Rediscover the predictive capacity of B-type natriuretic peptide applied to neonatal ventricular supertachycardia

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This study investigated early risk factors of acute heart failure (AHF) secondary to SVT in neonates, and explored their value on guiding the selection of efficient anti-arrhythmic treatment. Methods A total of 43 newborns with SVT diagnosed and treated between January 2017 and December 2022 were analyzed. According to the presence of AHF after initial restoring SVT to sinus rhythm, newborns were divided into SVT with AHF group and SVT without AHF group, and the clinical data and anti-arrhythmic therapies were analyzed. Risk factors of AHF secondary to SVT in neonates were determined by logistic regression. The cut-off value for predictors of AHF secondary to SVT and demanding of a second line anti-arrhythmic treatment was determined by receiver operating characteristic curve analysis. Results Time to initial control of tachycardia > 24h, hyperkalemia, anemia, plasma B-type natriuretic peptide (BNP) were risk factors of AHF secondary to SVT in neonates. BNP exhibited AUC of 0.804 in predicting AHF, and BNP > 2460.5pg/ml (OR 2.281, 95% CI 1.270 ~ 45.399, P = 0.026) was an independent predictor yielded sensitivity of 70.59% and specificity of 84.62%. The neonates with BNP > 2460.5pg/ml (37.5% versus 7.4%, P = 0.037) had a higher demand for a second line anti-arrhythmic treatment to terminate SVT, and the sensitivity and and specificity for BNP in predicting were 75.0%, 71.4%, respectively. Conclusions BNP could be used to predict an incident of AHF secondary to SVT and a demand of second line anti-arrhythmic treatment for terminating SVT hastily to prevent decompensation in neonates. Supraventricular tachycardia Acute heart failure B-type natriuretic peptide Anti-arrhythmic treatment Prediction Neonates Figures Figure 1 Figure 2 Introduction Supraventricular tachycardia (SVT), one of the most common neonatal arrhythmias, is frequently asymptomatic and rarely life-threatening [ 1 ]. However, there are still a small number of newborns may develop signs of congestive heart failure and cardiogenic shock before or even after anti-arrhythmic therapy [ 2 ]. Prolonged or intermittent recurrence of SVT may relate to immaturity of the conduction system in neonates, but more than that, unstable prenatal and postnatal state may also trigger this kind of arrhythmia [ 3 – 5 ]. The factors affecting overall cardiovascular status could collectively contribute to hemodynamic instability leading to acute heart failure (AHF) secondary to SVT in neonates, that increase the mortality and extended hospitalization [ 6 ]. The best protocol in terms of both safety and efficacy for terminating SVT has not been established, however, the goal of immediately converting to sinus rhythm is important for preventing cardiac decompensation and mortality [ 7 – 8 ]. Early recognition of AHF prior to appearance of obvious signs and symptoms could hasten treatment for avoiding poor prognosis. Our retrospective study evaluated the early risk factors of AHF secondary to SVT in neonates and preliminary explored their role on the choice of anti-arrhythmic treatment. Methods Patients were identified by retrospective analysis of the database at the Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China (UESTC) from January 2017 to December 2022. Our study included all newborns ≤ 28days of age suffering from SVT and treated in the Neonatal Intensive Care Unit. Those who had AHF prior to onset of PSVT tachycardia or tachycardia following cardiac surgery were excluded from analysis. Data on acute heart failure—as the variables of primary interest—as well as information on age at SVT diagnosis, sex, birth weight, time to initial control of tachycardia, associated prematurity, birth asphyxia, elderly parturient, fetal distress, prenatal history of tachycardia, caesarian section, maternal systemic disease, level of plasma B-type natriuretic peptide (BNP), and comorbid conditions including congenital heart disease (CHD), electrolyte disorders, systemic infection, hypoproteinemia, anemia, acidosis, hyoxemia, anti-arrhythmic treatment including pharmacological and non-pharmacological procedures were reviewed for every patient. As preserved left ventricular function measured by echocardiography in all included neonates, heart failure was defined as sum of clinical score ≥ 3 according to a modified Ross scoring system (range, 0–12 points) after initial success of restoring sinus rhythm to avoid the disturbance of SVT on heart rate [ 9 ]. Initial tachycardia control was defined as no tachycardia recurrence within 24h. Prematurity was defined as a gestational age < 37 weeks. Birth asphyxia (BA) was defined as a failure to initiate spontaneous respiration and/or 5-minute Apgar score 2 standard deviations below the mean for postnatal age [ 11 ]. Acidosis and hyoxemia were defined as pH ≤ 7.2 and PaO 2 ≤ 50mmHg respectively. Hypoproteinemia was defined as serum albumin < 30g/l. Normal level of sodium, potassium and ionized calcium was taken as 130–145 meq/l, 3.7–5.9 meq/l and 1-1.5 mmol/l. Fetal distress was diagnosed basing on fetal heart electronic monitoring, fetal movement count, amniotic fluid character by obstetrician [ 12 ]. Level of plasma B-type natriuretic peptide (BNP) measured before anti-arrhythmic treatment, the normal reference value for children is 0-500ng/ mL, but not exactly in neonates. Type of tachycardia was assessed on the basis of the surface electrocardiogram (ECG) and broadly classified SVT into two sub-groups: re-entry or automatic tachycardias [ 13 ]. All the patients were received acute therapy for restoring the sinus rhythm, anti-arrhythmic drugs and doses were selected after echocardiography at the preference of the physician on duty based on the international consensus statement. In general, vagal maneuvers (diving reflex), application of cold water ice to the face, was given to all patients, adenosine was used in re-entry tachycardias, while digitalis and beta-blocking (Esmolol) were used in automatic tachycardias. These treatments were classified as first line treatment in our study like reported [ 14 ]. Intravenous propafenone was used for longstanding, recurrent SVT if there was no sign of heart failure, amiodarone was the treatment of choice in the presence of heart failure. DC cardioversion was performed when hemodynamic instability or drug cardioversion is ineffective. Despite attractive efficacy, owing to their relatively high incidence of systemic adverse effects [ 2 , 15 ], these treatments were reserved as second line therapy in case of refractoriness of SVT. This retrospective study was approved by the Ethics Committee of Chengdu Women’s and Children’s Central Hospital, School of Medicine, UESTC, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The requirement for informed patient consent was waived. Statistical analysis Continuous variables are presented as mean ± standard deviation. Categorical variables are presented as frequency with percentage. Univariate and multivariate logistic regression analyses were performed to determine risk factors of AHF secondary to SVT in neonates. Receiver operating characteristic curve (ROC) analysis for predictors of AHF secondary to SVT and demanding of a second line anti-arrhythmic treatment was performed. Fisher's exact test was used to compare categorical variables. Statistical significance was defined as a P < 0.05. Results A total of 43 newborns diagnosed SVT—17 boys and 26 girls, aged from 0 to 27 days old— met the inclusion criteria. Of these patients, 17 newborns developed AHF secondary to SVT were assigned to SVT with AHF group, the other 23 patients were assigned to SVT without AHF group. A history of prenatal tachyarrhythmia and fetal distress were present in 12 patients (27.9%), 13 patients (30.2%) respectively, no patients required transplacental anti-arrhythmic drug therapy and developed hydrops. Thirty-three (76.7%) children were born after urgent caesarian section, and 18 (41.8%) children were born prematurely. Maternal systemic disease was present in 19 patients (44.1%), including pregnant infection (n = 6), hypothyroidism (n = 5), preeclampsia (n = 3), intrahepatic cholestasis of pregnancy(n = 4), gestational diabetes mellitus (n = 1). Time to initial control of tachycardia > 24h was present in 12 patients (27.9%), and digitalis was used in 23 patients (53.4%). CHD was present in 20 patients (46.5%), that were complex in 1 patients (2.3%) with Ebstein anomaly, and simple in 19 patients including atrial septal defect, patent ductus arteriosus, and the combination of these two, or with a ventricular septal defect. Systemic infection during initial therapy was in 35 patients (81.3%), mainly for neonatal pneumonia, few with necrotizing enterocolitis and suppurative encephalitis. Electrolyte disorders were in 27 patients (62.7%), including hyperkalemia (n = 8), hypokalemia (n = 8), hypernatremia (n = 5), hypocalcemia (n = 21) that exist alone or in combination. Lab results showed that hypoproteinemia, anemia, acidosis, hyoxemia were in 14 (32.5%), 10 (23.2%), 8 (18.6%), 20 (46.5%) patients respectively, and the average plasma BNP level was significantly higher than normal. Univariate logistic analysis for AHF secondary to SVT was performed on above variables (Table 1 ). Time to initial control of tachycardia > 24h (OR 4.889, 95% CI 1.171 ~ 20.408), hyperkalemia (OR 6.545, 95% CI 1.135 ~ 37.750), anemia (OR 5.367, 95% CI 1.147 ~ 25.105), and plasma BNP level (OR 1.001, 95% CI 1.000 ~ 1.001) were significant in univariate analysis (all P 0.05). The ROC curves of using BNP to predict AHF secondary to SVT were analyzed (Fig. 1 ), AUCs was demonstrated to be 0.804. According to the maximum Youden index, the classical cutoff points for BNP were 2460.5pg/ml, yield the specificity of 84.6% and sensitivity of 70.6%. A multivariate logistic regression analysis conducted for the model consisted of above 4 significant variables showed that BNP > 2460.5pg/ml was the only predictor for AHF secondary to SVT in neonates (OR 2.281, 95% CI 1.270 ~ 45.399) (Table 2 ). Table 1 Data of the study subjects and univariate logistic regression analysis for AHF secondary to SVT in neonates SVT with AHF (n = 17) SVT without AHF (n = 26) OR 95% CI P value Female gender, n (%) 9(52.9) 17(65.4) 1.679 0.482–5.854 0.416 Gestational age (wk) 37.18 ± 2.92 36.38 ± 3.21 1.094 0.882–1.357 0.411 Birth weight (g) 3018.53 ± 717.80 2997.5 ± 789.52 1.000 0.999–1.001 0.928 Age at diagnosis (d) 9.29 ± 8.75 8.69 ± 11.37 1.006 0.947–1.068 0.850 Prematurity, n (%) 6(35.3) 12(46.2) 0.636 0.181–2.240 0.482 Birth asphyxia, n (%) 2(11.8) 1(3.8) 3.333 0.278–39.977 0.342 Urgent cesarean rate, n (%) 13(76.5) 20(76.9) 0.975 0.230–4.136 0.973 Fetal distress, n (%) 5(29.4) 8(30.8) 0.938 0.247–3.562 0.925 Prenatal tachyarrhythmia, n (%) 3(17.6) 9(34.6) 0.405 0.092–1.788 0.233 Maternal systemic disease,n (%) 8(47.1) 11(42.3) 1.212 0.354–4.146 0.759 Time to initial control of tachycardia > 24h, n (%) 8(47.1) 4(15.4) 4.889 1.171–20.408 0.030* Comorbid conditions, n (%) Congenital heart disease 9(52.9) 11(42.3) 1.534 0.449–5.247 0.495 Acyanotic lesions ASD 4(23.5) 1(3.8) 7.692 0.778–76.075 0.081 PDA 3(17.6) 6(23.1) 0.714 0.152–3.349 0.670 ASD + VSD 0 1(3.8) - - - PDA + ASD 0 3(11.5) - - - ASD + VSD + PDA 1(5.9) 0 - - - Ebstein anomaly 1(5.9) 0 - - - Electrolyte disorders, n (%) 11(64.7) 16(61.5) 1.146 0.322–4.081 0.834 Hyperkalemia 6(35.3) 2(7.7) 6.545 1.135–37.750 0.036* Hypokalemia 3(17.6) 5(19.2) 0.900 0.185–4383 0.896 Hypernatremia 2(11.8) 3(11.5) 1.022 0.152–6.860 0.982 Hypocalcemia 7(41.2) 14(53.8) 0.600 0.174–2.065 0.418 Other systemic diseases, n (%) 16(94.9) 19(73.1) 5.895 0.654–53.110 0.114 Hypoproteinemia,n (%) 6(35.3) 8(30.8) 1.227 0.335–4.491 0.757 Anemia,n (%) 7(41.2) 3(11.5) 5.367 1.147–25.105 0.033* Acidosis,n (%) 5(29.4) 3(11.5) 3.194 0.650-15.703 0.153 Hyoxemia,n (%) 10(58.8) 10(38.5) 2.286 0.656–7.961 0.194 BNP(pg/ml) 3371.87 ± 1749.19 1557.68 ± 1816.17 1.001 1.000-1.001 0.010* Digitalis , n (%) 10(58.8) 13(50.0) 1.429 0.416–4.909 0.571 *Statistically significant ( P < 0.05) SVT: supraventricular tachycardia; AHF: acute heart failure; ASD: atrial septal defect; PDA: patent ductus arteriosus; VSD: ventricular septal defect; BNP: B-type natriuretic peptide Table 2 Multivariate logistic regression model for AHF secondary to SVT in neonates Indicator P OR 95%CI Hyperkalemia 0.516 2.037 0.238 ~ 19.431 Anemia 0.354 2.593 0.346 ~ 19.431 time to initial control of tachycardia > 24h 0.844 1.216 0.174 ~ 8.497 BNP > 2460.5pg/ml 0.026 2.281 1.270 ~ 45.399 SVT:supraventricular tachycardia; AHF:heart failure; BNP: B-type natriuretic peptide Anti-arrhythmic therapy of each newborn received from initiation to termination of SVT is presented in Table 3 . As a first line treatment, independent vagal maneuver succeeded in 10 patients (23.2%), while intravenous adenosine, digitalis and esmolol alone or in combination succeeded in 25 patients (58.1%). Second line therapies of intravenous propafenone, amiodarone or DC cardioversion were demanded in 8 cases (18.6%) to terminate tachycardia ultimately. The ROC curves of using BNP to predict demanding of second line therapy were analyzed (Fig. 2 ), AUCs was demonstrated to be 0.664, and the classical cutoff points for BNP were 2460.5pg/ml, yield the specificity of 71.4% and sensitivity of 75.0%. Patients with a BNP 2460.5pg/ml (37.5% versus 7.4%, P = 0.037) had a higher demand for second line therapy to control SVT (Table 4 ). Table 3 Anti-arrhythmic therapy received from initiation to termination of supraventricular tachycardia anti-arrhythmic therapy Total number of the patients (N = 43) SVT with AHF (N = 17) SVT without AHF (N = 26) Vagal maneuvers 10 2 8 Adenosine 6 1 4 Digitalis 6 2 5 Esmolol 1 0 1 Adenosine + digitalis 9 5 4 Digitalis + esmolol 2 0 2 Adenosine + digitalis + esmolol 1 0 1 DC cardioversion 1 1 0 Adenosine + DC cardioversion 2 2 0 Digitalis + propafenone 1 0 1 Adenosine + digitalis + amiodarone 2 2 0 Esmolol + amiodarone 1 1 0 Adenosine + digitalis + propafenone + DC cardioversion 1 1 0 Vagal maneuvers was used in all objects, only valid terminations listed separately on the first line; +:used to represent sequential links; SVT: paroxysmalsupraventricular tachycardia; AHF: acute heart failure Table 4 Predictive value of BNP at cut-off values for a demand of second line therapy Treatment BNP > 2460.5pg/ml BNP ≤ 2460.5pg/ml X 2 P First line therapy (n, %) 10 (62.5%) 25 (92.6%) 5.889 0.037 Second line therapy(n, %) 6 (37.5%) 2 (7.4%) Vagal maneuvers, adenosine, esmolol and digitalis are defined as first line therapy; DC cardioversion, propafenone, and amiodarone are defined as second line therapy; BNP: B-type natriuretic peptide; DISCUSSION Supraventricular tachycardia (SVT) is the most common sustained arrhythmia in the neonatal age group, with an estimated incidence of infants as 0.25 per 1000 patient and < 1 month as 0.06 per 1000 patient [ 16 ]. AHF occurred more commonly in 35% of patients under 4 months of age [ 17 ], that is close to the incidence of 39.5% in our study. As well toleration in the first 12–24 hours in SVT of neonate, symptoms may be mild and tachycardia may not be recognized for a long time, thus leading to AHF commonly [ 18 ], so that explicit risk factors influence the occurrence of AHF would do me a favor to early detection for preventing decompensation. In this study, we found that longer duration of SVT— time to initial control of tachycardia > 24h could increase the risk of AHF, similarly to the finding reported by Nadas et al that a 19% incidence of AHF if tachycardia continued until 30 h, and a 50% incidence of AHF if tachycardia last 48 h [ 19 ]. Comorbid conditions such as an inflammatory state, hypoxia, acidosis and electrolyte imbalance etc may be capable of triggering arrhythmia of SVT and devoted to hemodynamic instability [ 20 , 21 ]. In our study, hyperkalemia and anemia were risk factors for AHF in SVT. B-type natriuretic peptide (BNP), a cardiac peptide released by the heart ventricles in response to changes in the ventricular pressure and/or volume, reported associating with AHF in children from other causes such as CHD [ 22 ]. Gisela L. Salas has found that an increase in BNP levels measured in critically-ill neonates requiring assisted mechanical ventilation may predict hemodynamic changes and poor prognosis [ 23 ]. BNP in our study was identified to be a risk factor for AHF in neonates secondary to SVT. Structural heart disease contributes to cardiovascular collapse during a tachycardia episode [ 24 ], but in our study not identify it as a risk factor, may be that major subjects were simple congenital heart diseases with small shunt volumes, while others’ study involved large shunt volumes or complex congenital heart disease. As cardiac pump reserve function is limited especially in immature, and fast heart rate would lead to a declined cardiac output, prenatal history, prematurity, intrauterine tachycardia and urgent caesarian section regarded as an indicator of decreased fetal circulation might be associated with unfavorable clinical outcome in neonates with SVT [ 25 , 26 ]. But, we didn’t find these results, perhaps condition is not that serious. Lower body weight and younger age reported associating with fatal or near-fatal outcome in infant with SVT [ 8 ], that seems not with AHF in our study, maybe because that subject of similar age and weight in each group. Indeed, BNP is rarely used as a biomarker in newborns, because it can be affected by extra-cardiac conditions like anemia, severe infections, even by some prenatal and postnatal factors like mothers with type 1diabetes, prematurity, cesarean section [ 27 ]. Shawn Reeves etal observed a extremely high level approximately 20,000 pg/mL of N-terminal pro-brain natriuretic peptide (NT-proBNP), which originating from breaking down of BNP, in 3 neonates with decompensated SVT [ 28 ], indicating the potential of plasma BNP in predicting AHF secondary to SVT in neonates. In our study, the value of BNP for predicting AHF was identified to be 2460.5pg/ml. That is significantly higher than 758.7 pg/mL ~ 741.4 pg/mL at 97.5th percentile in normal infants aged from 0-30d reported by Cantinotti M [ 27 ]. Further more, among the associated risk factors, BNP > 2460.5pg/ml was identified to be an independent predictor, indicating that the incidence of AHF secondary to SVT is not only affected by the tachycardia itself, but also by many other factors associated the overall cardiovascular status, precisely that BNP may appropriately reflect the picture. In addition to early intervention according to type of tachycardia, an efficient option of treatment to hasten terminating SVT is also critical to prevent decompensation. Digitalis was the most used first line drug in our study, it seems not superior to other first-line drugs in preventing HF, though the combination of positive inotropic activity with negative chronotropic effects has been shown to reduce hospital admissions in heart failure [ 29 ]. Inverse, esmolol seems more beneficial for preventing AHF, as we found that esmolol terminated SVT without developing HF in 4 neonates including who did not respond to digitalis, indicating the positive inotropic effect may be not fully advantageous when tachycardia with preserved ejection. In this case, esmolol alone or in combination with digitalis may be more effective in the control of elevated haemodynamic parameters in patients with SVT as reported [ 30 ]. Till now, it's still a dilemma for cardiologists to balance efficiency and safety in terminating acute recurrent and persistent SVT in neonates. Compared to first-line treatment, the second line therapy has an attractive efficacy in case of refractory SVT, but remains a reserved option owing to reported relatively high incidence of systemic adverse effects, such as cardiac arrest inducing by propafenone, hypothyroidism and pulmonary fibrosis by amiodarone, cardiac depression by DC cardioversion, potential pro-arrhythmia in themselves [ 2 , 15 ]. However, some authors advocate amiodarone and propafenone are equally safe and effective used with monitoring as a first choice drug especially in infancy [ 31 , 32 , 33 ]. In this study, 8 newborns who developed AHF terminated the prolonged SVT by the second line therapy ultimately without adverse effects, and we found that neonates with a BNP > 2460.5pg/ml had a higher demand for second-line therapy to control SVT. The equal value of BNP in predicting AHF and anti-arrhythmic treatment may be not only a coincidentally. That's exactly Bjeloševič M reported that heart failure is a possible predictor of arrhythmia persistence, the need for ablation and mortality rate are reduced by commonly use amiodarone and propafenone in arrhythmia termination [ 34 ]. Though the diagnostic accuracy is not significant, the value of BNP in monitoring and predicting response to treatment deserves further study. This study has some limitations. First, the sample size of this study is small. Second, the diagnosis of heart failure is made by ROSS score, which is partly subjective. Third, selection of anti-arrhythmic drugs and doses were at the preference of the physician on duty. This circumstance made it impossible to study and characterize a well-defined therapy protocol. Forth, retrospective study design impeded assessment of adverse effect of anti-arrhythmic treatment, none of these neonates showed significant adverse reactions. Therefore, the definition of relatively higher risk anti-arrhythmic treatment is based on previous literature reports. Despite these limitations, we believe that our data about neonatal SVT can be useful for neonatologists in the neonatal emergency room. Further multicenter prospective studies are needed to confirm our findings. Conclusions Our study illustrates the neonates with plasma level BNP > 2460.5pg/ml increased the risk of AHF after SVT onset, and may require a second line anti-arrhythmic treatment to hasten terminating SVT for preventing decompensation in neonates. Abbreviations SVT: supraventricular tachycardia; AHF: acute heart failure; BNP: B-type natriuretic peptide; CHD: congenital heart disease Declarations Acknowledgments We thank all parents and infants who participated in the study and the staff at the neonatal intensive care unit of the Department of Neonatology of Chengdu Women’s and Children’s Central Hospital, School of Medicine, UESTC. Authors’ contributions Yaheng LU and Ying Xiong provided study conception and design, wrote the first draft of the manuscript. Yizhou Wen, Yanfeng Yang provided data collection and statistical analysis. Hanmin Liu reviewed this manuscript. All authors have revised and edited the manuscript and accepted the final version of the manuscript. Funding Not Applicable. Availability of data and material The datasets used and analyzed during the current study are not publicly available due to limitations of ethical approval involving the patient data and anonymity but are available from the corresponding author on reasonable request. Ethics approval and consent to participate This retrospective study was approved by the Medical Ethics Committee of the Chengdu Women’s and Children’s Central Hospital, Chengdu, China, and was approved with a waiver of informed consent due to research not involving greater than minimal risk and the retrospective nature of the study. This study was performed in accordance with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Consent for publication Not Applicable. Competing interests The authors declare no competing interests. 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J Matern Fetal Neonatal Med. 2011;24(3):541-544. Guerrier K, Shamszad P, Czosek RJ, Spar DS, Knilans TK, Anderson JB. Variation in Antiarrhythmic Management of Infants Hospitalized with Supraventricular Tachycardia: A Multi-Institutional Analysis. Pediatr Cardiol. 2016;37(5):946-952. Tunca Sahin G, Ozturk E, Kasar T, Guzeltas A, Ergul Y. Sustained tachyarrhythmia in children younger than 1 year of age: Six year single-center experience. Pediatr Int. 2018;60(2):115-121. Bjeloševič M, Illíková V, Tomko J, Olejník P, Chalupka M, Hatala R. Supraventricular tachyarrhythmias during the intrauterine, neonatal, and infant period: A 10-year population-based study. Pacing Clin Electrophysiol. 2020;43(7):680-686. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 08 Dec, 2023 Read the published version in BMC Cardiovascular Disorders → Version 1 posted Editorial decision: Major revision 16 Oct, 2023 Reviews received at journal 03 Sep, 2023 Reviewers agreed at journal 13 Aug, 2023 Reviewers agreed at journal 11 Aug, 2023 Reviews received at journal 09 Aug, 2023 Reviewers agreed at journal 09 Aug, 2023 Reviewers invited by journal 07 Aug, 2023 Editor assigned by journal 07 Aug, 2023 Editor invited by journal 10 Jul, 2023 Submission checks completed at journal 10 Jul, 2023 First submitted to journal 24 Jun, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3104256","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":217122476,"identity":"0084b728-d631-42bd-be9f-29519fdd5272","order_by":0,"name":"Yaheng Lu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYHACA4YHYBIIPhjY2BGnJQGqhXFGQVoyaVqYeT4cYmwgpJ5/dvM2icS2w/Lm7L2HX9sYHGBmYD98dAM+LRJ3jpWBtBju7DmXZp1jcIePgSct7QZea27kmIG0MG4AMoxzDJ4xM0jwmOHVIg/VYr/h/hszYwuDw4wNhLQYQLUkbrjBY/yYgRgthjfSii0SzqUnbziTY8bYY5CWzEbIL3I3kjfe+FBmbbvh+BnjDz/+2Njxsx8+ht/7DAwsEgwMzSAGmwSYJKAcBJg/MDDUwRijYBSMglEwCjABABh9UI+7MDXiAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Pediatrics, West China Second University Hospital, Sichuan University.","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yaheng","middleName":"","lastName":"Lu","suffix":""},{"id":217122477,"identity":"c3a9b14d-8992-41ea-8cda-9fc91b8f817e","order_by":1,"name":"Ying Xiong","email":"","orcid":"","institution":"Department of Pediatrics, West China Second University Hospital, Sichuan University.","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Xiong","suffix":""},{"id":217122478,"identity":"e8fa449d-aca2-4d7d-909f-61ab541fd9d2","order_by":2,"name":"Yizhou Wen","email":"","orcid":"","institution":"Department of Pediatric Cardiology, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, Sichuan, China.","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yizhou","middleName":"","lastName":"Wen","suffix":""},{"id":217122479,"identity":"69bb52fa-3bc0-46be-a38e-1cb408c4ffbe","order_by":3,"name":"Yanfeng Yang","email":"","orcid":"","institution":"Department of Pediatric Cardiology, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, Sichuan, China.","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yanfeng","middleName":"","lastName":"Yang","suffix":""},{"id":217122480,"identity":"c3c37f9a-8f85-4e16-bab5-c4a073b726e0","order_by":4,"name":"Hanmin Liu","email":"","orcid":"","institution":"Department of Pediatrics, West China Second University Hospital, Sichuan University.","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hanmin","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2023-06-24 14:44:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3104256/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3104256/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12872-023-03646-5","type":"published","date":"2023-12-08T15:02:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":39982052,"identity":"67cb74ee-1085-47be-b75d-59fe4ea5c086","added_by":"auto","created_at":"2023-07-13 14:17:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47537,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve analysis of BNP in predicting AHF secondary to SVT in neonates\u003c/p\u003e\n\u003cp\u003eSVT: supraventricular tachycardia; AHF: acute heart failure; BNP: B-type natriuretic peptide\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-3104256/v1/f719589805c640730e45c097.png"},{"id":39984153,"identity":"28820e53-2b71-4668-87b8-017f55eddb2e","added_by":"auto","created_at":"2023-07-13 14:25:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":47218,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve analysis of BNP in predicting a demand of second line therapy\u003c/p\u003e\n\u003cp\u003eDC cardioversion, propafenone, and amiodarone are defined as second line therapy; BNP: B-type natriuretic peptide\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-3104256/v1/f99191c8d3f255f4d5f87064.png"},{"id":47989516,"identity":"d6972fe5-72ec-4140-90ce-02eb4cc75df2","added_by":"auto","created_at":"2023-12-11 15:09:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":467444,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3104256/v1/d318d8f6-3eb2-4ccc-811f-00a732f8dc5d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rediscover the predictive capacity of B-type natriuretic peptide applied to neonatal ventricular supertachycardia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSupraventricular tachycardia (SVT), one of the most common neonatal arrhythmias, is frequently asymptomatic and rarely life-threatening [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, there are still a small number of newborns may develop signs of congestive heart failure and cardiogenic shock before or even after anti-arrhythmic therapy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Prolonged or intermittent recurrence of SVT may relate to immaturity of the conduction system in neonates, but more than that, unstable prenatal and postnatal state may also trigger this kind of arrhythmia [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The factors affecting overall cardiovascular status could collectively contribute to hemodynamic instability leading to acute heart failure (AHF) secondary to SVT in neonates, that increase the mortality and extended hospitalization [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe best protocol in terms of both safety and efficacy for terminating SVT has not been established, however, the goal of immediately converting to sinus rhythm is important for preventing cardiac decompensation and mortality [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Early recognition of AHF prior to appearance of obvious signs and symptoms could hasten treatment for avoiding poor prognosis. Our retrospective study evaluated the early risk factors of AHF secondary to SVT in neonates and preliminary explored their role on the choice of anti-arrhythmic treatment.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003ePatients were identified by retrospective analysis of the database at the Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China (UESTC) from January 2017 to December 2022. Our study included all newborns ≤ 28days of age suffering from SVT and treated in the Neonatal Intensive Care Unit. Those who had AHF prior to onset of PSVT tachycardia or tachycardia following cardiac surgery were excluded from analysis.\u003c/p\u003e\u003cp\u003eData on acute heart failure—as the variables of primary interest—as well as information on age at SVT diagnosis, sex, birth weight, time to initial control of tachycardia, associated prematurity, birth asphyxia, elderly parturient, fetal distress, prenatal history of tachycardia, caesarian section, maternal systemic disease, level of plasma B-type natriuretic peptide (BNP), and comorbid conditions including congenital heart disease (CHD), electrolyte disorders, systemic infection, hypoproteinemia, anemia, acidosis, hyoxemia, anti-arrhythmic treatment including pharmacological and non-pharmacological procedures were reviewed for every patient.\u003c/p\u003e\u003cp\u003eAs preserved left ventricular function measured by echocardiography in all included neonates, heart failure was defined as sum of clinical score ≥ 3 according to a modified Ross scoring system (range, 0–12 points) after initial success of restoring sinus rhythm to avoid the disturbance of SVT on heart rate [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Initial tachycardia control was defined as no tachycardia recurrence within 24h. Prematurity was defined as a gestational age \u0026lt; 37 weeks. Birth asphyxia (BA) was defined as a failure to initiate spontaneous respiration and/or 5-minute Apgar score \u0026lt; 7 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Anemia, defined as a hemoglobin (Hb) or hematocrit concentration of \u0026gt; 2 standard deviations below the mean for postnatal age [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Acidosis and hyoxemia were defined as pH ≤ 7.2 and PaO\u003csub\u003e2\u003c/sub\u003e ≤ 50mmHg respectively. Hypoproteinemia was defined as serum albumin \u0026lt; 30g/l. Normal level of sodium, potassium and ionized calcium was taken as 130–145 meq/l, 3.7–5.9 meq/l and 1-1.5 mmol/l. Fetal distress was diagnosed basing on fetal heart electronic monitoring, fetal movement count, amniotic fluid character by obstetrician [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Level of plasma B-type natriuretic peptide (BNP) measured before anti-arrhythmic treatment, the normal reference value for children is 0-500ng/ mL, but not exactly in neonates.\u003c/p\u003e\u003cp\u003eType of tachycardia was assessed on the basis of the surface electrocardiogram (ECG) and broadly classified SVT into two sub-groups: re-entry or automatic tachycardias [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. All the patients were received acute therapy for restoring the sinus rhythm, anti-arrhythmic drugs and doses were selected after echocardiography at the preference of the physician on duty based on the international consensus statement. In general, vagal maneuvers (diving reflex), application of cold water ice to the face, was given to all patients, adenosine was used in re-entry tachycardias, while digitalis and beta-blocking (Esmolol) were used in automatic tachycardias. These treatments were classified as first line treatment in our study like reported [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Intravenous propafenone was used for longstanding, recurrent SVT if there was no sign of heart failure, amiodarone was the treatment of choice in the presence of heart failure. DC cardioversion was performed when hemodynamic instability or drug cardioversion is ineffective. Despite attractive efficacy, owing to their relatively high incidence of systemic adverse effects [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], these treatments were reserved as second line therapy in case of refractoriness of SVT.\u003c/p\u003e\u003cp\u003e This retrospective study was approved by the Ethics Committee of Chengdu Women’s and Children’s Central Hospital, School of Medicine, UESTC, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The requirement for informed patient consent was waived.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eContinuous variables are presented as mean ± standard deviation. Categorical variables are presented as frequency with percentage. Univariate and multivariate logistic regression analyses were performed to determine risk factors of AHF secondary to SVT in neonates. Receiver operating characteristic curve (ROC) analysis for predictors of AHF secondary to SVT and demanding of a second line anti-arrhythmic treatment was performed. Fisher's exact test was used to compare categorical variables. Statistical significance was defined as a \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 43 newborns diagnosed SVT\u0026mdash;17 boys and 26 girls, aged from 0 to 27 days old\u0026mdash; met the inclusion criteria. Of these patients, 17 newborns developed AHF secondary to SVT were assigned to SVT with AHF group, the other 23 patients were assigned to SVT without AHF group.\u003c/p\u003e \u003cp\u003eA history of prenatal tachyarrhythmia and fetal distress were present in 12 patients (27.9%), 13 patients (30.2%) respectively, no patients required transplacental anti-arrhythmic drug therapy and developed hydrops. Thirty-three (76.7%) children were born after urgent caesarian section, and 18 (41.8%) children were born prematurely. Maternal systemic disease was present in 19 patients (44.1%), including pregnant infection (n\u0026thinsp;=\u0026thinsp;6), hypothyroidism (n\u0026thinsp;=\u0026thinsp;5), preeclampsia (n\u0026thinsp;=\u0026thinsp;3), intrahepatic cholestasis of pregnancy(n\u0026thinsp;=\u0026thinsp;4), gestational diabetes mellitus (n\u0026thinsp;=\u0026thinsp;1). Time to initial control of tachycardia\u0026thinsp;\u0026gt;\u0026thinsp;24h was present in 12 patients (27.9%), and digitalis was used in 23 patients (53.4%).\u003c/p\u003e \u003cp\u003eCHD was present in 20 patients (46.5%), that were complex in 1 patients (2.3%) with Ebstein anomaly, and simple in 19 patients including atrial septal defect, patent ductus arteriosus, and the combination of these two, or with a ventricular septal defect. Systemic infection during initial therapy was in 35 patients (81.3%), mainly for neonatal pneumonia, few with necrotizing enterocolitis and suppurative encephalitis. Electrolyte disorders were in 27 patients (62.7%), including hyperkalemia (n\u0026thinsp;=\u0026thinsp;8), hypokalemia (n\u0026thinsp;=\u0026thinsp;8), hypernatremia (n\u0026thinsp;=\u0026thinsp;5), hypocalcemia (n\u0026thinsp;=\u0026thinsp;21) that exist alone or in combination. Lab results showed that hypoproteinemia, anemia, acidosis, hyoxemia were in 14 (32.5%), 10 (23.2%), 8 (18.6%), 20 (46.5%) patients respectively, and the average plasma BNP level was significantly higher than normal.\u003c/p\u003e \u003cp\u003eUnivariate logistic analysis for AHF secondary to SVT was performed on above variables (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Time to initial control of tachycardia\u0026thinsp;\u0026gt;\u0026thinsp;24h (OR 4.889, 95% CI 1.171\u0026thinsp;~\u0026thinsp;20.408), hyperkalemia (OR 6.545, 95% CI 1.135\u0026thinsp;~\u0026thinsp;37.750), anemia (OR 5.367, 95% CI 1.147\u0026thinsp;~\u0026thinsp;25.105), and plasma BNP level (OR 1.001, 95% CI 1.000\u0026thinsp;~\u0026thinsp;1.001) were significant in univariate analysis (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Other variables were not found an association (all \u003cem\u003eP\u0026thinsp;\u0026gt;\u003c/em\u003e\u0026thinsp;0.05). The ROC curves of using BNP to predict AHF secondary to SVT were analyzed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), AUCs was demonstrated to be 0.804. According to the maximum Youden index, the classical cutoff points for BNP were 2460.5pg/ml, yield the specificity of 84.6% and sensitivity of 70.6%. A multivariate logistic regression analysis conducted for the model consisted of above 4 significant variables showed that BNP\u0026thinsp;\u0026gt;\u0026thinsp;2460.5pg/ml was the only predictor for AHF secondary to SVT in neonates (OR 2.281, 95% CI 1.270\u0026thinsp;~\u0026thinsp;45.399) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eData of the study subjects and univariate logistic regression analysis for AHF secondary to SVT in neonates\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSVT with AHF\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSVT without AHF\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale gender, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(52.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(65.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.482\u0026ndash;5.854\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.416\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGestational age (wk)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.38\u0026thinsp;\u0026plusmn;\u0026thinsp;3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.882\u0026ndash;1.357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.411\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirth weight (g)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3018.53\u0026thinsp;\u0026plusmn;\u0026thinsp;717.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2997.5\u0026thinsp;\u0026plusmn;\u0026thinsp;789.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.999\u0026ndash;1.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.928\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at diagnosis (d)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.29\u0026thinsp;\u0026plusmn;\u0026thinsp;8.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.69\u0026thinsp;\u0026plusmn;\u0026thinsp;11.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.947\u0026ndash;1.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrematurity, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.181\u0026ndash;2.240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirth asphyxia, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.278\u0026ndash;39.977\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.342\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrgent cesarean rate, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(76.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(76.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.975\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.230\u0026ndash;4.136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.973\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFetal distress, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.247\u0026ndash;3.562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.925\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrenatal tachyarrhythmia, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(34.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.405\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.092\u0026ndash;1.788\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.233\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal systemic disease,n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.354\u0026ndash;4.146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.759\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime to initial control of tachycardia\u0026thinsp;\u0026gt;\u0026thinsp;24h, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.171\u0026ndash;20.408\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.030*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbid conditions, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongenital heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(52.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.534\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.449\u0026ndash;5.247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.495\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcyanotic lesions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.692\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.778\u0026ndash;76.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePDA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.714\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.152\u0026ndash;3.349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.670\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASD\u0026thinsp;+\u0026thinsp;VSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePDA\u0026thinsp;+\u0026thinsp;ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASD\u0026thinsp;+\u0026thinsp;VSD\u0026thinsp;+\u0026thinsp;PDA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEbstein anomaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElectrolyte disorders, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(64.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.322\u0026ndash;4.081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.834\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperkalemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.135\u0026ndash;37.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.036*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypokalemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.185\u0026ndash;4383\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.896\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypernatremia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.152\u0026ndash;6.860\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.982\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypocalcemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.174\u0026ndash;2.065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther systemic diseases, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(94.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(73.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.895\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.654\u0026ndash;53.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypoproteinemia,n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.335\u0026ndash;4.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.757\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia,n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.367\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.147\u0026ndash;25.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.033*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcidosis,n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.650-15.703\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyoxemia,n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.656\u0026ndash;7.961\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBNP(pg/ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3371.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1749.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1557.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1816.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000-1.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.010*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDigitalis\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.429\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.416\u0026ndash;4.909\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.571\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSVT: supraventricular tachycardia; AHF: acute heart failure; ASD: atrial septal defect; PDA: patent ductus arteriosus; VSD: ventricular septal defect; BNP: B-type natriuretic peptide\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression model for AHF secondary to SVT in neonates\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eOR\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e95%CI\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperkalemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.516\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.238\u0026thinsp;~\u0026thinsp;19.431\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.354\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.346\u0026thinsp;~\u0026thinsp;19.431\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etime to initial control of tachycardia\u0026thinsp;\u0026gt;\u0026thinsp;24h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.844\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.174\u0026thinsp;~\u0026thinsp;8.497\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBNP\u0026thinsp;\u0026gt;\u0026thinsp;2460.5pg/ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.270\u0026thinsp;~\u0026thinsp;45.399\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSVT:supraventricular tachycardia; AHF:heart failure; BNP: B-type natriuretic peptide\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAnti-arrhythmic therapy of each newborn received from initiation to termination of SVT is presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. As a first line treatment, independent vagal maneuver succeeded in 10 patients (23.2%), while intravenous adenosine, digitalis and esmolol alone or in combination succeeded in 25 patients (58.1%). Second line therapies of intravenous propafenone, amiodarone or DC cardioversion were demanded in 8 cases (18.6%) to terminate tachycardia ultimately. The ROC curves of using BNP to predict demanding of second line therapy were analyzed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), AUCs was demonstrated to be 0.664, and the classical cutoff points for BNP were 2460.5pg/ml, yield the specificity of 71.4% and sensitivity of 75.0%. Patients with a BNP 2460.5pg/ml (37.5% versus 7.4%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037) had a higher demand for second line therapy to control SVT (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnti-arrhythmic therapy received from initiation to termination of supraventricular tachycardia\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eanti-arrhythmic therapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal number of the\u003c/p\u003e \u003cp\u003epatients (N\u0026thinsp;=\u0026thinsp;43)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSVT with AHF\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSVT without AHF\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVagal maneuvers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenosine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDigitalis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEsmolol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenosine\u0026thinsp;+\u0026thinsp;digitalis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDigitalis\u0026thinsp;+\u0026thinsp;esmolol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenosine\u0026thinsp;+\u0026thinsp;digitalis\u0026thinsp;+\u0026thinsp;esmolol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDC cardioversion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenosine\u0026thinsp;+\u0026thinsp;DC cardioversion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDigitalis\u0026thinsp;+\u0026thinsp;propafenone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenosine\u0026thinsp;+\u0026thinsp;digitalis\u0026thinsp;+\u0026thinsp;amiodarone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEsmolol\u0026thinsp;+\u0026thinsp;amiodarone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenosine\u0026thinsp;+\u0026thinsp;digitalis\u0026thinsp;+\u0026thinsp;propafenone\u0026thinsp;+\u0026thinsp;DC cardioversion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eVagal maneuvers was used in all objects, only valid terminations listed separately on the first line; +:used to represent sequential links; SVT: paroxysmalsupraventricular tachycardia; AHF: acute heart failure\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePredictive value of BNP at cut-off values for a demand of second line therapy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBNP\u0026thinsp;\u0026gt;\u0026thinsp;2460.5pg/ml\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBNP\u0026thinsp;\u0026le;\u0026thinsp;2460.5pg/ml\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst line therapy (n, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (62.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (92.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecond line therapy(n, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eVagal maneuvers, adenosine, esmolol and digitalis are defined as first line therapy; DC cardioversion, propafenone, and amiodarone are defined as second line therapy; BNP: B-type natriuretic peptide;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSupraventricular tachycardia (SVT) is the most common sustained arrhythmia in the neonatal age group, with an estimated incidence of infants as 0.25 per 1000 patient and \u0026lt;\u0026thinsp;1 month as 0.06 per 1000 patient [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. AHF occurred more commonly in 35% of patients under 4 months of age [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], that is close to the incidence of 39.5% in our study. As well toleration in the first 12\u0026ndash;24 hours in SVT of neonate, symptoms may be mild and tachycardia may not be recognized for a long time, thus leading to AHF commonly [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], so that explicit risk factors influence the occurrence of AHF would do me a favor to early detection for preventing decompensation.\u003c/p\u003e \u003cp\u003eIn this study, we found that longer duration of SVT\u0026mdash; time to initial control of tachycardia\u0026thinsp;\u0026gt;\u0026thinsp;24h could increase the risk of AHF, similarly to the finding reported by Nadas et al that a 19% incidence of AHF if tachycardia continued until 30 h, and a 50% incidence of AHF if tachycardia last 48 h [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Comorbid conditions such as an inflammatory state, hypoxia, acidosis and electrolyte imbalance etc may be capable of triggering arrhythmia of SVT and devoted to hemodynamic instability [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our study, hyperkalemia and anemia were risk factors for AHF in SVT. B-type natriuretic peptide (BNP), a cardiac peptide released by the heart ventricles in response to changes in the ventricular pressure and/or volume, reported associating with AHF in children from other causes such as CHD [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Gisela L. Salas has found that an increase in BNP levels measured in critically-ill neonates requiring assisted mechanical ventilation may predict hemodynamic changes and poor prognosis [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. BNP in our study was identified to be a risk factor for AHF in neonates secondary to SVT.\u003c/p\u003e \u003cp\u003eStructural heart disease contributes to cardiovascular collapse during a tachycardia episode [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], but in our study not identify it as a risk factor, may be that major subjects were simple congenital heart diseases with small shunt volumes, while others\u0026rsquo; study involved large shunt volumes or complex congenital heart disease. As cardiac pump reserve function is limited especially in immature, and fast heart rate would lead to a declined cardiac output, prenatal history, prematurity, intrauterine tachycardia and urgent caesarian section regarded as an indicator of decreased fetal circulation might be associated with unfavorable clinical outcome in neonates with SVT [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. But, we didn\u0026rsquo;t find these results, perhaps condition is not that serious. Lower body weight and younger age reported associating with fatal or near-fatal outcome in infant with SVT [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], that seems not with AHF in our study, maybe because that subject of similar age and weight in each group.\u003c/p\u003e \u003cp\u003eIndeed, BNP is rarely used as a biomarker in newborns, because it can be affected by extra-cardiac conditions like anemia, severe infections, even by some prenatal and postnatal factors like mothers with type 1diabetes, prematurity, cesarean section [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Shawn Reeves etal observed a extremely high level approximately 20,000 pg/mL of N-terminal pro-brain natriuretic peptide (NT-proBNP), which originating from breaking down of BNP, in 3 neonates with decompensated SVT [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], indicating the potential of plasma BNP in predicting AHF secondary to SVT in neonates. In our study, the value of BNP for predicting AHF was identified to be 2460.5pg/ml. That is significantly higher than 758.7 pg/mL\u0026thinsp;~\u0026thinsp;741.4 pg/mL at 97.5th percentile in normal infants aged from 0-30d reported by Cantinotti M [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Further more, among the associated risk factors, BNP\u0026thinsp;\u0026gt;\u0026thinsp;2460.5pg/ml was identified to be an independent predictor, indicating that the incidence of AHF secondary to SVT is not only affected by the tachycardia itself, but also by many other factors associated the overall cardiovascular status, precisely that BNP may appropriately reflect the picture.\u003c/p\u003e \u003cp\u003eIn addition to early intervention according to type of tachycardia, an efficient option of treatment to hasten terminating SVT is also critical to prevent decompensation. Digitalis was the most used first line drug in our study, it seems not superior to other first-line drugs in preventing HF, though the combination of positive inotropic activity with negative chronotropic effects has been shown to reduce hospital admissions in heart failure [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Inverse, esmolol seems more beneficial for preventing AHF, as we found that esmolol terminated SVT without developing HF in 4 neonates including who did not respond to digitalis, indicating the positive inotropic effect may be not fully advantageous when tachycardia with preserved ejection. In this case, esmolol alone or in combination with digitalis may be more effective in the control of elevated haemodynamic parameters in patients with SVT as reported [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTill now, it's still a dilemma for cardiologists to balance efficiency and safety in terminating acute recurrent and persistent SVT in neonates. Compared to first-line treatment, the second line therapy has an attractive efficacy in case of refractory SVT, but remains a reserved option owing to reported relatively high incidence of systemic adverse effects, such as cardiac arrest inducing by propafenone, hypothyroidism and pulmonary fibrosis by amiodarone, cardiac depression by DC cardioversion, potential pro-arrhythmia in themselves [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, some authors advocate amiodarone and propafenone are equally safe and effective used with monitoring as a first choice drug especially in infancy [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In this study, 8 newborns who developed AHF terminated the prolonged SVT by the second line therapy ultimately without adverse effects, and we found that neonates with a BNP\u0026thinsp;\u0026gt;\u0026thinsp;2460.5pg/ml had a higher demand for second-line therapy to control SVT. The equal value of BNP in predicting AHF and anti-arrhythmic treatment may be not only a coincidentally. That's exactly Bjeloševič M reported that heart failure is a possible predictor of arrhythmia persistence, the need for ablation and mortality rate are reduced by commonly use amiodarone and propafenone in arrhythmia termination [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Though the diagnostic accuracy is not significant, the value of BNP in monitoring and predicting response to treatment deserves further study.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, the sample size of this study is small. Second, the diagnosis of heart failure is made by ROSS score, which is partly subjective. Third, selection of anti-arrhythmic drugs and doses were at the preference of the physician on duty. This circumstance made it impossible to study and characterize a well-defined therapy protocol. Forth, retrospective study design impeded assessment of adverse effect of anti-arrhythmic treatment, none of these neonates showed significant adverse reactions. Therefore, the definition of relatively higher risk anti-arrhythmic treatment is based on previous literature reports. Despite these limitations, we believe that our data about neonatal SVT can be useful for neonatologists in the neonatal emergency room. Further multicenter prospective studies are needed to confirm our findings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur study illustrates the neonates with plasma level BNP\u0026thinsp;\u0026gt;\u0026thinsp;2460.5pg/ml increased the risk of AHF after SVT onset, and may require a second line anti-arrhythmic treatment to hasten terminating SVT for preventing decompensation in neonates.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSVT: supraventricular tachycardia; AHF: acute heart failure; BNP: B-type natriuretic peptide; CHD: congenital heart disease\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e We thank all parents and infants who participated in the study and the staff at the neonatal intensive care unit of the Department of Neonatology of Chengdu Women\u0026rsquo;s and Children\u0026rsquo;s Central Hospital, School of Medicine, UESTC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e Yaheng LU and Ying Xiong provided study conception and design, wrote the first draft of the manuscript. Yizhou Wen, Yanfeng Yang provided data collection and statistical analysis. Hanmin Liu reviewed this manuscript. All authors have revised and edited the manuscript and accepted the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e Not Applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u0026nbsp;\u003c/strong\u003eThe datasets used and analyzed during the current study are not publicly available due to limitations of ethical approval involving the patient data and anonymity but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003eThis retrospective study was approved by the Medical Ethics Committee of the Chengdu Women\u0026rsquo;s and Children\u0026rsquo;s Central Hospital, Chengdu, China, and \u0026nbsp;was approved with a waiver of informed consent due to research not involving greater than minimal risk and the retrospective nature of the study. This study was performed in accordance with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u0026nbsp;\u003c/strong\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Pediatrics, West China Second University Hospital, Sichuan University. \u003csup\u003e2\u003c/sup\u003eKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China. \u003csup\u003e3\u003c/sup\u003eDepartment of Pediatric Cardiology, School of Medicine, Chengdu Women\u0026apos;s and Children\u0026apos;s Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, Sichuan, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSrinivasan C, Balaji S. 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Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S526-S542.\u003c/li\u003e\n\u003cli\u003eCapponi G, Belli G, Giovannini M, et al. Supraventricular tachycardias in the first year of life: what is the best pharmacological treatment? 24 years of experience in a single centre. BMC Cardiovasc Disord. 2021;21(1):137. \u003c/li\u003e\n\u003cli\u003eK\u0026ouml;rnyei L, Szab\u0026oacute; A, R\u0026oacute;th G, Ferenci T, Kardos A. Supraventricular tachycardias in neonates and infants: factors associated with fatal or near-fatal outcome. Eur J Pediatr. 2021;180(8):2669-2676. doi:10.1007/s00431-021-04159-z.\u003c/li\u003e\n\u003cli\u003eRoss RD. The Ross classification for heart failure in children after 25 years: a review and an age-stratified revision. Pediatr Cardiol. 2012;33(8):1295-1300. \u003c/li\u003e\n\u003cli\u003eErsdal HL, Mduma E, Svensen E, Perlman J. Birth asphyxia: a major cause of early neonatal mortality in a Tanzanian rural hospital. Pediatrics. 2012;129(5):e1238-e1243.\u003c/li\u003e\n\u003cli\u003eColombatti R, Sainati L, Trevisanuto D. Anemia and transfusion in the neonate. Semin Fetal Neonatal Med. 2016;21(1):2-9. \u003c/li\u003e\n\u003cli\u003eMartis R, Emilia O, Nurdiati DS, Brown J. Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being. Cochrane Database Syst Rev. 2017;13(2):CD008680. \u003c/li\u003e\n\u003cli\u003eButt\u0026agrave; C, Tuttolomondo A, Giarrusso L, Pinto A. Electrocardiographic diagnosis of atrial tachycardia: classification, P-wave morphology, and differential diagnosis with other supraventricular tachycardias. Ann Noninvasive Electrocardiol. 2015;20(4):314-327. \u003c/li\u003e\n\u003cli\u003eBan JE. Neonatal arrhythmias: diagnosis, treatment, and clinical outcome. 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Paroxysmal tachycardia in infants and children; study of 41 cases. Pediatrics. 1952;9(2):167-181.\u003c/li\u003e\n\u003cli\u003ePrzybylski R, Michelson KA, Neuman MI, Porter JJ, Alexander ME, Lyons TW. Care of Children with Supraventricular Tachycardia in the Emergency Department. Pediatr Cardiol. 2021;42(3):569-577. \u003c/li\u003e\n\u003cli\u003eBassareo PP, Fanos V, Pala M, et al. Supraventricular tachycardia during the first year of life: is subclinical inflammation the trigger?. J Matern Fetal Neonatal Med. 2018;31(1):53-58. \u003c/li\u003e\n\u003cli\u003eCantinotti M, Law Y, Vittorini S, et al. The potential and limitations of plasma BNP measurement in the diagnosis, prognosis, and management of children with heart failure due to congenital cardiac disease: an update. Heart Fail Rev. 2014;19(6):727-742. \u003c/li\u003e\n\u003cli\u003eSalas GL, Jozefkowicz M, Goldsmit GS, et al. B-type natriuretic peptide: Usefulness in the management of critically-ill neonates. P\u0026eacute;ptido natriur\u0026eacute;tico tipo B: utilidad en el manejo de reci\u0026eacute;n nacidos cr\u0026iacute;ticamente enfermos. Arch Argent Pediatr. 2017;115(5):483-489. \u003c/li\u003e\n\u003cli\u003eSalerno JC, Garrison MM, Larison C, Seslar SP. Case fatality in children with supraventricular tachycardia in the United States. Pacing Clin Electrophysiol. 2011;34(7):832-836. \u003c/li\u003e\n\u003cli\u003eO\u0026apos;Leary ET, Alexander ME, Bezzerides VJ, et al. Low mortality in fetal supraventricular tachycardia: Outcomes in a 30-year single-institution experience. J Cardiovasc Electrophysiol. 2020;31(5):1105-1113. \u003c/li\u003e\n\u003cli\u003eGilljam T, Jaeggi E, Gow RM. Neonatal supraventricular tachycardia: outcomes over a 27-year period at a single institution. Acta Paediatr. 2008;97(8):1035-1039.\u003c/li\u003e\n\u003cli\u003eCantinotti M. B-Type Cardiac Natriuretic Peptides in the Neonatal and Pediatric Intensive Care Units. J Pediatr Intensive Care. 2016;5(4):189-197. \u003c/li\u003e\n\u003cli\u003eReeves S, Womack C, Lutherer LO, Todd C, Pinkney K, Kasemsri T. What Is High Enough? Elevated NT-pro-BNP in Decompensated Paroxysmal Supraventricular Tachycardia. J Pediatr Intensive Care. 2018;7(1):49-53. \u003c/li\u003e\n\u003cli\u003eZiff OJ, Kotecha D. Digoxin: The good and the bad. Trends Cardiovasc Med. 2016;26(7):585-595. \u003c/li\u003e\n\u003cli\u003eGarnock-Jones KP. Esmolol: a review of its use in the short-term treatment of tachyarrhythmias and the short-term control of tachycardia and hypertension. Drugs. 2012;72(1):109-132. \u003c/li\u003e\n\u003cli\u003eTavera MC, Bassareo PP, Neroni P, et al. Supraventricular tachycardia in neonates: antiarrhythmic drug choice dilemma. J Matern Fetal Neonatal Med. 2011;24(3):541-544. \u003c/li\u003e\n\u003cli\u003eGuerrier K, Shamszad P, Czosek RJ, Spar DS, Knilans TK, Anderson JB. Variation in Antiarrhythmic Management of Infants Hospitalized with Supraventricular Tachycardia: A Multi-Institutional Analysis. Pediatr Cardiol. 2016;37(5):946-952.\u003c/li\u003e\n\u003cli\u003eTunca Sahin G, Ozturk E, Kasar T, Guzeltas A, Ergul Y. Sustained tachyarrhythmia in children younger than 1 year of age: Six year single-center experience. Pediatr Int. 2018;60(2):115-121. \u003c/li\u003e\n\u003cli\u003eBjelo\u0026scaron;evič M, Ill\u0026iacute;kov\u0026aacute; V, Tomko J, Olejn\u0026iacute;k P, Chalupka M, Hatala R. Supraventricular tachyarrhythmias during the intrauterine, neonatal, and infant period: A 10-year population-based study. Pacing Clin Electrophysiol. 2020;43(7):680-686. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Supraventricular tachycardia, Acute heart failure, B-type natriuretic peptide, Anti-arrhythmic treatment, Prediction, Neonates","lastPublishedDoi":"10.21203/rs.3.rs-3104256/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3104256/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSupraventricular tachycardia (SVT) is one of the most common non-benign arrhythmias in neonates that could lead to cardiac decompensation. This study investigated early risk factors of acute heart failure (AHF) secondary to SVT in neonates, and explored their value on guiding the selection of efficient anti-arrhythmic treatment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 43 newborns with SVT diagnosed and treated between January 2017 and December 2022 were analyzed. According to the presence of AHF after initial restoring SVT to sinus rhythm, newborns were divided into SVT with AHF group and SVT without AHF group, and the clinical data and anti-arrhythmic therapies were analyzed. Risk factors of AHF secondary to SVT in neonates were determined by logistic regression. The cut-off value for predictors of AHF secondary to SVT and demanding of a second line anti-arrhythmic treatment was determined by receiver operating characteristic curve analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTime to initial control of tachycardia\u0026thinsp;\u0026gt;\u0026thinsp;24h, hyperkalemia, anemia, plasma B-type natriuretic peptide (BNP) were risk factors of AHF secondary to SVT in neonates. BNP exhibited AUC of 0.804 in predicting AHF, and BNP\u0026thinsp;\u0026gt;\u0026thinsp;2460.5pg/ml (OR 2.281, 95% CI 1.270\u0026thinsp;~\u0026thinsp;45.399, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026) was an independent predictor yielded sensitivity of 70.59% and specificity of 84.62%. The neonates with BNP\u0026thinsp;\u0026gt;\u0026thinsp;2460.5pg/ml (37.5% versus 7.4%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037) had a higher demand for a second line anti-arrhythmic treatment to terminate SVT, and the sensitivity and and specificity for BNP in predicting were 75.0%, 71.4%, respectively.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBNP could be used to predict an incident of AHF secondary to SVT and a demand of second line anti-arrhythmic treatment for terminating SVT hastily to prevent decompensation in neonates.\u003c/p\u003e","manuscriptTitle":"Rediscover the predictive capacity of B-type natriuretic peptide applied to neonatal ventricular supertachycardia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-13 14:17:46","doi":"10.21203/rs.3.rs-3104256/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-10-16T16:52:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-09-03T14:08:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"d7d64ccd-c56e-4c48-85fd-af7c94a3c88c","date":"2023-08-13T12:20:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8c039e4b-ebf9-444f-a86e-569551e6de33","date":"2023-08-11T07:14:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-08-09T11:46:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94db7025-f3a8-4d60-b82b-e19e28d189af","date":"2023-08-09T10:07:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-08-07T12:09:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-08-07T12:06:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-07-10T04:51:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-07-10T04:45:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2023-06-24T14:35:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf5c153d-2f57-44f0-acdd-2b476d03e153","owner":[],"postedDate":"July 13th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-12-11T15:07:46+00:00","versionOfRecord":{"articleIdentity":"rs-3104256","link":"https://doi.org/10.1186/s12872-023-03646-5","journal":{"identity":"bmc-cardiovascular-disorders","isVorOnly":false,"title":"BMC Cardiovascular Disorders"},"publishedOn":"2023-12-08 15:02:08","publishedOnDateReadable":"December 8th, 2023"},"versionCreatedAt":"2023-07-13 14:17:46","video":"","vorDoi":"10.1186/s12872-023-03646-5","vorDoiUrl":"https://doi.org/10.1186/s12872-023-03646-5","workflowStages":[]},"version":"v1","identity":"rs-3104256","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3104256","identity":"rs-3104256","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}