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A high-pass sigma-delta modulator (HPSDM) is proposed for electrocardiography (ECG) signal acquisition system. The HPSDM is implemented using operational amplifier (op-amp) sharing and programmable feedforward coefficients. The op-amp sharing is adopted to reduce the quantity of amplifiers because they dominate the power consumption of the HPSDM. In addition, given that the magnitude of the ECG is dependent on different persons, programmable feedforward coefficients are utilized to extend the dynamic range of the HPSDM to fit the actual application. The proposed HPSDM is fabricated in a 0.18-μm standard CMOS process. Measurement results reveal that the proposed HPSDM has a signal-to-noise and distortion ratio (SNDR) of 54.5 dB and a power consumption of 2.25 μW under a 1.2 V supply voltage and achieves a figure of merit (FoM) of 12.96 pJ/conv. Moreover, the proposed HPSDM has an SNDR of 64.8 dB and a power consumption of 5.2 μW under a 1.8 V supply voltage and achieves a FoM of 9.15 pJ/conv due to the op-amp sharing technique. Under the 1.2 V and 1.8 V supply voltages, the dynamic range of the HPSDM is extended to approximately 12 dB due to the technique of programmable feedforward coefficients.

This work presents a third-order high-pass sigma-delta modulator (HPSDM) for biomedical signal acquisition. The operational amplifier (op-amp) sharing and noise-coupling techniques are adopted to reduce the required quantity of op-amps and add a noise-shaping order, which can achieve low power consumption and high resolution. A novel switched-capacitor architecture is proposed to suppress the increasing in-band noise and alleviate the circuit sensitivity to capacitor mismatch in the high-pass integrator. The proposed HPSDM was fabricated in a 0.18-μm standard CMOS process. Measurement results reveal that the proposed HPSDM has a signal-to-noise and distortion ratio (SNDR) of 75.26/74 dB in 200 Hz bandwidth and consumes 1.52/0.8 μW under 1.2/1 V supply voltage, which can achieve a peak Schreier Figure-of-Merit of 156.45/157.98 dB and a peak Walden FoM of 0.802/0.488 pJ/conv.

Introduction: Emergency department (ED) visits for decompensated heart failure (HF) are frequent and associated with poor long-term outcomes. Plasma N-terminal pro B-type natriuretic peptide (NT-proBNP) and cyclic guanosine monophosphate (cGMP) are used in diagnosis and prognosis of HF patients, while clinical values of urine NT-proBNP/cGMP ratio have been rarely explored. This study aims to compare the predictive values of urine NT-proBNP/cGMP ratio versus plasma NT-proBNP for ED visits for decompensated HF. Methods: This prospective study included 126 HF patients with reduced left ventricular ejection fraction (Results: Patients with subsequent ED visits had significantly higher levels of plasma and urine NT-proBNP and urine cGMP in than those without. Multivariate Cox regression analysis disclosed that Lg10urine NT-proBNP/cGMP was an independent risk factor for subsequent ED visits (OR = 3.267; 95% CI: 1.105–9.663; p = 0.032). ROC analysis revealed an Lg10urine NT-proBNP/cGMP ratio optimal cut-off value of 0.1706 (AUC, 0.700; 95% CI: 0.543–0.857; p = 0.036) for predicting subsequent HF-related ED visits. Conclusion: A single measurement of urinary NT-proBNP/cGMP ratio is predictive of subsequent ED visits for decompensated HF. This noninvasive and easy measurement may be a clinically useful tool for identifying a subset of patients at higher risk of ED visits.

Background Patients with atrial high‐rate episode (AHRE) are at higher risk of neurological events. This study aimed to identify the optimal cutoff threshold for AHRE duration in patients with dual chamber permanent pacemakers (PPM) without prior atrial fibrillation. Methods We included 355 consecutive patients receiving dual chamber pacemaker implantation. Primary outcome was composite endpoint of subsequent neurological events after various AHRE durations. AHRE was defined as >175 bpm (MEDTRONIC) or > 200 bpm (BIOTRONIK) for longer than 30 s. Cox regression analysis with time‐dependent covariates was conducted. Results The mean age of included patients was 75.6 ± 11.3 years. Among 355 included patients, some had multiple AHREs; 125 patients (35.2%) developed AHRE ≥2 min, 107 (30.1%) had ≥5 min, 55 (15.5%) had ≥6 h, and 37 (10.4%) had ≥24 h. The mean follow‐up was 42.1 ± 31.2 months. During follow‐up, 19 neurological events occurred. After adjustment for CHA2DS2‐VASc score and device type, multivariate Cox regression analysis indicated AHRE ≥2 min (HR 13.605, 95% CI 3.010–61.498), and AHRE ≥5 min (HR 5.819, 95% CI 2.056–16.470) were significantly associated with neurological events. Hence, the optimal AHRE cutoff value was 2 min with the highest Youden index (sensitivity, 89.5%; specificity, 67.8%; AUC, 0.823, 95% CI, 0.763–0.884; p

Background Patients with atrial high-rate episodes (AHRE) have a high risk of cardiovascular and cerebrovascular events (CCE); however, the optimal cut-off threshold for AHRE duration and the prediction power of AHRE with CHA2DS2-VASc score is unknown. Methods We enrolled 355 consecutive patients undergoing dual chamber pacemaker implantations. The primary endpoint was subsequent CCE after AHRE ≥ 30 seconds, 1 minute, 2 minutes, 5 minutes, 6 hours, and 24 hours. AHRE was defined as >175 bpm (Medtronic, Dublin, Ireland) or >200 bpm (Biotronik, Berlin, Germany) lasting ≥30 seconds. Multivariate Cox regression analysis with time-dependent covariates was used to determine the variables associated with higher risks of CCE. Results The average age of the patients was 75.6 ± 11.3 years, and 162 patients (45.6%) developed AHRE ≥ 30 seconds, 145 (40.8%) ≥1 minute, 125 (35.2%) ≥2 minutes, 107 (30.1%) ≥5 minutes, 55 (15.5%) ≥6 hours, and 37 (10.4%) ≥24 hours. During follow-up (mean 42.1 ± 31.2 months), 145 CCE occurred in 107 patients (incidence rate 11.64/100 patient-years, 95% CI 9.99-13.70). The optimal AHRE cut-off value was 1 minute (sensitivity, 57.9%; specificity, 66.0%; area-under-the-curve, 0.631; 95% CI, 0.563–0.698; p Conclusion Patients with dual chamber pacemakers who develop AHRE ≥ 30 seconds have an increased risk of CCE. The combination of AHRE duration ≥30 seconds and CHA2DS2-VASc score ≥2 (males) or ≥3 (females) is a useful risk-stratification predictor for subsequent CCE.

We present the case of a patient with anxiety who attempted suicide by self-removal of her permanent pacemaker (PPM). Self-harm involving a pacemaker is associated with significantly endangering patient well-being and often with greatly increased health care costs. It is an indication that the numbers of patients with a PPM who are clinically depressed and anxious has been underestimated. Early detection of depression, using a validated questionnaire, followed by ongoing care and shared decision making (SDM), a focus on psychosocial stressors, medication adherence, somatic complaints and attention to any adverse drug reactions, are likely to improve clinical outcomes.

OBJECTIVES Patients with permanent pacemaker (PPM) implantation may have altered coronary perfusion patterns that may influence the accuracy of myocardial perfusion examination modalities, which was observed in previous studies but with limited statistic power. Our aim was to examine the performance of thallium-201 (TL-201) myocardial perfusion examination in patients with implanted PPM. METHODS Data of consecutive patients from our institution who had coronary angiography examination followed by TL-201 myocardial perfusion examination in pairs within 1 year were collected between January 2010 and December 2016 and were divided into PPM and control groups. Propensity score matching (PSM) was performed to compare the positive predictive value (PPV) of perfusion examinations. RESULTS A total of 934 pairs of studies were evaluated, with 81 in the PPM group and 853 controls. The PPV decreased significantly in the PPM group (28.2 vs. 62.9%, P 20%) ischemic areas correlated significantly with all-cause mortality in the control group (OR, 2.34; P = 0.001), but not in the PPM group (OR,1.05; P = 0.943). After PSM, the PPV was still significantly lower in the PPM group than in the non-PPM group (28.6 vs. 66.2%, P

Background Subclavian vein obstruction may occur in patients with pacemaker leads, which may make the implantation of new pacemaker leads difficult. Case summary We report two cases in which upgrading to cardiac resynchronization therapy pacemaker was challenging due to total central vein occlusion. In the first case, a 78-year-old woman with permanent pacemaker implantation, 5 years ago, was successfully treated by balloon venoplasty. In the second case, balloon venoplasty was unsuccessful in a 46-year-old woman who has received twice single-chamber implantable cardioverter-defibrillator, 12 years and 5 years ago, due to vessel crowding, so a contralateral side puncture, along with a tunnel technique, was performed to solve this problem. Discussion Cardiac implantable electronic device-related subclavian vein stenosis can present a challenge to common cardiac resynchronization therapy device upgrades in the absence of appropriate techniques.

Background: The HAT2CH2 score has been evaluated for predicting new onset atrial fibrillation, but never for adverse systemic thromboembolic events (STE) in elderly. We aimed to evaluate the HAT2CH2 score and comparing to atrial high rate episodes (AHRE) ≥24 h for predicting STE in older patients with cardiac implantable electronic devices (CIED) implantation.Methods: We retrospective enrolled 219 consecutive patients ≥ 65 years of age undergoing CIED implantation. The primary endpoint was subsequent STE. For all patients in the cohort, the CHA2DS2-VASc, C2HEST, mC2HEST, HAVOC, HAT2CH2 scores and AHRE ≥ 24 h were determined. AHRE was defined as > 175 bpm lasting ≥ 30 s. Multivariate Cox regression analysis with time-dependent covariates was used to determine variables associated with independent risk of STE.Results: The median patient age was 77 years, and 61.2% of the cohort was male. During follow-up (median, 35 months), 16 STE occurred (incidence rate, 2.51/100 patient-years; 95% CI, 1.65–5.48). Multiple Cox regression analysis showed that the HAT2CH2 score (HR, 3.405; 95% CI, 2.272–5.104; p < 0.001) was an independent predictor for STE. The optimal HAT2CH2 score cutoff value was 3, with the highest Youden index (AUC, 0.907; 95% CI, 0.853–0.962; p < 0.001). The STE rate increased with increasing HAT2CH2 score (p < 0.001).Conclusions: This study is the first to show the prognostic value of the HAT2CH2 score for STE occurrence in older patients with CIEDs.

The HAT2CH2 score has been evaluated for predicting new-onset atrial fibrillation in several clinical conditions, but never for adverse neurologic events. We aimed to evaluate the effectiveness of HAT2CH2 score in predicting neurologic events in patients with cardiac implantable electronic device (CIED), comparing with atrial high-rate episodes (AHRE). This case-control study enrolled 314 consecutive patients aged 18 years or older with CIED implantation between January 2015 and April 2021. Patient data were analyzed retrospectively. The primary endpoint was subsequent neurologic events (NE) after implantation. AHRE was defined as > 175 bpm (Medtronic®) lasting ≥ 30 seconds. Variables associated with independent risk of NE were identified using multivariate Cox regression analysis with time-dependent covariates. Patients’ median age was 73 years and 61.8% of them were male. During follow-up (median 32 months), 18 NE occurred (incidence rate 2.15/100 patient-years, 95% CI 1.32-4.30). Multiple Cox regression analysis showed that the HAT2CH2 score (HR 2.972, 95% CI 2.143-4.123, p < 0.001) was an independent predictor for NE. Optimal HAT2CH2 score cutoff value was 3 with highest Youden index (AUC, 0.923; 95% CI, 0.881–0.966; p < 0.001). Significant increase was observed in NE occurrence rates using the HAT2CH2 score (p < 0.001). The HAT2CH2 score and episodes of AHRE lasting ≥ 1 minute are independent risk factors for NE in patients with CIED.

Background: Patients with sustained atrial high-rate episodes (AHRE) have a high risk of major adverse cardio/cerebrovascular events (MACCE). However, the prediction model and factors for the occurrence of AHRE are unknown. We aimed to identify independent factors and various risk models for predicting MACCE and AHRE.Methods: We retrospectively enrolled 314 consecutive patients who had cardiac implantable electronic devices (CIEDs). The primary endpoint was MACCE after AHRE ≥3, 6 min, and 6 h. Atrial high-rate episodes was defined as >175 bpm (Medtronic®) lasting ≥30 s. Multivariate Cox and logistic regression analysis with time-dependent covariates were used to determine variables associated with independent risk of MACCE and occurrence of AHRE ≥3 min, respectively.Results: One hundred twenty-five patients (39.8%) developed AHRE ≥3 min, 103 (32.8%) ≥6 min, and 55 (17.5%) ≥6 h. During follow-up (median 32 months), 77 MACCE occurred (incidence 9.20/100 patient years, 95% CI 5.66–18.39). The optimal AHRE cutoff value was 3 min for MACCE, with highest Youden index 1.350 (AUC, 0.716; 95% CI, 0.638–0.793; p < 0.001). Atrial high-rate episodes ≥3 min−6 h were independently associated with MACCE. HATCH score and left atrial diameter were independently associated with AHRE ≥3 min. The optimal cutoff for HATCH score was 3 and for left atrial diameter was 4 cm for AHRE ≥3 min.Conclusion: Patients with CIEDs who develop AHRE ≥3 min have an independently increased risk of MACCE. Comprehensive assessment using HATCH score and echocardiography of patients with CIEDs is warranted.

The HATWe retrospectively reviewed 470 consecutive patients who had CIED without a history of AF. The primary endpoint was a neurologic event, i.e. ischemic stroke or transient ischemic attack. Multivariate Cox regression analysis with time-dependent covariates was used to determine variables associated with independent factors of neurologic events. Patients' median age was 76 years, and 58.7% were male. During follow-up (median 29 months), 21 neurologic events occurred (incidence rate 1.85/100 patient-years, 95% CI 1.03-3.83). Multivariable Cox regression analysis revealed that the HATThe HAT

Patients with atrial high-rate episodes (AHRE) have a high risk of neurologic events, although the causal role and optimal cutoff threshold of AHRE for major adverse cardio/cerebrovascular events (MACCE) are unknown. This study aimed to identify independent factors for AHRE and subsequent atrial fibrillation (AF) after documented AHRE. We enrolled 470 consecutive patients undergoing cardiac implantable electrical device (CIED) implantations. The primary endpoint was subsequent MACCE after AHRE ≥ 6 min, 6 h, and 24 h. AHRE was defined as > 175 beats per minute (bpm) (Medtronic®) or > 200 bpm (Biotronik®) lasting ≥ 30 s. Multivariate Cox regression analysis with time-dependent covariates was used to determine variables associated with independent risk of MACCE. The patients’ median age was 76 year, and 126 patients (26.8%) developed AHRE ≥ 6 min, 63 (13.4%) ≥ 6 h, and 39 (8.3%) ≥ 24 h. During follow-up (median: 29 months), 142 MACCE occurred in 123 patients. Optimal AHRE cutoff value was 6 min, with highest Youden index for MACCE. AHRE ≥ 6 min ~ 24 h was independently associated with MACCE and predicted subsequent AF. Male gender, lower body mass index, or BMI, and left atrial diameter were independently associated with AHRE ≥ 6 min ~ 24 h. Patients with CIEDs who develop AHRE ≥ 6 min have an independently increased risk of MACCE. Comprehensive assessment of patients with CIEDs is warranted.

BackgroundPost cardiac injury syndrome (PCIS) is induced by myocardial infarction or cardiac surgery, as well as minor insults to the heart such as percutaneous coronary intervention (PCI), or insertion of a pacing lead. PCIS is characterized by pericarditis after injury to the heart. The relatively low incidence makes differential diagnosis of PCIS after PCI or implantation of a pacemaker a challenge. This report describes two typical cases of PCIS.Case presentationThe first patient presented with signs of progressive cardiac tamponade that occurred two weeks after implantation of a permanent pacemaker. Echocardiography confirmed the presence of a moderate amount of newly-formed pericardial effusion. The second patient underwent PCI for the right coronary artery. However, despite an uneventful procedure, the patient experienced dyspnea, tightness of chest and cold sweats, and bradycardia two hours after the procedure. Echocardiography findings, which showed a moderate amount of newly-formed pericardial effusion, suggested acute cardiac tamponade, and compromised hemodynamics. Both patients recovered with medication.ConclusionThese cases illustrated that PCIS can occur after minor myocardial injury, and that the possibility of PCIS should be considered if there is a history of possible cardiac insult.

This work presents a portable wireless urine detection system which consists of an electrochemical readout application specific integrated circuit (ASIC) and a biosensor composed of 2, 2'-azino-bis(3-ethylbenzothiazoline-6-sulphonic acid) and carbon nanotube (ABTS-CNT) for the detection of urine albumin-to-creatinine ratio (UACR). The ASIC includes a potentiostat, a digital circuitry and a power management circuit which can perform electrochemistry techniques with a dual-channel screen-printing carbon electrode (SPCE). Electrochemical experiments on the proposed biosensor (SPCE|ABTS-CNT|Nafion) have revealed promising sensing characteristics for creatinine and human serum albumin detection. Practical urine tests has demonstrated the capability of the proposed urine detection system for UACR detection with both the power-efficient readout ASIC and the ABTS-CNT biosensor. A user-friendly prototype has also been designed which can be useful for either personal health administrationor homecare.

Left ventricular hypertrophy (LVH) is common among older adults. Amidst all causes, Fabry disease (FD) should be considered when LVH occurs with family history, specific clinical manifestations, or cardiac alert signs. Here, we report a case of a 76-year-old male who presented late onset concentric LVH with symptomatic high-grade atrioventricular (AV) block. After dual-chamber pacemaker implantation, interrogation revealed frequent right ventricular (RV) pacing with a wide QRS duration. The patient developed heart failure symptoms with rapid deterioration of LV systolic function. Pacing-induced cardiomyopathy (PICM) was suspected, and the pacemaker was upgraded to biventricular pacing. Further FD surveys were performed, including biochemical examinations, cardiac biopsies, and genetic sequencing, and the patient was ultimately diagnosed with a cardiac variant of FD. Particularly, we strongly suggest that physiologic pacing should be initially considered for patients with FD who have symptomatic high-grade AV block, rather than traditional RV pacing to prevent PICM.

Background Obesity-related cardiovascular risk, end points, and mortality are strongly related to arterial stiffening. Current therapeutic approaches for arterial stiffening are not focused on direct targeting within the vessel. Perivascular adipose tissue (PVAT) surrounding the artery has been shown to modulate vascular function and inflammation. Peroxisome proliferator-activated receptor γ (PPARγ) activation significantly decreases arterial stiffness and inflammation in diabetic patients with coronary artery disease. Thus, we hypothesized that PPARγ activation alters the PVAT microenvironment, thereby creating a favorable environment for the attenuation of arterial stiffening in obesity. Methods Obese ob/ob mice were used to investigate the effect of PPARγ activation on the attenuation of arterial stiffening. Various cell types, including macrophages, fibroblasts, adipocytes, and vascular smooth muscle cells, were used to test the inhibitory effect of pioglitazone, a PPARγ agonist, on the expression of elastolytic enzymes. Results PPARγ activation by pioglitazone effectively attenuated arterial stiffening in ob/ob mice. This beneficial effect was not associated with the repartitioning of fat from or changes in the browning of the PVAT depot but was strongly related to improvement of the PVAT microenvironment, as evidenced by reduction in the expression of pro-inflammatory and pro-oxidative factors. Pioglitazone treatment attenuated obesity-induced elastin fiber fragmentation and elastolytic activity and ameliorated the obesity-induced upregulation of cathepsin S and metalloproteinase 12, predominantly in the PVAT. In vitro, pioglitazone downregulated Ctss and Mmp12 in macrophages, fibroblasts, and adipocytes—cell types residing within the adventitia and PVAT. Ultimately, several PPARγ binding sites were found in Ctss and Mmp12 in Raw 264.7 and 3T3-L1 cells, suggesting a direct regulatory mechanism by which PPARγ activation repressed the expression of Ctss and Mmp-12 in macrophages and fibroblasts. Conclusions PPARγ activation attenuated obesity-induced arterial stiffening and reduced the inflammatory and oxidative status of PVAT. The improvement of the PVAT microenvironment further contributed to the amelioration of elastin fiber fragmentation, elastolytic activity, and upregulated expression of Ctss and Mmp12. Our data highlight the PVAT microenvironment as an important target against arterial stiffening in obesity and provide a novel strategy for the potential clinical use of PPARγ agonists as a therapeutic against arterial stiffness through modulation of PVAT function.

Additional file 1. Additional figures and tables.

In patients with diabetes mellitus (DM), incident cardiovascular (CV) events are associated with poor long-term outcomes. Serum high-sensitivity troponin I (hs-TnI) is widely used to diagnose and predict outcomes in patients with acute coronary syndrome, however, few studies have investigated the accuracy of urine hs-TnI as a predictor for incident CV events in patients with DM. The enrolled participants included patients with DM. Fresh urine hs-TnI levels were measured. Medical records of enrolled patients were used to determine the number of incident CV events prospectively for 3 months. The study cohort comprised 378 participants. We observed significantly higher levels of urine hs-TnI in those with than without subsequent incident CV events. The multivariate logistic regression analysis using different models consistently showed that urine hs-TnI &gt, 4.10 pg/mL was an independent factor predictive of incident CV events. The ROC-AUC analysis revealed that the optimal cutoff value for urine hs-TnI for predicting incident CV events was 1.55 pg/mL and the area was 0.611 (p = 0.027). A single measurement of urinary hs-TnI, collected easily and non-invasively, may be an acceptable biomarker for predicting subsequent incident CV events in patients with DM.