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Genetic predisposition is a risk factor for office hypertension. We tested whether genetic background could identify individuals with ambulatory daytime hypertension in a sample of white Europeans from Liechtenstein. We evaluated two measures of predisposition to hypertension: family history and polygenic risk scores (PRS). Our analytic sample contained 1444 participants aged 25 to 41. Of the participants, 12% had office hypertension, while 37% had out-of-office hypertension. The correlation between blood pressure PRS and family history of hypertension was low (R2= 4.96×10−3), but both were strongly associated with ambulatory blood pressure (2.2 mmHg per 1 SD increase [95% CI: 1.6, 2.7] & 2.4 mmHg increase with positive family history [95% CI: 1.3, 3.4], respectively). The PRS provides incremental improvement in predicting ambulatory systolic blood pressure beyond a validated blood pressure prediction score (ΔAIC = - 33), whereas family history does not (ΔAIC = 1). However, the difference in performance between a baseline prediction algorithm for identifying ambulatory systolic daytime hypertension (positive likelihood ratio of 6.87 [95% CI: 5.56, 8.49]; negative likelihood ratio of 0.45 [95% CI: 0.39, 0.51]) and the same model with PRS integrated (positive likelihood ratio of 7.69 [95% CI: 6.18, 9.57]; negative likelihood ratio of 0.43 [95% CI: 0.37, 0.49]) was modest. In conclusion, in a white European sample from Liechtenstein, PRS and family history are distinct constructs that are associated with increased clinical and ambulatory blood pressure. Unlike family history, polygenic risk scores provide incremental information in the identification of individuals with ambulatory hypertension. However, these gains are modest and warrant further development to improve predictive utility at the point-of-care.

ImportanceBody mass index (BMI) is an easily obtainable surrogate for adiposity. However, there is substantial variability in body composition and adipose tissue distribution between individuals with the same BMI. Furthermore, previous literature is conflicting regarding the optimal BMI linked with the lowest mortality risk.ObjectiveTo determine which of BMI, fat mass index (FMI), and waist-to-hip (WHR) is the strongest and most consistent causal predictor for mortality.DesignWe created a case-control cohort using all incident deaths from the UK Biobank (UKB; 2006 to 2022).Setting22 Clinical assessment centres across the United Kingdom.ParticipantsWe partitioned UKB British participants (N= 387,672) into a discovery (N = 337,078) and validation cohort (N = 50,594), the latter consisting of 25,297 deaths and 25,297 randomly selected age- and sex-matched controls. The discovery cohort was used to derive genetically-determined adiposity measures while the validation cohort was used for all other analyses. Relationships between exposures and outcomes were analyzed through both observational and Mendelian randomization (MR) analyses to infer causality.ExposuresBMI, FMI and WHR.Main Outcomes and MeasuresAll-cause mortality; Cause-specific mortality (cancer, cardiovascular disease (CVD), respiratory disease, or other causes).ResultsObservational relationships between measured BMI and FMI with all-cause mortality were J-shaped, whereas the relationship with WHR was linear. Genetically-determined WHR had a stronger association with all-cause mortality compared to BMI or FMI (OR per SD increase of WHR (95% CI): 1.51 (1.32 – 1.72); 1.29 (1.20 – 1.38) for BMI, and 1.45 (1.36 – 1.54) for FMI, heterogeneity PPP > 0.05).Conclusions and RelevanceWHR has the strongest and most consistent causal association with risk of mortality irrespective of BMI, with the effect being stronger in males than females. Clinical recommendations and interventions should prioritize adiposity distribution rather than mass.Key PointsQuestionAmong body mass index (BMI), fat mass index (FMI), or waist-to-hip (WHR) ratio, what is the optimal adiposity measure for predicting mortality outcomes in adults?FindingsIn this Mendelian randomization study consisting of 387,672 British adult participants from the UK Biobank (UKB), WHR was found to have the strongest and most consistent causal relationship with all-cause and cause-specific mortality.MeaningWHR was the most robust predictor of mortality risk and may serve as a more appropriate target for health care intervention.

Background: Atherosclerotic cardiovascular diseases (CVDs) are leading causes of death despite effective therapies and result in unnecessary morbidity and mortality throughout the world. We aimed to investigate the cost-effectiveness of polygenic risk scores (PRS) to guide statin therapy for Canadians with intermediate CVD risk and model its economic outlook. Methods: This cost-utility analysis was conducted using UK Biobank prospective cohort study participants, with recruitment from 2006 to 2010, and at least 10 years of follow-up. We included nonrelated white British-descent participants (n=96 116) at intermediate CVD risk with no prior lipid lowering medication or statin-indicated conditions. A coronary artery disease PRS was used to inform decision to use statins. The effects of statin therapy with and without PRS, as well as CVD events were modelled to determine the incremental cost-effectiveness ratio from a Canadian public health care perspective. We discounted future costs and quality-adjusted life-years by 1.5% annually. Results: The optimal economic strategy was when intermediate risk individuals with a PRS in the top 70% are eligible for statins while the lowest 1% are excluded. Base-case analysis at a genotyping cost of $70 produced an incremental cost-effectiveness ratio of $172 906 (143 685 USD) per quality-adjusted life-year. In the probabilistic sensitivity analysis, the intervention has approximately a 50% probability of being cost-effective at $179 100 (148 749 USD) per quality-adjusted life-year. At a $0 genotyping cost, representing individuals with existing genotyping information, PRS-guided strategies dominated standard care when 12% of the lowest PRS individuals were withheld from statins. With improved PRS predictive performance and lower genotyping costs, the incremental cost-effectiveness ratio demonstrates possible cost-effectiveness under thresholds of $150 000 and possibly $50 000 per quality-adjusted life-year. Conclusions: This study suggests that using PRS alongside existing guidelines might be cost-effective for CVD. Stronger predictiveness combined with decreased cost of PRS could further improve cost-effectiveness, providing an economic basis for its inclusion into clinical care.

Background and ObjectivesLow buffy coat mitochondrial DNA copy number (mtDNA-CN) is associated with incident risk of stroke and poststroke mortality; however, its prognostic utility has not been extensively explored. Our goal was to investigate whether low buffy coat mtDNA-CN is a marker and causal determinant of poststroke outcomes using epidemiologic and genetic studies.MethodsFirst, we performed association testing between baseline buffy coat mtDNA-CN measurements and 1-month poststroke outcomes in 3,498 cases of acute, first stroke from 25 countries from the international, multicenter case-control study Importance of Conventional and Emerging Risk Factors of Stroke in Different Regions and Ethnic Groups of the World (INTERSTROKE). Then, we performed 2-sample mendelian randomization analyses to evaluate potential causative effects of low mtDNA-CN on 3-month modified Rankin Scale (mRS) score. Genetic variants associated with mtDNA-CN levels were derived from the UK Biobank study (N = 383,476), and corresponding effects on 3-month mRS score were ascertained from the Genetics of Ischemic Stroke Functional Outcome (GISCOME; N = 6,021) study.ResultsA 1-SD lower mtDNA-CN at baseline was associated with stroke severity (baseline mRS score: odds ratio [OR] 1.27, 95% confidence interval [CI] 1.19–1.36; p = 4.7 × 10−12). Independently of baseline stroke severity, lower mtDNA-CN was associated with increased odds of greater 1-month disability (ordinal mRS score: OR 1.16, 95% CI 1.08–1.24; p = 4.4 × 10−5), poor functional outcome status (mRS score 3–6 vs 0–2: OR 1.21, 95% CI 1.08–1.34; p = 6.9 × 10−4), and mortality (OR 1.35, 95% CI 1.14–1.59; p = 3.9 × 10−4). Subgroup analyses demonstrated consistent effects across stroke type, sex, age, country income level, and education level. In addition, mtDNA-CN significantly improved reclassification of poor functional outcome status (net reclassification index [NRI] score 0.16, 95% CI 0.08–0.23; p = 3.6 × 10−5) and mortality (NRI score 0.31, 95% CI 0.19–0.43; p = 1.7 × 10−7) beyond known prognosticators. With the use of independent datasets, mendelian randomization revealed that a 1-SD decrease in genetically determined mtDNA-CN was associated with increased odds of greater 3-month disability quantified by ordinal mRS score (OR 2.35, 95% CI 1.13–4.90; p = 0.02) and poor functional outcome status (OR 2.68, 95% CI 1.05–6.86; p = 0.04).DiscussionBuffy coat mtDNA-CN is a novel and robust marker of poststroke prognosis that may also be a causal determinant of poststroke outcomes.Classification of EvidenceThis study provides Class II evidence that low buffy coat mtDNA-CN (>1 SD) was associated with worse baseline severity and 1-month outcomes in patients with ischemic or hemorrhagic stroke.

BACKGROUND Many patients undergoing cardiac device implantation are taking direct oral anticoagulation (DOAC). Continuing DOAC during device implantation may increase periprocedural bleeding risk; however, interrupting DOACs may increase thromboembolic risk. OBJECTIVE To compare the incidence of clinically significant pocket hematoma and thromboembolism in patients who have their DOAC continued or interrupted for cardiac device implantation. METHODS We searched MEDLINE, EMBASE, and randomized controlled trial (CENTRAL) until December 2019 and included randomized controlled trials (RCTs) and observational studies that compared outcomes after continuing or interrupting DOAC during cardiac device implantation. Independently and in duplicate, reviewers screened titles, abstracts, and full text of potentially eligible studies. They then evaluated risk of bias and abstracted data. RCT data were pooled using a fixed-effect model. Quality of evidence was assessed using grading of recommendations assessment, development and evaluation (GRADE). RESULTS Two RCTs, representing 763 patients, and three observational studies met eligibility criteria. In RCTs, continuing DOAC for device implantation compared to interrupting DOAC resulted in no significant difference in clinically significant pocket hematoma (2.1% vs 1.8%; RR 1.15; 95% CI 0.44-3.05) or thromboembolism (0.03% vs 0.03%; RR 1.02; 95% CI 0.06-16.21). Quality of evidence for both outcomes was moderate due to imprecision. Observational studies showed similar results. CONCLUSIONS Continuing DOACs for device implantation results in little to no difference in the incidence of clinically significant pocket hematoma or thromboembolism. Given the ease of stopping and restarting DOACs, interrupting DOACs may be the preferred strategy for most patients. However, whenever continuous therapeutic anticoagulation is desired, DOAC continuation should be preferred over bridging with parenteral anticoagulation.

Mitochondrial DNA copy number (mtDNA-CN) is an accessible blood-based measurement believed to capture underlying mitochondrial (MT) function. The specific biological processes underpinning its regulation, and whether those processes are causative for disease, is an area of active investigation.We developed a novel method for array-based mtDNA-CN estimation suitable for biobank-scale studies, called 'automatic mitochondrial copy (AutoMitoC).' We applied AutoMitoC to 395,781 UKBiobank study participants and performed genome- and exome-wide association studies, identifying novel common and rare genetic determinants. Finally, we performed two-sample Mendelian randomization to assess whether genetically low mtDNA-CN influenced select MT phenotypes.Overall, genetic analyses identified 71 loci for mtDNA-CN, which implicated several genes involved in rare mtDNA depletion disorders, deoxynucleoside triphosphate (dNTP) metabolism, and the MT central dogma. Rare variant analysis identifiedAltogether, our genetic findings indicate that mtDNA-CN is a complex biomarker reflecting specific MT processes related to mtDNA regulation, and that these processes are causally related to human diseases.No funds supported this specific investigation. Awards and positions supporting authors include: Canadian Institutes of Health Research (CIHR) Frederick Banting and Charles Best Canada Graduate Scholarships Doctoral Award (MC, PM); CIHR Post-Doctoral Fellowship Award (RM); Wellcome Trust Grant number: 099313/B/12/A; Crasnow Travel Scholarship; Bongani Mayosi UCT-PHRI Scholarship 2019/2020 (TM); Wellcome Trust Health Research Board Irish Clinical Academic Training (ICAT) Programme Grant Number: 203930/B/16/Z (CJ); European Research Council COSIP Grant Number: 640580 (MO); E.J. Moran Campbell Internal Career Research Award (MP); CISCO Professorship in Integrated Health Systems and Canada Research Chair in Genetic and Molecular Epidemiology (GP).Our cells are powered by small internal compartments known as mitochondria, which host several copies of their own ‘mitochondrial’ genome. Defects in these semi-autonomous structures are associated with a range of severe, and sometimes fatal conditions: easily checking the health of mitochondria through cheap, quick and non-invasive methods can therefore help to improve human health. Measuring the concentration of mitochondrial DNA molecules in our blood cells can help to estimate the number of mitochondrial genome copies per cell, which in turn act as a proxy for the health of the compartment. In fact, having lower or higher concentration of mitochondrial DNA molecules is associated with diseases such as cancer, stroke, or cardiac conditions. However, current approaches to assess this biomarker are time and resource-intensive; they also do not work well across people with different ancestries, who have slightly different versions of mitochondrial genomes. In response, Chong et al. developed a new method for estimating mitochondrial DNA concentration in blood samples. Called AutoMitoC, the automated pipeline is fast, easy to use, and can be used across ethnicities. Applying this method to nearly 400,000 individuals highlighted 71 genetic regions for which slight sequence differences were associated with changes in mitochondrial DNA concentration. Further investigation revealed that these regions contained genes that help to build, maintain, and organize mitochondrial DNA. In addition, the analyses yield preliminary evidence showing that lower concentration of mitochondrial DNA may be linked to a higher risk of dementia. Overall, the work by Chong et al. demonstrates that AutoMitoC can be used to investigate how mitochondria are linked to health and disease in populations across the world, potentially paving the way for new therapeutic approaches.

Although most current guidelines recommend a daily sodium intake of less than 2.3 g/day, most people do not have a reliable estimate of their usual sodium intake. In this review, we describe the different methods used to estimate sodium intake and discuss each method in the context of specific clinical or research questions. We suggest the following classification for sodium measurement methods: preingestion measurement (controlled intake), peri-ingestion measurement (concurrent), and postingestion measurement. On the basis of the characteristics of the available tools, we suggest that: validated 24-h recall methods are a reasonable approach to estimate sodium intake in large epidemiologic studies and individual clinical counselling sessions, methods (such as single 24-h urine collection, single-time urine collection, or 24-h recall methods), are of value in population-level estimation of mean sodium intake, but are less suited for individual level estimation and a feeding-trial design using a controlled diet is the most valid and reliable method for establishing the effect of reducing sodium to a specific intake target in early phase clinical trials. By considering the various approaches to sodium measurement, investigators and public health practitioners may be better informed in assessing the health implications of sodium consumption at the individual and population level.

Aims Clinical scoring systems for pulmonary embolism (PE) screening have low specificity and contribute to computed tomography pulmonary angiogram (CTPA) overuse. We assessed whether deep learning models using an existing and routinely collected data modality, electrocardiogram (ECG) waveforms, can increase specificity for PE detection. Methods and results We create a retrospective cohort of 21 183 patients at moderate- to high suspicion of PE and associate 23 793 CTPAs (10.0% PE-positive) with 320 746 ECGs and encounter-level clinical data (demographics, comorbidities, vital signs, and labs). We develop three machine learning models to predict PE likelihood: an ECG model using only ECG waveform data, an EHR model using tabular clinical data, and a Fusion model integrating clinical data and an embedded representation of the ECG waveform. We find that a Fusion model [area under the receiver-operating characteristic curve (AUROC) 0.81 ± 0.01] outperforms both the ECG model (AUROC 0.59 ± 0.01) and EHR model (AUROC 0.65 ± 0.01). On a sample of 100 patients from the test set, the Fusion model also achieves greater specificity (0.18) and performance (AUROC 0.84 ± 0.01) than four commonly evaluated clinical scores: Wells’ Criteria, Revised Geneva Score, Pulmonary Embolism Rule-Out Criteria, and 4-Level Pulmonary Embolism Clinical Probability Score (AUROC 0.50–0.58, specificity 0.00–0.05). The model is superior to these scores on feature sensitivity analyses (AUROC 0.66–0.84) and achieves comparable performance across sex (AUROC 0.81) and racial/ethnic (AUROC 0.77–0.84) subgroups. Conclusion Synergistic deep learning of ECG waveforms with traditional clinical variables can increase the specificity of PE detection in patients at least at moderate suspicion for PE.

Analyses of medical data have been steered to support and justify orthodox systems and graphical models that reproduce the relatively subjective reasoning of experts. Evidence-based decision tree analyses and risk scores are valid tools for clinical decision-making that are widely used in medicine

To reduce unnecessary laboratory testing, a three-phase intervention was designed by students to decrease serum folate laboratory testing in the inpatient setting. These included an educational phase, a personalized feedback phase, and the uncoupling of orders in the electronic medical record. Average monthly serum folate ordering decreased by 87% over the course of the intervention, from 98.4 orders per month at baseline to 12.7 per month in the last phase of the intervention. In the segmented regression analysis, joint ordering of folate and vitamin B12 significantly decreased during the intervention ([INCREMENT]slope = -4.22 tests/month, p = .0089), whereas single ordering of vitamin B12 significantly increased ([INCREMENT]slope = +5.6 tests/month; p < .001). Our intervention was successful in modifying ordering patterns to decrease testing for a deficiency that is rare in the U.S. population.

Objectives This study sought to explore the natural clustering of echocardiographic variables used for assessing left ventricular (LV) diastolic dysfunction (DD) in order to isolate high-risk phenotypic patterns and assess their prognostic significance. Background Assessment of LV DD is important in the management and prognosis of cardiovascular diseases. Data-driven approaches such as cluster analysis may be useful in segregating similar cases without the constraint of an a priori algorithm for risk stratification. Methods The study included a convenience sample of 866 consecutive patients referred for myocardial function assessment (age: 65 ± 17 years; 55.3% women; ejection fraction: 60 ± 9%) for whom echocardiographic parameters of DD assessment were obtained per conventional guideline recommendations. Unsupervised, hierarchical cluster analysis of these parameters was conducted using the Ward linkage method. Major adverse cardiovascular events, hospitalization, and mortality were compared between conventional and cluster-based classifications. Results Clustering algorithms for screening the presence of DD in 559 of 866 patients identified 2 distinct groups and revealed modest agreement with conventional classification (kappa = 0.41, p Conclusions An unsupervised assessment of echocardiographic variables for assessing LV DD revealed unique patterns of grouping. These natural patterns of clustering may better identify patient groups who have similar risk, and their incorporation into clinical practice may help eliminate indeterminate results and improve clinical outcome prediction.

Mitochondrial DNA copy number (mtDNA-CN) is an accessible blood-based measurement believed to capture underlying mitochondrial function. The specific biological processes underpinning its regulation, and whether those processes are causative for disease, is an area of active investigation. We developed a novel method for array-based mtDNA-CN estimation suitable for biobank-scale studies, called “AutoMitoC”. We applied AutoMitoC to 395,781 UKBiobank study participants and performed genome and exome-wide association studies, identifying novel common and rare genetic determinants. Overall, genetic analyses identified 73 loci for mtDNA-CN, which implicated several genes involved in rare mtDNA depletion disorders, dNTP metabolism, and the mitochondrial central dogma. Rare variant analysis identified SAMHD1 mutation carriers as having higher mtDNA-CN (beta=0.23 SDs; 95% CI, 0.18-0.29; P=2.6×10−19), a potential therapeutic target for patients with mtDNA depletion disorders, but at increased risk of breast cancer (OR=1.91; 95% CI, 1.52-2.40; P=2.7×10−8). Finally, Mendelian randomization analyses suggest a causal effect of low mtDNA-CN on dementia risk (OR=1.94 per 1 SD decrease in mtDNA-CN; 95% CI, 1.55-2.32; P=7.5×10−4). Altogether, our genetic findings indicate that mtDNA-CN is a complex biomarker reflecting specific mitochondrial processes related to mtDNA regulation, and that these processes are causally related to human diseases.

Background: Clinical scoring systems for pulmonary embolism (PE) screening have low specificity and contribute to CT pulmonary angiogram (CTPA) overuse. We assessed whether deep learning models using an existing and routinely collected data modality, electrocardiogram (ECG) waveforms, can increase specificity for PE detection. Methods: We use clinical variables, annotated CTPAs, and ECG waveform and morphological parameter data from five hospitals to conduct a retrospective cohort study and develop three models to predict PE likelihood: an ECG model using only ECG waveform data, an EHR model using tabular clinical data, and a Fusion model integrating tabular clinical data and an embedded representation of the ECG waveform. We benchmark the best model against four clinical scores: Wells’ Criteria, Revised Geneva Score, Pulmonary Embolism Rule-Out Criteria, and 4-Level Pulmonary Embolism Clinical Probability Score. Finally, we investigate model robustness through feature sensitivity analyses and assess for demographic subgroup performance parity. Findings: We create a dataset linking 23,793 CTPAs (10·0% PE-positive) and 320,746 ECGs from 21,183 patients for model development and testing. We find that a Fusion model (area under receiver-operating characteristic [AUROC] 0·81 ± 0·01) outperforms both the ECG model (AUROC 0·59 ± 0·01) and EHR model (AUROC 0·65 ± 0·01). On a sample of 100 patients from the test set, the Fusion model has greater specificity (0·18) and performance (AUROC 0·84 ± 0.01) than the all four clinical criteria (AUROC 0·50-0·58, specificity 0·00-0·05). The model also retains superiority over clinical scores in feature sensitivity analyses (AUROC 0·66 to 0·84) and achieves comparable performance across different sex (AUROC 0·81) and racial (AUROC 0·77 to 0·84) subgroups. Interpretation: Integration of electrocardiogram waveforms with traditional clinical variables synergistically increases prediction performance and specificity for PE detection in those who are at least at moderate suspicion for PE. Funding: National Center for Advancing Translational Sciences, National Institutes of Health. Declaration of Interest: All authors declare no competing interests with this study. Ethical Approval: The study was approved by the Mount Sinai Institutional Review Board.

Summary Background Angiotensin-converting enzyme 2 (ACE2) is an endogenous counter-regulator of the renin–angiotensin hormonal cascade. We assessed whether plasma ACE2 concentrations were associated with greater risk of death or cardiovascular disease events. Methods We used data from the Prospective Urban Rural Epidemiology (PURE) prospective study to conduct a case-cohort analysis within a subset of PURE participants (from 14 countries across five continents: Africa, Asia, Europe, North America, and South America). We measured plasma concentrations of ACE2 and assessed potential determinants of plasma ACE2 levels as well as the association of ACE2 with cardiovascular events. Findings We included 10 753 PURE participants in our study. Increased concentration of plasma ACE2 was associated with increased risk of total deaths (hazard ratio [HR] 1·35 per 1 SD increase [95% CI 1·29–1·43]) with similar increases in cardiovascular and non-cardiovascular deaths. Plasma ACE2 concentration was also associated with higher risk of incident heart failure (HR 1·27 per 1 SD increase [1·10–1·46]), myocardial infarction (HR 1·23 per 1 SD increase [1·13–1·33]), stroke (HR 1·21 per 1 SD increase [1·10–1·32]) and diabetes (HR 1·44 per 1 SD increase [1·36–1·52]). These findings were independent of age, sex, ancestry, and traditional cardiac risk factors. With the exception of incident heart failure events, the independent relationship of ACE2 with the clinical endpoints, including death, remained robust after adjustment for BNP. The highest-ranked determinants of ACE2 concentrations were sex, geographic ancestry, and body-mass index (BMI). When compared with clinical risk factors (smoking, diabetes, blood pressure, lipids, and BMI), ACE2 was the highest ranked predictor of death, and superseded several risk factors as a predictor of heart failure, stroke, and myocardial infarction. Interpretation Increased plasma ACE2 concentration was associated with increased risk of major cardiovascular events in a global study. Funding Canadian Institute of Health Research, Heart & Stroke Foundation of Canada, and Bayer.

Insonation, or the use of ultrasound, has been proposed to be included in the medical school curriculum, both for education and bedside physical examination. It is important to consider what impact insonation should have on medical student education. Increasingly students are exposed to ultrasound use on clinical rotations, but to what extent should ultrasound be an integrated part of the preclinical curriculum in the United States? Ultrasound can serve to augment an existing curriculum in anatomy, physiology, physical examination, and disease assessment and treatment. In addition, the actual performance and interpretation of the insonation component of physical examination in real time may be an emerging skill set to be expected of medical students. Here we describe the utility and challenges of incorporating an ultrasound curriculum into undergraduate medical education, including examples from institutions that have pioneered this innovative curricular change.

We thank Dr. Kampaktsis and colleagues for their interest in our investigation. Although we agree that the 2016 guidelines may have made diastolic dysfunction (DD) more conceptually simple in a clinical approach; there are 2 problems with this apparent simplification. First, the large number of

Background Machine-learning models may aid cardiac phenotypic recognition by using features of cardiac tissue deformation. Objectives This study investigated the diagnostic value of a machine-learning framework that incorporates speckle-tracking echocardiographic data for automated discrimination of hypertrophic cardiomyopathy (HCM) from physiological hypertrophy seen in athletes (ATH). Methods Expert-annotated speckle-tracking echocardiographic datasets obtained from 77 ATH and 62 HCM patients were used for developing an automated system. An ensemble machine-learning model with 3 different machine-learning algorithms (support vector machines, random forests, and artificial neural networks) was developed and a majority voting method was used for conclusive predictions with further K -fold cross-validation. Results Feature selection using an information gain (IG) algorithm revealed that volume was the best predictor for differentiating between HCM ands. ATH (IG = 0.24) followed by mid-left ventricular segmental (IG = 0.134) and average longitudinal strain (IG = 0.131). The ensemble machine-learning model showed increased sensitivity and specificity compared with early-to-late diastolic transmitral velocity ratio (p 13 mm. In this subgroup analysis, the automated model continued to show equal sensitivity, but increased specificity relative to early-to-late diastolic transmitral velocity ratio, e′, and strain. Conclusions Our results suggested that machine-learning algorithms can assist in the discrimination of physiological versus pathological patterns of hypertrophic remodeling. This effort represents a step toward the development of a real-time, machine-learning–based system for automated interpretation of echocardiographic images, which may help novice readers with limited experience.

Purpose of Review Peripheral artery disease (PAD) affects an estimated 200 million people worldwide and is associated with significant cardiovascular morbidity and mortality. Cardiovascular risk is further increased among individuals with polyvascular disease, where either cerebrovascular or coronary artery disease is present in addition to PAD. In this review, we present common clinical scenarios encountered when managing patients with PAD and provide an evidence-based approach to prescribing optimal antithrombotics in this population. Recent Findings The COMPASS trial recently demonstrated that rivaroxaban 2.5 mg BID + ASA daily significantly reduces major adverse cardiac and limb events in patients with PAD. Despite these advances, morbidity following MALE events remains high. Summary With widespread approval by federal health regulators, the COMPASS regimen should be strongly considered in PAD patients who do not have a high bleeding risk. Implementing the COMPASS regimen in patients with PAD, along with other vascular risk reduction strategies, will have a substantial impact on reducing atherothromboembolic risk in patients with established vascular disease.

The prevailing roadway and traffic conditions on expressways in India are vastly different when compared with the other roads in India and also, there is no perfect lane-discipline. The knowledge of roadway capacity is an important basic input required for planning, design, analysis, and operation of roadway systems. Hence, this work aims to model traffic flow on Indian urban expressways with specific reference to Delhi–Gurgaon expressway and estimate its capacity using the micro-simulation model using VISSIM 5·40. For this purpose, the field data collected on traffic-flow characteristics on expressways was used in calibration and validation of the simulation model. The validated simulation model was then used to develop fundamental traffic–flow relationships, namely, speed–flow, speed–area occupancy, and flow–area occupancy for the traffic-flow levels, starting from near-zero until the capacity of the facility. The capacity of an eight-lane divided urban expressway in level terrain with 14·0-m wide road ...

This study sought to explore the natural clustering of echocardiographic variables used for assessing left ventricular (LV) diastolic dysfunction (DD) in order to isolate high-risk phenotypic patterns and assess their prognostic significance.Assessment of LV DD is important in the management and prognosis of cardiovascular diseases. Data-driven approaches such as cluster analysis may be useful in segregating similar cases without the constraint of an a priori algorithm for risk stratification.The study included a convenience sample of 866 consecutive patients referred for myocardial function assessment (age 65 ± 17 years; 55.3% women; ejection fraction 60 ± 9%) for whom echocardiographic parameters of DD assessment were obtained per conventional guideline recommendations. Unsupervised, hierarchical cluster analysis of these parameters was conducted using the Ward linkage method. Major adverse cardiovascular events, hospitalization, and mortality were compared between conventional and cluster-based classifications.Clustering algorithms for screening the presence of DD in 559 of 866 patients identified 2 distinct groups and revealed modest agreement with conventional classification (kappa = 0.41, p 0.001). Further cluster analysis in 387 patients with DD helped to classify the severity of DD into 2 groups, with good agreement with conventional classification (kappa = 0.619, p 0.001). Survival analyses of patients assessed by both clustering algorithms for screening and grading DD showed improved prediction of event-free survival by clusters over conventional classification for all-cause mortality and cardiac mortality, even after accounting for a multivariable, balanced propensity score.An unsupervised assessment of echocardiographic variables for assessing LV DD revealed unique patterns of grouping. These natural patterns of clustering may better identify patient groups who have similar risk, and their incorporation into clinical practice may help eliminate indeterminate results and improve clinical outcome prediction.

There is very less research literature available on urban freeways or expressways in India. Hence, this study focuses on understanding the nature of traffic flow on a very busy eight-lane divided urban freeway namely the Delhi–Gurgaon expressway. To this end, we first present the statistics such as vehicle–class mix and lane utilization on the selected section of expressway and move on to fit time-gap models for the flow values of 7189 and 9114 vehicles h−1 (vph) in one direction of traffic flow on the expressway. A k-sample A–D test was conducted to assess the goodness of fit of the time-gap models. It was found from the study that the combination of Weibull and Extreme Value mixture distribution gives the best fit for modeling time gaps at observed flow levels of 7189 and 9114 vph with 5 and 1% level of significance, respectively.

The estimation of left ventricular (LV) filling pressure from the ratio of transmitral and annular velocities (E/e′) is used commonly for identifying diastolic dysfunction in patients who complain of exertional dyspnea [(1)][1]. We have recently illustrated that LV and left atrial speckle tracking

Limited understanding of the heterogeneity of heart failure with preserved ejection fraction (HFpEF) is a barrier to therapeutics. We studied the clinical and echocardiographic (echo) variations in HFpEF and their effect on clinical outcomes We retrospectively studied 556 HFpEF patients [Age: 66±

Objectives The aim of this study was to investigate whether cluster analysis of left atrial and left ventricular (LV) mechanical deformation parameters provide sufficient information for Doppler-independent assessment of LV diastolic function. Background Medical imaging produces substantial phenotyping data, and superior computational analyses could allow automated classification of repetitive patterns into patient groups with similar behavior. Methods The authors performed a cluster analysis and developed a model of LV diastolic function from an initial exploratory cohort of 130 patients that was subsequently tested in a prospective cohort of 44 patients undergoing cardiac catheterization. Patients in both study groups had standard echocardiographic examination with Doppler-derived assessment of diastolic function. Both the left ventricle and the left atrium were tracked simultaneously using speckle-tracking echocardiography (STE) for measuring simultaneous changes in left atrial and ventricular volumes, volume rates, longitudinal strains, and strain rates. Patients in the validation group also underwent invasive measurements of pulmonary capillary wedge pressure and LV end diastolic pressure immediately after echocardiography. The similarity between STE and conventional 2-dimensional and Doppler methods of diastolic function was investigated in both the exploratory and validation cohorts. Results STE demonstrated strong correlations with the conventional indices and independently clustered the patients into 3 groups with conventional measurements verifying increasing severity of diastolic dysfunction and LV filling pressures. A multivariable linear regression model also allowed estimation of E/e′ and pulmonary capillary wedge pressure by STE in the validation cohort. Conclusions Tracking deformation of the left-sided cardiac chambers from routine cardiac ultrasound images provides accurate information for Doppler-independent phenotypic characterization of LV diastolic function and noninvasive assessment of LV filling pressures.

We would like to thank Dr. Krittanawong and colleagues for the encouraging comment about our work on introducing machine learning for artificial intelligence (AI)–aided interpretation of cardiac imaging. The authors make an interesting proposition through introducing the emerging concept of deep

Unsupervised learning methods can find hidden patterns in data and uncover disease subphenotypes. We investigated unsupervised clustering of echocardiographic variables for grading diastolic dysfunction (DD) and test its concordance and prognostic performance in comparison with expert-guided

Background: Speckle tracking echocardiography (STE) derived left ventricular (LV) mechanical variables can vary based upon the severity LV diastolic dysfunction (DD) and filling pressures (LVFP). We sought to investigate the concordance between 2D-Doppler variables of DD suggested in 2016 American

Medical imaging in the era of precision medicine aims for accurate phenotyping of diseases that can benefit from early targeted therapies. We hypothesize that cardiac biomechanics generate high level of information that can leverage big data analytics and machine-learning frameworks for automated