Quality of anticoagulation with vitamin K antagonists

[Abstract] Background. Vitamin K antagonists (VKA) have a narrow therapeutic range, and literature analysis reveals poor quality of anticoagulation control. We sought to assess the prevalence of poor anticoagulant control in patients under VKA treatment in the prevention of stroke for atrial fibrillation (AF). Hypothesis.Control of anticoagulation with VKA is inadequate in a high percentage of patients with AF. Methods.Patients with AF under VKA treatment were prospectively recruited in this observational registry. The sample comprised 948 patients. The estimated time spent in the therapeutic range (TTR) was calculated, and variables related with a TTR >65% were analyzed. Results.Mean age was 73.8 ± 9.4 years, and 42.5% of the patients were women. Mean TTR was 63.77% ± 23.80% for the direct method and 60.27% ± 24.48% for the Rosendaal method. Prevalence of poor anticoagulation control was 54%. Variables associated with good anticoagulation control were university studies (odds ratio [OR]: 1.99, 95% confidence interval [CI]: 1.08-3.64), chronic hepatic disease (OR: 8.15, 95% CI: 1.57-42.24), low comorbidity expressed as Charlson index (OR: 0.87, 95% CI: 0.76-0.99), no previous cardiac disease (OR: 0.64, 95% CI: 0.41-0.98), lower risk of bleeding assessed as hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly age, and use of drugs or alcohol (HAS-BLED; OR: 0.81, 95% CI: 0.69-0.95), and lower heart rate (OR: 0.99, 95% CI: 0.98-0.99). Conclusions.Patients who receive VKA to prevent stroke for AF spend less than half the time within therapeutic range.Instituto de Salud Carlos III; RD12/0042/0068Instituto de Salud Carlos III; RD12/0042/0010Instituto de Salud Carlos III; RD12/0042/0069Instituto de Salud Carlos III; RD12/0042/0049Instituto de Salud Carlos III; RD12/0042/006

Splitting the P-Wave: Improved Evaluation of Left Atrial Substrate Modification after Pulmonary Vein Isolation of Paroxysmal Atrial Fibrillation

[EN] Atrial substrate modification after pulmonary vein isolation (PVI) of paroxysmal atrial fibrillation (pAF) can be assessed non-invasively by analyzing P-wave duration in the electrocardiogram (ECG). However, whether right (RA) and left atrium (LA) contribute equally to this phenomenon remains unknown. The present study splits fundamental P-wave features to investigate the different RA and LA contributions to P-wave duration. Recordings of 29 pAF patients undergoing first-ever PVI were acquired before and after PVI. P-wave features were calculated: P-wave duration (PWD), duration of the first (PWDon-peak) and second (PWDpeak-off) P-wave halves, estimating RA and LA conduction, respectively. P-wave onset (PWon-R) or offset (PWoff-R) to R-peak interval, measuring combined atrial/atrioventricular and single atrioventricular conduction, respectively. Heart-rate fluctuation was corrected by scaling. Pre- and post-PVI results were compared with Mann-Whitney U-test. PWD was correlated with the remaining features. Only PWD (non-scaling: & UDelta;=-9.84%, p=0.0085, scaling: & UDelta;=-17.96%, p=0.0442) and PWDpeak-off (non-scaling: & UDelta;=-22.03%, p=0.0250, scaling: & UDelta;=-27.77%, p=0.0268) were decreased. Correlation of all features with PWD was significant before/after PVI (p < 0.0001), showing the highest value between PWD and PWon-R (rho max=0.855). PWD correlated more with PWDon-peak (rho= 0.540-0.805) than PWDpeak-off (rho= 0.419-0.710). PWD shortening after PVI of pAF stems mainly from the second half of the P-wave. Therefore, noninvasive estimation of LA conduction time is critical for the study of atrial substrate modification after PVI and should be addressed by splitting the P-wave in order to achieve improved estimations.This research received financial support from public grants DPI2017-83952-C3, PID2021-00X128525-IV0 and PID2021-123804OB-I00 of the Spanish Government 10.13039/501100011033 jointly with the European Regional Development Fund (EU), SBPLY/17/180501/000411 from Junta de Comunidades de Castilla-La Mancha and AICO/2021/286 from Generalitat Valenciana.Vraka, A.; Bertomeu-González, V.; Hornero, F.; Quesada, A.; Alcaraz, R.; Rieta, JJ. (2022). Splitting the P-Wave: Improved Evaluation of Left Atrial Substrate Modification after Pulmonary Vein Isolation of Paroxysmal Atrial Fibrillation. Sensors. 22(1):1-13. https://doi.org/10.3390/s2201029011322

Los desafíos del profesorado clínico en la educación médica

Background: There is a unique particularity of clinical teaching in medical education that isbeyond knowledge, skills or teaching methods of each clinician: this is clinical teaching context.This study aimed to analyze the main barriers in clinical teaching in a single medical school in Spain. Methods: This was a descriptive study in which all the clinical teachers (all of them associateprofessors) of a single and novel faculty of medicine were asked to answer an online, anonymousand voluntary questionnaire about aspects of support to clinical work, promotion of clinicalresearch and recognition of their professional careers. The questionnaires were organized andanalyzed into these three main issues.Results: 61 clinical teachers (42%) answered the questionnaire. The main findings that emergedwere: (i) lack of protected time for practical teaching at hospital; (ii) lack of support for clinicalresearch from hospital or faculty; and (iii) lack of recognition of their professional careers.Conclusions: The clinical teaching in medical education is a continuing challenge for busyclinicians. Further studies on this topic are needed.Antecedentes: La enseñanza clínica en la educación médica tiene una particularidad única:el contexto clínico. Este estudio tiene como objetivo analizar las principales barreras de laense˜nanza clínica en una facultad joven de Medicina de Espa˜na.Métodos: Se trata de un estudio transversal descriptivo en el que se solicitó a todos losprofesores clínicos (todos ellos profesores asociados) de una facultad joven de Medicina que res-pondieran a un cuestionario en línea, anónimo y voluntario sobre aspectos de carga asistencial,promoción de la investigación clínica y reconocimiento de sus carreras profesionales.Resultados: Sesenta y un profesores (42%) respondieron al cuestionario. Los principales hallaz-gos que se obtuvieron fueron: 1) la falta de tiempo protegido para la ense˜nanza práctica en lainstitución sanitaria; 2) el escaso apoyo para la investigación clínica por parte de la instituciónsanitaria o de la facultad; y 3) el escaso de reconocimiento de la carrera profesional.Conclusiones: La ense˜nanza clínica en la educación médica es un desafío continuo para elclínico. Son necesarios futuros estudios que analicen estos aspectos de forma más exhaustiva

Are Coronary Sinus Features Reflecting the Effect of Catheter Ablation of Atrial Fibrillation as P-waves Do?

[EN] Atrial substrate alteration due to catheter ablation (CA) of atrial fibrillation (AF) is primarily assessed from P-waves. Nonetheless, how CA affects critical structures is ignored. The aim of the current study is to investigate if CA effect on CS, the principal CA reference, is related to that observed from P-waves analysis. Five-minute lead II and bipolar CS recordings of 29 paroxysmal AF patients were obtained before, during and after CA. Duration, amplitude, area and heart-rate (HR) variability (HRV) features were calculated for P-waves and local activation waves (LAWs). Normalization mitigated the effect of HR fluctuations. Linear correlations between each P-wave and LAW were tested with linear regression (LR) and Pearson correlation (PC) and nonlinear correlations with cross-quadratic sample entropy (CQSE). Correlation between the CA effect on P-waves and LAWs was investigated with PC. Negligent statistical correlations were found by PC and LR for amplitude and area (¿3.30% 90%, p < 0.0297). Apart from HRV, no significant correlations between CS LAWs and P-waves have been found. HR fluctuations mask any possible tuning and normalization should be applied prior to the analysis.Research supported by grants DPI2017¿83952¿C3 from MINECO/AEI/FEDER UE, SBPLY/17/180501/000411 from JCCLM and AICO/2021/286 from GVA.Vraka, A.; Bertomeu-González, V.; Hornenro, F.; Langley, P.; Alcaraz, R.; Rieta, JJ. (2021). Are Coronary Sinus Features Reflecting the Effect of Catheter Ablation of Atrial Fibrillation as P-waves Do?. IEEE. 1-4. https://doi.org/10.1109/EHB52898.2021.96576391

Is Short-Term Heart Rate Variability Good Enough to Predict Vascular Events in Hypertensive Patients?

[EN] Vascular events are the main cause of premature death and disability in the developed countries, where there is great interest in the development of computational tools for their early detection. A very relevant variable for their study is the heart rate, that can be analyzed through heart rate variability (HRV). Furthermore, high blood pressure is an important risk factor for most cardiovascular diseases. In fact, small reductions in blood pressure are known to markedly reduce cardiovascular morbidity and mortality. This study evaluates the predictive value of short-term HRV (STHRV) by developing models based on data mining algorithms to stratify the risk of vascular events from hypertensive patients. For this specific framework, the performance of various machine learning models (Random Forest, Support Vector Machines, Gaussian Naive Bayes, K-N Nearest Neighbours and Logistic regression), trained with different time lengths of 5, 30 and 60 minutes of HRV features during sleep stage was compared. The analyzed HRV parameters were associated to time, frequency and nonlinear features. A total of 139 Holter recordings from hypertensive patients of whom 17 developed a vascular event were analyzed. Results indicated that classification models developed using STHRV, with only 5 minutes length, provided similar or even better results than those developed with longer time series. Furthermore, the STHRV models provided a higher sensitivity and a slightly higher F1 score. The best one, based on Support Vector Machines, yielded 88.2% sensitivity and 75% F1 score. Thus, this research suggests the feasibility of STHRV analysis for risk stratification of hypertensive patients to anticipate serious vascular events.Research supported by grants DPI2017¿83952¿C3 from MINECO/AEI/FEDER UE, SBPLY/17/180501/000411 from JCCLM and AICO/2021/286 from GVA.Tornero, R.; Fácila, L.; Bertomeu-González, V.; Zangróniz, R.; Alcaraz, R.; Rieta, JJ. (2021). Is Short-Term Heart Rate Variability Good Enough to Predict Vascular Events in Hypertensive Patients?. IEEE. 1-4. https://doi.org/10.1109/EHB52898.2021.96576591

Hypertension Risk Assessment from Photoplethysmographic Recordings Using Deep Learning Classifiers

[EN] Regular monitoring of blood pressure (BP) is essential for early detection of cardiovascular diseases caused by hypertension, a potentially deadly condition without symptoms in its first stages. This study investigates whether deep learning techniques can assess risk levels of BP using only photoplethysmographic (PPG) recordings without the need of electrocardiographic (ECG) recordings, as in many previous studies. 15.240 segments from 50 different patients containing simultaneous PPG and arterial blood pressure (ABP) signals were analysed. GoogleNet and ResNet pretrained convolutional neural networks (CNN) with the scalogram of PPG signals obtained by continuous wavelet transform (CWT) used as input images were employed for the classification. The highest F1 score was achieved by discriminating normotensive (NT) patients from prehypertensive (PH) and hypertensive (HT), being 92.10% for GoogleNet and 93.91% for ResNet, respectively. In addition, intra-patient classification using different data segments for training and validation provided an F1 score of 90.28% with GoogleNet and 89.04% with ResNet. Time frequency transformation of PPG recordings to feed deep learning classifiers has been able to provide outstanding results in hypertension risk assessment without requiring either ECG recordings or feature extraction.Research supported by grants DPI2017-83952-C3 from MINECO/AEI/FEDER UE, SBPLY/17/180501/000411 from JCCLM and AICO/2021/286 from GVA.Cano, J.; Bertomeu-González, V.; Fácila, L.; Zangróniz, R.; Alcaraz, R.; Rieta, JJ. (2021). Hypertension Risk Assessment from Photoplethysmographic Recordings Using Deep Learning Classifiers. 1-4. https://doi.org/10.22489/CinC.2021.0311

Linear and Nonlinear Correlations Between Surface and Invasive Atrial Activation Features in Catheter Ablation of Paroxysmal Atrial Fibrillation

[EN] P-waves are vastly used to assess the outcome of catheter ablation (CA) of atrial fibrillation (AF). It remains unknown, however, if coronary sinus (CS), the key reference structure in CA procedures, follows similar patterns. This study¿s objective is to detect any correlations between the behavior of P-waves and CS local activation waves (LAWs) with regard to CA procedure. Duration, amplitude, area and slope rate were studied in P-waves and LAWs of five-minute recordings from 29 patients undergoing paroxysmal AF CA. Normalization (N) due to heart rate (HR) fluctuations was performed. Pearson¿s correlation (PC) between CA-induced variations (¿) of P-waves and LAWs was calculated. Linear correlations between each P-wave/LAW were studied with PC and linear regression with 10¿fold cross-validation. Cross-quadratic sample entropy (CQSE) assessed nonlinear correlations. PC (¿ : ¿ < 52.27%, p = 0.015, P-wave/LAW: ¿ < 40.37%, p = 0.001) and linear regression analysis (R2 ¿ adj < 16.02%, p = 0.015 ) showed low/mediocre linear correlations. CQSE ( 0.8 ¿ 1.3) also suggested weak nonlinear relationships. P-waves and LAWs are poorly correlated and do not describe to the same degree the substrate modification after CA. It is possible that P-waves reflect the cumulative CA-induced modifications of various atrial sites, with CS being one of them but not the dominant.Research supported by grants DPI2017-83952-C3 from MINECO/AEI/FEDER UE, SBPLY/17/180501/000411 from JCCLM and AICO/2021/286 from GVA.Vraka, A.; Bertomeu-González, V.; Hornero, F.; Ravelli, F.; Alcaraz, R.; Rieta, JJ. (2021). Linear and Nonlinear Correlations Between Surface and Invasive Atrial Activation Features in Catheter Ablation of Paroxysmal Atrial Fibrillation. 1-4. https://doi.org/10.22489/CinC.2021.0291

Choice of new oral anticoagulant agents versus vitamin K antagonists in atrial fibrillation: FANTASIIA study

[Abstract] Introduction: Atrial fibrillation (AF) is associated with an increased risk of thromboembolic events. Many patients with AF receive chronic anticoagulation, either with vitamin K antagonists (VKAs) or with non-VKA oral anticoagulants (NOACs). We sought to analyze variables associated with prescription of NOAC. Methods: Patients with AF under anticoagulation treatment were prospectively recruited in this observational registry. The sample comprised 1290 patients under chronic anticoagulation for AF, 994 received VKA (77.1%) and 296 NOAC (22.9%). Univariate and multivariate analyses were performed to identify variables associated with use of NOAC. Results: Mean age was 73.8 ± 9.4 years, and 42.5% of the patients were women. The CHA2DS2-VASc score was 0 in 4.9% of the population, 1 in 24.1%, and ≥2 in 71% (median = 4, interquartile range = 2). Variables associated with NOAC treatment were major bleeding (odds ratio [OR] = 3.36; confidence interval [CI] 95%: 1.73-6.51; P < .001), hemorrhagic stroke (OR = 3.19; CI 95% 1.00-10.15, P = .049), university education (OR = 2.44; CI 95%: 1.55-3.84; P < .001), high diastolic blood pressure (OR = 1.02; CI 95%: 1.00-1.03; P = .006), and higher glomerular filtration rate (OR 1.01, CI 95% 1.00-1.01; P = .01). And variables associated with VKA use were history of cancer (OR = 0.46; CI 95%: 0.25-0.85; P = .013) and bradyarrhythmia (OR = 0.40; CI 95% 0.19-0.85; P = .020). Conclusion: Medical and social variables were associated with prescription of NOAC. Major bleeding, hemorrhagic stroke, university education, and higher glomerular filtration rate were more frequent among patients under NOAC. On the contrary, patients with history of cancer or bradyarrhythmias more frequently received VKA.Instituto de Salud Carlos III; RD12/0042/0068Instituto de Salud Carlos III; RD12/0042/0063Instituto de Salud Carlos III; RD12/0042/0010Instituto de Salud Carlos III; RD12/0042/0069Instituto de Salud Carlos III; RD12/0042/004

The Dissimilar Impact in Atrial Substrate Modification of Left and Right Pulmonary Veins Isolation after Catheter Ablation of Paroxysmal Atrial Fibrillation

[EN] Since the discovery of pulmonary veins (PVs) as foci of atrial fibrillation (AF), the commonest cardiac arrhythmia, investigation revolves around PVs catheter ablation (CA) results. Notwith-standing, CA process itself is rather neglected. We aim to decompose crucial CA steps: coronary sinus (CS) catheterization and the impact of left and right PVs isolation (LPVI, RPVI), separately. We recruited 40 paroxysmal AF patients undergoing first-time CA and obtained five-minute lead II and bipolar CS recordings during sinus rhythm (SR) before CA (B), after LPVI (L) and after RPVI (R). Among others, duration, amplitude and atrial-rate variability (ARV) were calculated for P-waves and CS local activation waves (LAWs). LAWs features were compared among CS channels for reliability analysis. P-waves and LAWs features were compared after each ablation step (B, L, R). CS channels: amplitude and area were different between distal/medial (p = 93%) than distal (+73.12%, p <= 0.0480, R: <-33.94%, p <= 0.0642). Medial/mid-proximal channels are recommended during SR. CS LAWs are not significantly affected by CA but they describe more precisely CA-induced ARV modifications. LPVI provokes the highest impact in paroxysmal AF CA, significantly modifying P-wave duration.This research has received partial financial support from public grants DPI2017-83952-C3, PID2021-00X128525-IV0, PID2021-123804OB-I00 and TED2021-129996B-I00 of the Spanish Government 10.13039/501100011033 jointly with the European Regional Development Fund (EU), SBPLY/17/180501/000411 from Junta de Comunidades de Castilla-La Mancha and AICO/2021/286 from Generalitat Valenciana.Vraka, A.; Bertomeu-González, V.; Fácila, L.; Moreno-Arribas, J.; Alcaraz, R.; Rieta, JJ. (2022). The Dissimilar Impact in Atrial Substrate Modification of Left and Right Pulmonary Veins Isolation after Catheter Ablation of Paroxysmal Atrial Fibrillation. Journal of Personalized Medicine. 12(3):1-18. https://doi.org/10.3390/jpm1203046211812

Lifestyle and cardiovascular mortality in menopausal women: a population-based cohort study

Introduction and objectives: There are models for cardiovascular risk prediction in the general population, but the prediction of risk in postmenopausal women has not been specifically studied. This study aimed to determine the association of lifestyle habits and chronic diseases with cardiovascular risk in menopausal women, as well as to build a risk scale. Methods: Retrospective population-based cohort study using data from the 2011 National Health Survey of Spain as a data source, Women 50 years were included. The characteristics that best defined the life habits of the study women were collected, as well as their health status and self-reported medical history at the time of the survey. Follow-up data on all-cause mortality were obtained from participants from 2011 to 2017. Results: A total of 5953 women 50 years of age were included, with a mean age of 66.4 11.4 years. The incidence of cardiovascular mortality in the follow-up period was 4%. Vegetable consumption less than 1 time/week (HR, 1.758), smoking (HR, 1.816) or excess hours of sleep ( 9 h/day, HR, 1.809), or o have main daily activity sitting most of the time (HR, 2.757) were related to cardiovascular mortality. The predictive model presents an honest C-index in test sample of 0.8407 (95%CI, 0.8025-0.8789). Conclusions: Life habits such as the consumption of vegetables, daily main activity, sleeping hours or smoking are risk factors for cardiovascular mortality of great relevance among menopausal women. A simple 6-year self-reported risk scale with high predictive capacity is provide