Kevin C. Floyd

A 30-Year Perspective (1975–2005) Into the Changing Landscape of Patients Hospitalized With Initial Acute Myocardial Infarction Worcester Heart Attack Study

Background—The effects of lifestyle changes and evolving treatment practices on coronary disease incidence rates, demographic and clinical profile, and the short-term outcomes of patients hospitalized with acute myocardial infarction have not been well characterized. The purpose of this study was to examine multidecade-long trends (1975–2005) in the incidence rates, demographic and clinical characteristics, treatment practices, and hospital outcomes of patients hospitalized with an initial acute myocardial infarction from a population-based perspective. Methods and Results—Residents of the Worcester, Mass, metropolitan area (median age, 37 years; 89% white) hospitalized with an initial acute myocardial infarction (n=8898) at all greater-Worcester medical centers during 15 annual periods between 1975 and 2005 comprised the sample of interest. The incidence rates of initial acute myocardial infarction were lower in 2005 (209 of 100 000 population) than in 1975 (277 of 100 000), although these trends varied inconsistently over time. Patients hospitalized during the most recent study years were significantly older (mean age, 64 years in 1975; 71 years in 2005), more likely to be women (38% in 1975; 48% in 2005), and have a greater prevalence of comorbidities. Hospitalized patients were increasingly more likely to receive effective cardiac medications and coronary interventional procedures for the period under investigation. Hospital survival rates improved significantly over time (81% survived in 1975; 91% survived in 2005), although varying trends were observed in the occurrence of clinically important complications. Conclusions—The results of this community-wide investigation provide insight into the changing magnitude, characteristics, management practices, and outcomes of patients hospitalized with a first myocardial infarction.

A 30-Year Perspective (1975–2005) Into the Changing Landscape of Patients Hospitalized With Initial Acute Myocardial InfarctionCLINICAL PERSPECTIVE

Background—The effects of lifestyle changes and evolving treatment practices on coronary disease incidence rates, demographic and clinical profile, and the short-term outcomes of patients hospitalized with acute myocardial infarction have not been well characterized. The purpose of this study was to examine multidecade-long trends (1975–2005) in the incidence rates, demographic and clinical characteristics, treatment practices, and hospital outcomes of patients hospitalized with an initial acute myocardial infarction from a population-based perspective. Methods and Results—Residents of the Worcester, Mass, metropolitan area (median age, 37 years; 89% white) hospitalized with an initial acute myocardial infarction (n=8898) at all greater-Worcester medical centers during 15 annual periods between 1975 and 2005 comprised the sample of interest. The incidence rates of initial acute myocardial infarction were lower in 2005 (209 of 100 000 population) than in 1975 (277 of 100 000), although these trends varied inconsistently over time. Patients hospitalized during the most recent study years were significantly older (mean age, 64 years in 1975; 71 years in 2005), more likely to be women (38% in 1975; 48% in 2005), and have a greater prevalence of comorbidities. Hospitalized patients were increasingly more likely to receive effective cardiac medications and coronary interventional procedures for the period under investigation. Hospital survival rates improved significantly over time (81% survived in 1975; 91% survived in 2005), although varying trends were observed in the occurrence of clinically important complications. Conclusions—The results of this community-wide investigation provide insight into the changing magnitude, characteristics, management practices, and outcomes of patients hospitalized with a first myocardial infarction.

PULSE-SMART: Pulse-Based Arrhythmia Discrimination Using a Novel Smartphone Application

Atrial fibrillation (AF) is a common and dangerous rhythm abnormality. Smartphones are increasingly used for mobile health applications by older patients at risk for AF and may be useful for AF screening.

Classification and Atherosclerosis Distribution in Patients with Left Main Coronary Disease

OBJECTIVE The purpose of this investigation was to characterize clinical variables and angiographic distribution of coronary atherosclerosis to classify patients with de novo left main (LM) disease in a real-world population presenting for coronary angiography. BACKGROUND Limited quantitative and angiographic published data exist that provide detailed quantitative information to classify potential target population for elective LM percutaneous coronary intervention (PCI) and guide development of dedicated LM PCI platforms. METHODS Medical history and clinical presentation were prospectively collected on 177 consecutive patients with LM stenosis > or =50% by coronary angiography. Blinded quantitative coronary angiography (QCA) was performed on all LM stenoses to classify LM-A (ostial), LM-B (nonostial, non-bifurcation), and LM-C (bifurcation involvement). QCA was performed on the left anterior descending (LAD), left circumflex (LCx), and right coronary arteries (RCA) and branches (> or =2.5 mm) to identify lesions with > or =60% stenosis or occlusion. RESULTS No differences in baseline clinical history or presentation discriminated the distribution patterns of LM stenosis. QCA revealed 66% of LM stenoses were LM-C. Mean LM reference vessel diameter was 4.65 mm and average lesion length was 11.12 mm. Around 88.7% of patients had at least one lesion > or =60% in a major epicardial artery and 32.2% of patients had RCA chronic total occlusion. Right-to-left coronary collateralization was only identified in patients with obstructive stenosis in the LAD or LCx in addition to the LM stenosis. CONCLUSION Dedicated LM stent platforms may need to be developed to accommodate larger vessel size and bifurcation distributions. A majority of patients with LM stenosis will require adjunctive epicardial vessel PCI to achieve complete anatomic revascularization.

Association of Left Atrial Function Index With Late Atrial Fibrillation Recurrence after Catheter Ablation.

Although catheter ablation (CA) for atrial fibrillation (AF) is commonly used to improve symptoms, AF recurrence is common and new tools are needed to better inform patient selection for CA. Left atrial function index (LAFI), an echocardiographic measure of atrial mechanical function, has shown promise as a noninvasive predictor of AF. We hypothesized that LAFI would relate to AF recurrence after CA.

Burden of Psychosocial and Cognitive Impairment in Patients With Atrial Fibrillation

Background: Impairments in psychosocial status and cognition relate to poor clinical outcomes in patients with atrial fibrillation (AF). However, how often these conditions co-occur and associations between burden of psychosocial and cognitive impairment and quality of life (QoL) have not been systematically examined in patients with AF. Methods: A total of 218 patients with symptomatic AF were enrolled in a prospective study of AF and psychosocial factors between May 2013 and October 2014 at the University of Massachusetts Medical Center. Cognitive function, depression, and anxiety were assessed at baseline and AF-specific QoL was assessed 6 months after enrollment using validated instruments. Demographic and clinical information were obtained from a structured interview and medical record review. Results: The mean age of the study participants was 63.5 ± 10.2 years, 35% were male, and 81% had paroxysmal AF. Prevalences of impairment in 1, 2, and 3 psychosocial/cognitive domains (eg, depression, anxiety, or cognition) were 75 (34.4%), 51 (23.4%), and 16 (7.3%), respectively. Patients with co-occurring psychosocial/cognitive impairments (eg, >1 domain) were older, more likely to smoke, had less education, and were more likely to have heart failure (all P < 0.05). Compared with participants with no psychosocial/cognitive impairments, AF-specific QoL at 6 months was significantly poorer among participants with baseline impairment in 2 (B = −13.6, 95% CI: −21.7 to −5.4) or 3 (B = −15.1, 95% CI: −28.0 to −2.2) psychosocial/cognitive domains. Conclusion: Depression, anxiety, and impaired cognition were common in our cohort of patients with symptomatic AF and often co-occurred. Higher burden of psychosocial/cognitive impairment was associated with poorer AF-specific QoL.

Addition of B-Type Natriuretic Peptide to Existing Clinical Risk Scores Enhances Identification of Patients at Risk for Atrial Fibrillation Recurrence After Pulmonary Vein Isolation.

INTRODUCTION Predicting which patients will be free from atrial fibrillation (AF) after pulmonary vein isolation (PVI) remains challenging. Clinical risk prediction scores show modest ability to identify patients at risk for AF recurrence after PVI. B-type natriuretic peptide (BNP) is associated with risk for incident and recurrent AF but is not currently included in existing AF risk scores. We sought to evaluate the incremental benefit of adding preoperative BNP to existing risk scores for predicting AF recurrence during the 6 months after PVI. METHODS One hundred sixty-one patients with paroxysmal or persistent AF underwent an index PVI procedure between 2010 and 2013; 77 patients (48%) had late AF recurrence after PVI (>3 months post-PVI) over the 6-month follow-up period. RESULTS A BNP greater than or equal to 100 pg/dL (P=0.01) and AF recurrence within 3 months after PVI (P<0.001) were associated with late AF recurrence in multivariate analyses. Addition of BNP to existing clinical risk scores significantly improved the areas under the curve for each score, with an integrated discrimination improvement of 0.08 (P=0.001) and a net reclassification improvement of 60% (P=0.001) for all risk scores. CONCLUSIONS Circulating BNP levels are independently associated with late AF recurrence after PVI. Inclusion of BNP significantly improves the discriminative ability of CHADS2, CHA2DS2-VASc, R2CHADS2, and the HATCH score in predicting clinically significant, late AF recurrence after PVI and should be incorporated in decision-making algorithms for management of AF. B-R2CHADS2 is the best score model for prediction of late AF recurrence.

A 30-Year Perspective (1975–2005) Into the Changing Landscape of Patients Hospitalized With Initial Acute Myocardial Infarction

Background—The effects of lifestyle changes and evolving treatment practices on coronary disease incidence rates, demographic and clinical profile, and the short-term outcomes of patients hospitalized with acute myocardial infarction have not been well characterized. The purpose of this study was to examine multidecade-long trends (1975–2005) in the incidence rates, demographic and clinical characteristics, treatment practices, and hospital outcomes of patients hospitalized with an initial acute myocardial infarction from a population-based perspective. Methods and Results—Residents of the Worcester, Mass, metropolitan area (median age, 37 years; 89% white) hospitalized with an initial acute myocardial infarction (n=8898) at all greater-Worcester medical centers during 15 annual periods between 1975 and 2005 comprised the sample of interest. The incidence rates of initial acute myocardial infarction were lower in 2005 (209 of 100 000 population) than in 1975 (277 of 100 000), although these trends varied inconsistently over time. Patients hospitalized during the most recent study years were significantly older (mean age, 64 years in 1975; 71 years in 2005), more likely to be women (38% in 1975; 48% in 2005), and have a greater prevalence of comorbidities. Hospitalized patients were increasingly more likely to receive effective cardiac medications and coronary interventional procedures for the period under investigation. Hospital survival rates improved significantly over time (81% survived in 1975; 91% survived in 2005), although varying trends were observed in the occurrence of clinically important complications. Conclusions—The results of this community-wide investigation provide insight into the changing magnitude, characteristics, management practices, and outcomes of patients hospitalized with a first myocardial infarction.

PERFORMANCE AND USABILITY OF A NOVEL SMARTPHONE APPLICATION FOR ATRIAL FIBRILLATION DETECTION IN AN AMBULATORY POPULATION REFERRED FOR CARDIAC MONITORING

Background: Current mHealth solutions for atrial fibrillation (AF) surveillance rely on smartphone-ECG dyads which require hardware that may limit widespread use. We previously described the development of an AF detection application (app) that leverages out-of-the-box smartphone (standard camera) to acquire pulsatile time series recordings and analyze using novel algorithms. Our aim in this study is to examine adherence and ambulatory performance of this prescribed app.

Plasma MicroRNAs Relate to Atrial Fibrillation Recurrence after Catheter Ablation: Longitudinal Findings from the MiRhythm Study

Introduction: Genetic and transcriptomic factors play important roles as mediators of new-onset and recurrent atrial fibrillation (AF). MicroRNAs (miRNAs) regulate expression of gene networks involved in key aspects of atrial remodeling. Associations between circulating miRNAs and AF recurrence are unknown. We tested the hypothesis that cardiac miRNAs associated with electrical and structural remodeling predict recurrent AF rhythm in post-ablation patients. Methods: We quantified plasma expression of 86 cardiac miRNAs using RT-qPCR in 83 consenting participants undergoing ablation for AF. MiRNA expression was re-measured 1-month post-ablation in a subset of 43 of 83 study participants. Then all 83 patients were followed over a 12-month period for AF recurrence and plasma miRNA expression was compared between baseline and 1-month post-ablation and between those with and without an AF recurrence. Results: The mean age of study participants was 59 years, 34% were female, and 63% had paroxysmal AF. Plasma levels of miRNAs 125a-5p and 10b were 3-fold lower after ablation compared to pre-ablation (p<0.01). Pre-ablation plasma expression of miRNAs 125a and 10b, as well as miRNAs 60, 30a-3p and 199b, were higher among patients with an AF recurrence compared to those without recurrence after ablation (p<0.05) even after adjustment for clinical risk factors. Conclusion: The plasma miRnome is dynamic after AF ablation and associated with AF recurrence. Higher pre-ablation levels of circulating gene regulators implicated in atrial remodeling and AF, including miRNAs 125a-5p and 10b, were associated with AF recurrence and that these same miRNAs decreased post-ablation. Our investigation highlights dynamic gene regulatory networks in patients undergoing ablation and identifies potentially new AF treatment targets.