Competence of general practitioners in requesting and interpreting ECGs - a case vignette study

Background

Performing electrocardiography is common in general practice, but the quality of indication setting and diagnostic accuracy have been disputed.

Objectives

To assess the competence of general practitioners (GPs) in their decision-making process with regard to recording and interpreting an electrocardiogram (ECG) and evaluating the relevance of the result for management.

Methods

An online case vignette survey was performed among GPs and cardiologists (in 2015). Nine cases describing situations for which Dutch clinical guidelines recommend or advise against recording an ECG were presented. In each case, the participant had to make choices on recording an ECG, interpreting it, and using the result in a management decision. The reference standard for each ECG diagnosis was set by the expert author team.

Results

Fifty GPs who interpret ECGs themselves, eight GPs who do not and 12 cardiologists completed the survey. Adherence to guidelines recommending an ECG was high for suspected atrial fibrillation, suspected arrhythmia present during consultation, including bradycardia, but much lower for progressive heart failure and stable angina. Diagnostic accuracy of GPs was best in atrial fibrillation (96%), sick sinus syndrome (85%) and old myocardial infarction (82%), but poor in left anterior fascicular block (16%) and incomplete right bundle branch block (10%). GPs often acknowledged the low relevance of the results of a non-indicated ECG.

Conclusion

GPs do not fully adhere to Dutch cardiovascular guidelines on indications for recording ECGs. Diagnostic accuracy was high for atrial fibrillation, sick sinus syndrome and old myocardial infarction and poor for left anterior fascicular block and incomplete right bundle branch block.

     

Predicting initiation and termination of atrial fibrillation from the ECG.

Atrial fibrillation is the most common cardiac arrhythmia, affecting more than two million people in the US. Several therapies for patients with atrial fibrillation are available, but methods to help physicians select the optimal therapy for an individual patient are still required. Knowledge of whether a patient with a normal ECG will exhibit atrial fibrillation in the future, as well as whether atrial fibrillation will terminate spontaneously, would be very useful in clinical routine. The paper presents a software system for predicting the initiation and termination of atrial fibrillation from the ECG. The algorithms have been validated on ECGs from several signal databases. Prediction of the initiation of atrial fibrillation was achieved by detecting premature heart beats and analyzing the morphology of their P waves. Prediction of the termination of atrial fibrillation was based on calculation of the major atrial frequency. This frequency has been shown to decrease significantly prior to the termination of atrial fibrillation. Nevertheless, the effect is much less distinct in the large data set used for this study compared to previous studies. The initiation of atrial fibrillation, however, could be correctly predicted in approximately 75% of the data analyzed.     

Alterations in electrocardiographic parameters induced by acute infection with Pseudomonas aeruginosa wild-type and mucoid strains in mice

Pseudomonas aeruginosa (PA) is a pathogen in patients with cystic fibrosis (CF) and burn wound infections. Few studies have investigated the role of PA in electrocardiogram parameters (ECGs) with acute infection. We hypothesized that PA induces adverse ECGs effects in mice. After inoculation with wild-type strain PA14, the mucoid CF isolate FRD1 (mucA22+), which produces extensive alginate and has a natural mucoid phenotype, and the PA14 algD^? strain that cannot produce alginate, were evaluated by computerized electrocardiographic. ECG conduction changes were present in the P wave, the R-R interval and heart frequency in all PA strains and the PR interval were significantly prolonged with PA infection with PA14 algD^? and FRD1, compared to the control (P < 0.05), indicating slowed atrial and atrial–ventricular conduction. We conclude that PA produces bradycardia and demonstrated dramatic decreases in other ECGs associated with exposure to wild-type and mutant from PA. Furthermore, the mechanisms by which PA affects cardiac conduction remain uncertain.     

老年人动态心电图心律失常特点及对阵发性 房颤的诊断

目的:分析65岁以上老年人十二导联动态心电图(12-Holter)心律失常的特点及其对阵发性房颤的诊断价值。方法:①采用回顾性分析的方法,随机选择500例65岁以上老年人的动态心电图进行心律失常情况的统计分析,并同时选择500例小于65岁的心电图作为对照;②另选择500例65岁以上老年人的十二导联普通心电图(ECG)作为对照,对比分析12-Holter与ECG两种方法对老年人阵发性房颤的检出率。结果:①65岁以上老年人动态心电图各种心律失常、ST-T改变的发生率高。而在各类心律失常中房性早搏、室性期前收缩、房性心动过速、房颤发生率较高。②动态心电图对于阵发性房颤的检出率显著高于普通十二导联心电图。结论:①老年人动态心电图检查结果异常率高;②与普通心电图比较,动态心电图诊断老年人阵发性房颤有较高的价值。     

Atrial fibrillation after but not before primary angioplasty for ST-segment elevation myocardial infarction of prognostic importance

Aim

In patients with ST-segment elevation myocardial infarction (STEMI), it is uncertain whether atrial fibrillation has prognostic implications. There may be a difference between atrial fibrillation before and after reperfusion therapy.

Methods and results

In patients with STEMI treated with primary percutaneous coronary intervention (PCI), ECGs were analysed before and after primary PCI. Of the 1623 patients with electrocardiographic data before primary PCI, 53 patients (3.3%) had atrial fibrillation. Patients with atrial fibrillation were older, were more often female, and less often had anterior MI location. Of the 1728 patients with electrocardiographic data after primary PCI, 52 patients (3.0%) had atrial fibrillation. Atrial fibrillation was more common in older patients and in those with Killip class >1. Also patients with occlusion of the right coronary artery or TIMI flow 0 before primary PCI more commonly had AF after the procedure. Not successful reperfusion was also associated with a higher incidence of AF after primary PCI. Although both atrial fibrillation before and after primary PCI were associated with increased mortality, multivariable analyses, adjusting for differences in age, gender and Killip class on admission, revealed that atrial fibrillation after PCI (OR 3.69, 95% CI 1.87–7.29) but not before PCI (OR 1.86, 95% CI 0.89–3.90) was independent and statistically significantly associated with long-term mortality.

Conclusion

In patients with STEMI, atrial fibrillation after but not before primary PCI has independent prognostic implications. Possibly, atrial fibrillation after the PCI is a symptom of failed reperfusion and a sign of heart failure.     

Analysis of changes in the beat-to-beat P-wave morphology using clustering techniques

Several pathologies related to the atrial electrical activity can be detected in the electrocardiogram P-wave. A protocol for analyzing P-wave morphology changes has been developed in this article. By using this protocol a study on the beat-to-beat P-wave morphology changes of 89 ECG signals is performed. An algorithm based on the embedding space techniques has been used to extract the P-wave information of the ECG. The P-waves obtained in several of these ECGs exhibit significant alternate morphology changes. The morphologies have been classified by using the K-means clustering algorithm. The mechanism behind the P-wave morphology change process and its possible pathophysiological importance remains to be clarified.     

Clinical Characteristics,Management, and Control of Permanent vs. Nonpermanent Atrial Fibrillation: Insights from the RealiseAF Survey

Background

Atrial fibrillation can be categorized into nonpermanent and permanent atrial fibrillation. There is less information on permanent than on nonpermanent atrial fibrillation patients. This analysis aimed to describe the characteristics and current management, including the proportion of patients with successful atrial fibrillation control, of these atrial fibrillation subsets in a large, geographically diverse contemporary sample.

Methods and Results

Data from RealiseAF, an international, observational, cross-sectional survey of 10,491 patients with atrial fibrillation, were used to characterize permanent atrial fibrillation (N = 4869) and nonpermanent atrial fibrillation (N = 5622) patients. Permanent atrial fibrillation patients were older, had a longer time since atrial fibrillation diagnosis, a higher symptom burden, and were more likely to be physically inactive. They also had a higher mean (SD) CHADS₂ score (2.2 [1.3] vs. 1.7 [1.3], p<0.001), and a higher frequency of CHADS₂ score ≥2 (67.3% vs. 53.0%, p<0.001) and comorbidities, most notably heart failure. Physicians indicated using a rate-control strategy in 84.2% of permanent atrial fibrillation patients (vs. 27.5% in nonpermanent atrial fibrillation). Only 50.2% (N = 2262/4508) of permanent atrial fibrillation patients were controlled. These patients had a longer time since atrial fibrillation diagnosis, a lower symptom burden, less obesity and physical inactivity, less severe heart failure, and fewer hospitalizations for acute heart failure than uncontrolled permanent atrial fibrillation patients, but with more arrhythmic events. The most frequent causes of hospitalization in the last 12 months were acute heart failure and stroke.

Conclusion

Permanent atrial fibrillation is a high-risk subset of atrial fibrillation, representing half of all atrial fibrillation patients, yet rate control is only achieved in around half. Since control is associated with lower symptom burden and heart failure, adequate rate control is an important target for improving the management of permanent atrial fibrillation patients.     

An integrated diabetic index using heart rate variability signal features for diagnosis of diabetes

Electrocardiogram (ECG) signals are difficult to interpret, and clinicians must undertake a long training process to learn to diagnose diabetes from subtle abnormalities in these signals. To facilitate these diagnoses, we have developed a technique based on the heart rate variability signal obtained from ECG signals. This technique uses digital signal processing methods and, therefore, automates the detection of diabetes from ECG signals. In this paper, we describe the signal processing techniques that extract features from heart rate (HR) signals and present an analysis procedure that uses these features to diagnose diabetes. Through statistical analysis, we have identified the correlation dimension, Poincaré geometry properties (SD2), and recurrence plot properties (REC, DET, L _mean) as useful features. These features differentiate the HR data of diabetic patients from those of patients who do not have the illness, and have been validated by using the AdaBoost classifier with the perceptron weak learner (yielding a classification accuracy of 86%). We then developed a novel diabetic integrated index (DII) that is a combination of these nonlinear features. The DII indicates whether a particular HR signal was taken from a person with diabetes. This index aids the automatic detection of diabetes, thereby allowing a more objective assessment and freeing medical professionals for other tasks.     

A mobile one-lead ECG device incorporated in a symptom-driven remote arrhythmia monitoring program. The first 5,982 Hartwacht ECGs

Background

In recent years many mobile devices able to record health-related data in ambulatory patients have emerged. However, well-organised programs to incorporate these devices are sparse. Hartwacht Arrhythmia (HA) is such a program, focusing on remote arrhythmia detection using the AliveCor Kardia Mobile (KM) and its algorithm.

Objectives

The aim of this study was to assess the benefit of the KM device and its algorithm in detecting cardiac arrhythmias in a real-world cohort of ambulatory patients.

Methods

All KM ECGs recorded in the HA program between January 2017 and March 2018 were included. Classification by the KM algorithm was compared with that of the Hartwacht team led by a cardiologist. Statistical analyses were performed with respect to detection of sinus rhythm (SR), atrial fibrillation (AF) and other arrhythmias.

Results

5,982 KM ECGs were received from 233 patients (mean age 58 years, 52% male). The KM algorithm categorised 59% as SR, 22% as possible AF, 17% as unclassified and 2% as unreadable. According to the Hartwacht team, 498 (8%) ECGs were uninterpretable. Negative predictive value for detection of AF was 98%. However, positive predictive value as well as detection of other arrhythmias was poor. In 81% of the unclassified ECGs, the Hartwacht team was able to provide a diagnosis.

Conclusions

This study reports on the first symptom-driven remote arrhythmia monitoring program in the Netherlands. Less than 10% of the ECGs were uninterpretable. However, the current performance of the KM algorithm makes the device inadequate as a stand-alone application, supporting the need for manual ECG analysis in HA and similar programs.

     

Identification of patients with atrial fibrillation using HRV parameters]

Atrial fibrillation is the most common sustained cardiac rhythm disturbance. One of the most drastic complications is embolism, particularly stroke. Patients with atrial fibrillation have to be identified. This can lead to early therapy and thus avoiding strokes. The algorithm presented here detects atrial fibrillation securely and reliably. It is based on a single-channel ECG, which takes 60 min. First, the R-peaks are detected from the ECG and the RR interval is calculated. To be independent from pulse variations, the RR interval is normalized to 60 bpm. A parameter of heart rate variability is calculated in time domain (SDSD) and the so-called Poincaré plot is generated. The image analysis of the figures of the Poincaré plot is made automatically. The results from analysis in time domain, as well as image analysis, yield a risk level, which indicates the probability for the occurrence of atrial fibrillation. Even if there is no atrial fibrillation in the ECG while analyzing, it is possible to identify patients with atrial fibrillation. The sensitivity depends on the burden of atrial fibrillation. Even if a burden of 0% is assumed, the results still prove satisfactory (sensitivity of nearly 83%).     

Assessment of the causal relevance of ECG parameters for risk of atrial fibrillation: A mendelian randomisation study

BackgroundAtrial electrical and structural remodelling in older individuals with cardiovascular risk factors has been associated with changes in surface electrocardiographic (ECG) parameters (e.g., prolongation of the PR interval) and higher risks of atrial fibrillation (AF). However, it has been difficult to establish whether altered ECG parameters are the cause or a consequence of the myocardial substrate leading to AF. This study aimed to examine the potential causal relevance of ECG parameters on risk of AF using mendelian randomisation (MR).Methods and findingsWeighted genetic scores explaining lifelong differences in P-wave duration, PR interval, and QT interval were constructed, and associations between these ECG scores and risk of AF were estimated among 278,792 UK Biobank participants (mean age: 57 years at recruitment; 19,132 AF cases). The independent genetic variants contributing to each of the separate ECG scores, and their corresponding weights, were based on published genome-wide association studies. In UK Biobank, genetic scores representing a 5 ms longer P-wave duration or PR interval were significantly associated with lower risks of AF (odds ratio [OR] 0.91; 95% confidence interval [CI]: 0.87–0.96, P = 2 × 10⁻⁴ and OR 0.94; 95% CI: 0.93–0.96, P = 2 × 10⁻¹⁹, respectively), while longer QT interval was not significantly associated with AF. These effects were independently replicated among a further 17,931 AF cases from the AFGen Consortium. Investigation of potential mechanistic pathways showed that differences in ECG parameters associated with specific ion channel genes had effects on risk of AF consistent with the overall scores, while the overall scores were not associated with changes in left atrial size. Limitations of the study included the inherent assumptions of MR, restriction to individuals of European ancestry, and possible restriction of results to the normal ECG ranges represented in UK Biobank.ConclusionsIn UK Biobank, we observed evidence suggesting a causal relationship between lifelong differences in ECG parameters (particularly PR interval) that reflect longer atrial conduction times and a lower risk of AF. These findings, which appear to be independent of atrial size and concomitant cardiovascular comorbidity, support the relevance of varying mechanisms underpinning AF and indicate that more individualised treatment strategies warrant consideration.

In a Mendelian randomization analysis, Parag Gajendragadkar and colleagues investigate associations between genetically-predicted EEG parameters and risk of atrial fibrillation among UK Biobank participants.     

Aortic Stiffness in Lone Atrial Fibrillation: A Novel Risk Factor for Arrhythmia Recurrence

Background

Recent community-based research has linked aortic stiffness to the development of atrial fibrillation. We posit that aortic stiffness contributes to adverse atrial remodeling leading to the persistence of atrial fibrillation following catheter ablation in lone atrial fibrillation patients, despite the absence of apparent structural heart disease. Here, we aim to evaluate aortic stiffness in lone atrial fibrillation patients and determine its association with arrhythmia recurrence following radio-frequency catheter ablation.

Methods

We studied 68 consecutive lone atrial fibrillation patients who underwent catheter ablation procedure for atrial fibrillation and 50 healthy age- and sex-matched community controls. We performed radial artery applanation tonometry to obtain central measures of aortic stiffness: pulse pressure, augmentation pressure and augmentation index. Following ablation, arrhythmia recurrence was monitored at months 3, 6, 9, 12 and 6 monthly thereafter.

Results

Compared to healthy controls, lone atrial fibrillation patients had significantly elevated peripheral pulse pressure, central pulse pressure, augmentation pressure and larger left atrial dimensions (all P<0.05). During a mean follow-up of 2.9±1.4 years, 38 of the 68 lone atrial fibrillation patients had atrial fibrillation recurrence after initial catheter ablation procedure. Neither blood pressure nor aortic stiffness indices differed between patients with and without atrial fibrillation recurrence. However, patients with highest levels (≥75^th percentile) of peripheral pulse pressure, central pulse pressure and augmentation pressure had higher atrial fibrillation recurrence rates (all P<0.05). Only central aortic stiffness indices were associated with lower survival free from atrial fibrillation using Kaplan-Meier analysis.

Conclusion

Aortic stiffness is an important risk factor in patients with lone atrial fibrillation and contributes to higher atrial fibrillation recurrence following catheter ablation procedure.     

SPEAR Trial: Smartphone Pediatric ElectrocARdiogram Trial

Objectives

Smartphone-enabled ECG devices have the potential to improve patient care by enabling remote ECG assessment of patients with potential and diagnosed arrhythmias. This prospective study aimed to assess the usefulness of pediatric ECG tracings generated by the AliveCor device (Oklahoma City, OK) and to assess user satisfaction.

Study Design

Enrolled pediatric patients with documented paroxysmal arrhythmia used the AliveCor device over a yearlong study period. Pediatric electrophysiologists reviewed all transmitted ECG tracings. Patient completed surveys were analyzed to assess user satisfaction.

Results

35 patients were enrolled with the following diagnoses: supraventricular tachycardia (SVT, 57%), atrial fibrillation (AF, 11%), ectopic atrial tachycardia (EAT, 6%), atrial tachycardia (AT, 3%), and ventricular tachycardia (VT, 23%). A total of 238 tracings were received from 20 patients, 96% of which were of diagnostic quality for sinus rhythm, sinus tachycardia, SVT, and AF. 126 patient satisfaction surveys (64% from parents) were completed. 98% of the survey responses indicated that it was easy to obtain tracings, 93% found it easy to transmit the tracings, 98% showed added comfort in managing arrhythmia by having the device, and 93% showed interest in continued use of the device after the study period ended.

Conclusions

Smartphone-enabled ECG devices can generate tracings of diagnostic quality in children. User satisfaction was extremely positive. Use of the device to manage certain patients with AF and SVT showcases the future role of remote ECGs in the successful outpatient management of arrhythmias in children by potentially reducing Emergency Department visits and healthcare costs.     

Uncovering chaotic structure in mechanomyography signals of fatigue biceps brachii muscle

The mechanomyography (MMG) signal reflects mechanical properties of limb muscles that undergo complex phenomena in different functional states. We undertook the study of the chaotic nature of MMG signals by referring to recent developments in the field of nonlinear dynamics. MMG signals were measured from the biceps brachii muscle of 5 subjects during fatigue of isometric contraction at 80% maximal voluntary contraction (MVC) level. Deterministic chaotic character was detected in all data by using the Volterra–Wiener–Korenberg model and noise titration approach. The noise limit, a power indicator of the chaos of fatigue MMG signals, was 22.20±8.73. Furthermore, we studied the nonlinear dynamic features of MMG signals by computing their correlation dimension D₂, which was 3.35±0.36 across subjects. These results indicate that MMG is a high-dimensional chaotic signal and support the use of the theory of nonlinear dynamics for analysis and modeling of fatigue MMG signals.     

Denoising of surface EMG with a modified Wiener filtering approach

The correlation dimension D₂ yields good results in several biomedical fields. Nonetheless, no clinical application to electromyography has been developed yet. One reason is the high electromagnetic noise typical of clinical environments. This noise is characterized by sharp spectral lines of variable intensity and frequency. The filtering techniques commonly implemented in electromyographs can efficiently deal with this kind of noise. They allow a safe estimate of linear quantities like the root mean square (r.m.s.) or the median frequency (MF). Their performance is not as good for nonlinear purposes. The filters may modify the nonlinear properties of the signal, leading to unacceptable estimates of D₂. We consider a simple procedure based on a modified Wiener filter. Its performance is compared with that from a bandpass followed by multiple notch filters. Our procedure leads to a gain in precision and accuracy when estimating D₂. The two filtering approaches are also compared with respect to a biomedical application proposed by others. Using data from 12 healthy subjects, the modified Wiener procedure raises the percentage of successes in that application from 17% to 83%. New experimental data suggest D₂ carries information not carried by r.m.s. or MF.     

The Application of Root Mean Square Electrocardiography (RMS ECG) for the Detection of Acquired and Congenital Long QT Syndrome

Background

Precise measurement of the QT interval is often hampered by difficulty determining the end of the low amplitude T wave. Root mean square electrocardiography (RMS ECG) provides a novel alternative measure of ventricular repolarization. Experimental data have shown that the interval between the RMS ECG QRS and T wave peaks (RT_PK) closely reflects the mean ventricular action potential duration while the RMS T wave width (TW) tracks the dispersion of repolarization timing. Here, we tested the precision of RMS ECG to assess ventricular repolarization in humans in the setting of drug-induced and congenital Long QT Syndrome (LQTS).

Methods

RMS ECG signals were derived from high-resolution 24 hour Holter monitor recordings from 68 subjects after receiving placebo and moxifloxacin and from standard 12 lead ECGs obtained in 97 subjects with LQTS and 97 age- and sex-matched controls. RT_PK, QT_RMS and RMS TW intervals were automatically measured using custom software and compared to traditional QT measures using lead II.

Results

All measures of repolarization were prolonged during moxifloxacin administration and in LQTS subjects, but the variance of RMS intervals was significantly smaller than traditional lead II measurements. TW was prolonged during moxifloxacin and in subjects with LQT-2, but not LQT-1 or LQT-3.

Conclusion

These data validate the application of RMS ECG for the detection of drug-induced and congenital LQTS. RMS ECG measurements are more precise than the current standard of care lead II measurements.     

The statistical correlation of nucleotides in protein-coding DNA sequences

The statistical correlation of nucleotides in a DNA sequence is described by a set of redundanciesD ₁,D ₂,D ₃,... By calculation of {D _n} of 2341 coding regions of nucleic acid sequences it is demonstrated that about 2/3 of sequences has correlation length ≤2, 10% of sequences—correlation with 3-periodicity and others—long range aperiodic correlations. The implications of the results from the interactions of random mutation and natural selection are discussed briefly. Project supported by National Science Foundation of China.     

A dynamic laser light-scattering study of chitosan in aqueous solution

The solution behavior of four chitosans (91% deacetylated chitin) with different molecular weights in 0.2M CH₃COOH/0.1M CH₃COONa aqueous solution was investigated at 25°C by dynamic laser light scattering (LLS). The Laplace inversion of the precisely measured intensity-intensity lime correlation function leads us to an estimate of the line-width distribution G(Γ), which could be further reduced too translational diffusion coefficient distributions G(D). By using a combination of static and dynamic LLS results, i.e., M_w and G (D), we were able to establish a calibration of D = k_DM with k_D = (3.14 ± 0.20) × 10⁻⁴ and α_D = 0.655 ± 0.015. By using this calibration, we successfully converted G(D) into a molecular weight distribution f_w(M). The larger α_D value confirms that the chitosan chain is slightly extended in aqueous solution even in the presence of salts. This is mainly due to its backbone and polyelectrolytes nature. As a very sensitive technique, our dynamic LLS results also revealed that even in dilute solution chitosan still forms a small amount of larger sized aggregates that have been overlooked in previous studies. The calibration obtained in this study will provide another way to characterize the molecular weight distribution of chitosan in aqueous solution at room temperature. © 1995 John Wiley & Sons, Inc.     

Surface Rheology Parameters of Source-Specific Surfactant Films as Indicators of Organic Matter Dynamics

The paper contains the results of natural film experiments carried out on inland and coastal waters in the Dead Vistula catchment area and mouth during 2000–2002, using the integrated Langmuir trough–Wilhelmy plate system. The static film parameters result from the generalized scaling procedures applied to the surface pressure–area isotherms. They appear to reflect in a quantitative and sensitive way the film composition (A_lim, M_w, E_isoth), film solubility and the miscibility of its components (via R, ΔS_c and y factors), and surface concentration (π_eq, Γ_eq). The adsorption kinetics parameters: effective diffusion coefficient D_eff/D and activation energy barrier E_a/RT are derived from dynamic surface pressure. There is a reason to suggest that certain classes of film-forming components or ‘end-members’ may dominate the static and dynamic surface properties. Variation in the surface rheological parameters of source-specific biosurfactants is postulated to reflect organic matter dynamics in natural waters and were measured for the Dead Vistula river, its tributaries and the adjacent coastal area.