EP Europace, 15(3), 447-452. doi:10.1093/europace/eus361Nollo, G., Marconcini, M., Faes, L., Bovolo, F., Ravelli, F., & Bruzzone, L. (2008). An Automatic System for the Analysis and Classification of Human Atrial Fibrillation Patterns from Intracardiac Electrograms. 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Discrimination Between CFAEs of Paroxysmal and Persistent Atrial Fibrillation With Simple Classification Models of Reduced Features

[EN] A significant number of variables to discriminate between paroxysmal and persistent atrial fibrillation (ParAF vs. PerAF) has been widely exploited, mostly assessed with statistical tests aimed to suggest adequate approaches for catheter ablation (CA) of AF. However, in practice, it would be desirable to utilize simple classification models readily understandable. In this work dominant frequency (DF), AF cycle length (AFCL), sample entropy (SE) and determinism (DET) of recurrent quantification analysis were applied to recordings of complex fractionated atrial electrograms (CFAEs) of AF patients, aimed to create simple models to discriminate between ParAF and PerAF. Correlation matrix filters removed redundant information and Random Forests ranked the variables by relevance. Next, coarse tree models were built, optimally combining high-ranking indexes, and tested with leave-one-out cross-validation. The best classification performance combined SE and DF with an Accuracy (Acc) of 88.2% to discriminate ParAF from PerAF, while the highest single Acc was provided by DET reaching 82.4%. Hence, careful selection of reduced sets of features feeding simple classification models is able to discriminate accurately between CFAEs of ParAF and PerAFFinotti, E.; Ciaccio, EJ.; Garan, H.; Bertomeu-Gonzalez, V.; Alcaraz, R.; Rieta, JJ. (2020). Discrimination Between CFAEs of Paroxysmal and Persistent Atrial Fibrillation With Simple Classification Models of Reduced Features. IEEE. 1-4. https://doi.org/10.22489/CinC.2020.360S1

Association of body mass index with clinical outcomes in patients with atrial fibrillation: a report from the FANTASIIA Registry

[Abstract] Background. Obesity and atrial fibrillation (AF) frequently coexist and independently increase mortality. We sought to assess the association between obesity and adverse events in patients receiving oral anticoagulants for AF. Methods and Results. Consecutive AF outpatients receiving anticoagulant agents (both vitamin K antagonists and direct oral anticoagulants) were recruited into the FANTASIIA (Atrial fibrillation: influence of the level and type of anticoagulation on the incidence of ischemic and hemorrhagic stroke) registry. This observational, multicenter, and prospective registry of AF patients analyzes the quality of anticoagulation, incidence of events, and differences between oral anticoagulant therapies. We analyzed baseline patient characteristics according to body mass index, normal: <25 kg/m2, overweight: 25–30 kg/m2, and obese: ≥30 kg/m2), assessing all‐cause mortality, stroke, major bleeding and major adverse cardiovascular events (a composite of ischemic stroke, myocardial infarction, and total mortality) at 3 years’ follow‐up. In this secondary prespecified substudy, the association of weight on prognosis was evaluated. We recruited 1956 patients (56% men, mean age 73.8±9.4 years): 358 (18.3%) had normal body mass index, 871 (44.5%) were overweight, and 727 (37.2%) were obese. Obese patients were younger (P<0.01) and had more comorbidities. Mean time in the therapeutic range was similar across body mass index categories (P=0.42). After a median follow‐up of 1070 days, 255 patients died (13%), 45 had a stroke (2.3%), 146 a major bleeding episode (7.5%) and 168 a major adverse cardiovascular event (8.6%). Event rates were similar between groups for total mortality (P=0.29), stroke (P=0.90), major bleeding (P=0.31), and major adverse cardiovascular events (P=0.24). On multivariate Cox analysis, body mass index was not independently associated with all‐cause mortality, cardiovascular mortality, stroke, major bleeding, or major adverse cardiovascular events. Conclusions. In this prospective cohort of patients anticoagulated for AF, obesity was highly prevalent and was associated with more comorbidities, but not with poor prognosis

Lipid profile, cardiovascular disease and mortality in a Mediterranean high-risk population: The ESCARVAL-RISK study.

The potential impact of targeting different components of an adverse lipid profile in populations with multiple cardiovascular risk factors is not completely clear. This study aims to assess the association between different components of the standard lipid profile with all-cause mortality and hospitalization due to cardiovascular events in a high-risk population. This prospective registry included high risk adults over 30 years old free of cardiovascular disease (2008-2012). Diagnosis of hypertension, dyslipidemia or diabetes mellitus was inclusion criterion. Lipid biomarkers were evaluated. Primary endpoints were all-cause mortality and hospital admission due to coronary heart disease or stroke. We estimated adjusted rate ratios (aRR), absolute risk differences and population attributable risk associated with adverse lipid profiles. 51,462 subjects were included with a mean age of 62.6 years (47.6% men). During an average follow-up of 3.2 years, 919 deaths, 1666 hospitalizations for coronary heart disease and 1510 hospitalizations for stroke were recorded. The parameters that showed an increased rate for total mortality, coronary heart disease and stroke hospitalization were, respectively, low HDL-Cholesterol: aRR 1.25, 1.29 and 1.23; high Total/HDL-Cholesterol: aRR 1.22, 1.38 and 1.25; and high Triglycerides/HDL-Cholesterol: aRR 1.21, 1.30, 1.09. The parameters that showed highest population attributable risk (%) were, respectively, low HDL-Cholesterol: 7.70, 11.42, 8.40; high Total/HDL-Cholesterol: 6.55, 12.47, 8.73; and high Triglycerides/HDL-Cholesterol: 8.94, 15.09, 6.92. In a population with cardiovascular risk factors, HDL-cholesterol, Total/HDL-cholesterol and triglycerides/HDL-cholesterol ratios were associated with a higher population attributable risk for cardiovascular disease compared to other common biomarkers.S

Effect of insulin on readmission for heart failure following a hospitalization for acute heart failure

Type 2 diabetes mellitus (T2DM) is common in patients with heart failure (HF) and is related with worse outcomes. Insulin treatment is associated with sodium and water retention, weight gain, and hypoglycaemia-all pathophysiological mechanisms related to HF decompensation. This study aimed to evaluate the association between insulin treatment and the risk of 1 year readmission for HF in patients discharged for acute HF. We prospectively included 2895 consecutive patients discharged after an episode of acute HF in a single tertiary hospital. Multivariable Cox regression, adapted for competing events, was used to assess the association between insulin treatment and 1 year readmission for HF in patients discharged after acute HF. Participants' mean age was 73.4 ± 11.2 years, 50.8% were women, 44.7% had T2DM [including 527 (18.2%) on insulin therapy], and 52.7% had preserved ejection fraction. At 1 year follow-up, 518 (17.9%) patients had died and 693 (23.9%) were readmitted for HF. The crude risk of readmission for HF was higher in patients on insulin, with no differences in 1 year mortality. After multivariable adjustment, patients on insulin were at significantly higher risk of 1 year readmission for HF than patients with diabetes who were not on insulin (hazard ratio 1.28; 95% confidence interval 1.04-1.59, P = 0.022) and patients without diabetes (hazard ratio 1.26; 95% confidence interval 1.02-1.55, P = 0.035). Following acute HF, patients with T2DM on insulin therapy are at increased risk of readmission for HF. Further studies unravelling the mechanisms behind this association are warranted

Iturri heated garments for extreme cold conditions

[EN] Biomechanics Institute of Valencia (IBV) participates in the project CENIT INFINITEX, coordinated by the company ITURRI, whose main objective is to develop a new generation of technical textiles, such as multifunctional textiles, which aims to integrate functionalities in a single textile; advanced textiles that offer high performance and specific technical characteristics; and intelligent textiles, capable to react under certain external stimuli. IBV has participated in the generation of specifications for the development of the different research lines; assessment for the development of the new technologies; and the evaluation of the demonstrators of the developed technologies during the Project. This paper presents the work carried out by IBV for ITURRI for the development of heated garments.[ES] El Instituto de Biomecánica (IBV) participa en el proyecto CENIT INFINITEX, coordinado por la empresa ITURRI, cuyo objetivo principal es desarrollar una nueva generación de textiles técnicos, entre ellos, textiles multifuncionales, que permiten integrar funcionalidades en un solo textil; textiles avanzados, que ofrecen unas altas prestaciones y tienen unas características técnicas muy específicas y textiles inteligentes, capaces de reaccionar en función de estímulos externos. El IBV ha participado en la generación de especificaciones para las distintas líneas de investigación, el asesoramiento para el desarrollo de las nuevas tecnologías y la evaluación de los demostradores de las tecnologías desarrolladas durante el proyecto. En este artículo se presenta el trabajo realizado por el IBV para ITURRI en el desarrollo de prendas calefactables.Agradecemos a la empresa ITURRI su liderazgo eficaz del consorcio, que ha hecho posible llevar este ambicioso proyecto a buen término. El proyecto INFINITEX se enmarca dentro de los proyectos CENIT (Consorcios Estratégicos Nacionales de Investigación Técnica) aprobados por el Ministerio de Ciencia e Innovación a través del Centro para el Desarrollo Tecnológico Industrial (CDTI).Gil Garcia, M.; Gonzalez Garcia, JC.; Priego Quesada, JI.; Pellicer Chenoll, MT.; Piqueras Fiszman, P.; Baydal Bertomeu, JM.; Dura Gil, J.... (2013). Prendas calefactables de ITURRI para combatir el frío extremo. Revista de biomecánica. 59:27-29. http://hdl.handle.net/10251/38694S27295

Correction: Lipid profile, cardiovascular disease and mortality in a Mediterranean high-risk population: The ESCARVAL-RISK study.

The potential impact of targeting different components of an adverse lipid profile in populations with multiple cardiovascular risk factors is not completely clear. This study aims to assess the association between different components of the standard lipid profile with all-cause mortality and hospitalization due to cardiovascular events in a high-risk populatio

Lipid profile, cardiovascular disease and mortality in a Mediterranean high-risk population: the ESCARVAL-RISK study

The potential impact of targeting different components of an adverse lipid profile in populations with multiple cardiovascular risk factors is not completely clear. This study aims to assess the association between different components of the standard lipid profile with all cause mortality and hospitalization due to cardiovascular events in a high-risk population. Methods This prospective registry included high risk adults over 30 years old free of cardiovascular disease (2008±2012). Diagnosis of hypertension, dyslipidemia or diabetes mellitus was inclusion criterion. Lipid biomarkers were evaluated. Primary endpoints were all-cause mortality and hospital admission due to coronary heart disease or stroke. We estimated adjusted rate ratios (aRR), absolute risk differences and population attributable risk associated with adverse lipid profiles. Results 51,462 subjects were included with a mean age of 62.6 years (47.6% men). During an average follow-up of 3.2 years, 919 deaths, 1666 hospitalizations for coronary heart disease and 1510 hospitalizations for stroke were recorded. The parameters that showed an increased rate for total mortality, coronary heart disease and stroke hospitalization were, respectively, low HDL-Cholesterol: aRR 1.25, 1.29 and 1.23; high Total/HDL-Cholesterol: aRR 1.22, 1.38 and 1.25; and high Triglycerides/HDL-Cholesterol: aRR 1.21, 1.30, 1.09. The parameters that showed highest population attributable risk (%) were, respectively, low HDL-Cholesterol: 7.70, 11.42, 8.40; high Total/HDL-Cholesterol: 6.55, 12.47, 8.73; and high Triglycerides/ HDL-Cholesterol: 8.94, 15.09, 6.92. Conclusions In a population with cardiovascular risk factors, HDL-cholesterol, Total/HDL-cholesterol and triglycerides/HDL-cholesterol ratios were associated with a higher population attributable risk for cardiovascular disease compared to other common biomarkers

CA125-Guided Diuretic Treatment Versus Usual Care in Patients With Acute Heart Failure and Renal Dysfunction

Background: The optimal diuretic treatment strategy for patients with acute heart failure and renal dysfunction remains unclear. Plasma carbohydrate antigen 125 (CA125) is a surrogate of fluid overload and a potentially valuable tool for guiding decongestion therapy. The aim of this study was to determine if a CA125-guided diuretic strategy is superior to usual care in terms of short-term renal function in patients with acute heart failure and renal dysfunction at presentation. Methods: This multicenter, open-label study randomized 160 patients with acute heart failure and renal dysfunction into 2 groups (1:1). Loop diuretics doses were established according to CA125 levels in the CA125-guided group (n = 79) and in clinical evaluation in the usual-care group (n = 81). Changes in estimated glomerular filtration rate (eGFR) at 72 and 24 hours were the co-primary endpoints, respectively. Results: The mean age was 78 ± 8 years, the median amino-terminal pro-brain natriuretic peptide was 7765 pg/mL, and the mean eGFR was 33.7 ± 11.3 mL/min/1.73m2. Over 72 hours, the CA125-guided group received higher furosemide equivalent dose compared to usual care (P = 0.011), which translated into higher urine volume (P = 0.042). Moreover, patients in the active arm with CA125 >35 U/mL received the highest furosemide equivalent dose (P <0.001) and had higher diuresis (P = 0.013). At 72 hours, eGFR (mL/min/1.73m2) significantly improved in the CA125-guided group (37.5 vs 34.8, P = 0.036), with no significant changes at 24 hours (35.8 vs 39.5, P = 0.391). Conclusion: A CA125-guided diuretic strategy significantly improved eGFR and other renal function parameters at 72 hours in patients with acute heart failure and renal dysfunction

The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase&nbsp;1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation&nbsp;disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age&nbsp; 6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score&nbsp; 652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc&nbsp;= 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N&nbsp;= 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in&nbsp;Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in&nbsp;Asia&nbsp;and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701