{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T23:06:22Z","timestamp":1788303982801,"version":"build-2803163510"},"reference-count":38,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"12","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["JAHA"],"published-print":{"date-parts":[[2021,6,15]]},"abstract":"<jats:sec xml:lang=\"en\">\n            <jats:title>Background<\/jats:title>\n            <jats:p xml:lang=\"en\">Low\u2010level tragus stimulation (LLTS) has been shown to significantly reduce atrial fibrillation (AF) burden in patients with paroxysmal AF. P\u2010wave alternans (PWA) is believed to be generated by the same substrate responsible for AF. Hence, PWA may serve as a marker in guiding LLTS therapy. We investigated the utility of PWA in guiding LLTS therapy in patients with AF.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec xml:lang=\"en\">\n            <jats:title>Methods and Results<\/jats:title>\n            <jats:p xml:lang=\"en\">\n              Twenty\u2010eight patients with AF were randomized to either active LLTS or sham (earlobe stimulation). LLTS was delivered through a transcutaneous electrical nerve stimulation device (pulse width 200\u00a0\u03bcs, frequency 20\u00a0Hz, amplitude 10\u201350\u00a0mA), for 1\u00a0hour daily over a 6\u2010month period. AF burden over 2\u2010week periods was assessed by noninvasive continuous ECG monitoring at baseline, 3 months, and 6 months. A 5\u2010minute control ECG for PWA analysis was recorded during all 3 follow\u2010up visits. Following the control ECG, an additional 5\u2010minute ECG was recorded during active LLTS in all patients. At baseline, acute LLTS led to a significant rise in PWA burden. However, active patients receiving chronic LLTS demonstrated a significant reduction in both PWA and AF burden after 6\u00a0months (\n              <jats:italic>P<\/jats:italic>\n              &lt;0.05). Active patients who demonstrated an increase in PWA burden with acute LLTS showed a significant drop in AF burden after 6\u00a0months of chronic LLTS.\n            <\/jats:p>\n          <\/jats:sec>\n          <jats:sec xml:lang=\"en\">\n            <jats:title>Conclusions<\/jats:title>\n            <jats:p xml:lang=\"en\">Chronic, intermittent LLTS resulted in lower PWA and AF burden than did sham control stimulation. Our results support the use of PWA as a potential marker for guiding LLTS treatment of paroxysmal AF.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1161\/jaha.120.020865","type":"journal-article","created":{"date-parts":[[2021,6,2]],"date-time":"2021-06-02T09:22:16Z","timestamp":1622625736000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":36,"title":["Low\u2010Level Tragus Stimulation Modulates Atrial Alternans and Fibrillation Burden in Patients With Paroxysmal Atrial Fibrillation"],"prefix":"10.1161","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3185-0484","authenticated-orcid":false,"given":"Kanchan","family":"Kulkarni","sequence":"first","affiliation":[{"name":"Cardiovascular Research Center Massachusetts General Hospital Boston MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2724-529X","authenticated-orcid":false,"given":"Jagmeet P.","family":"Singh","sequence":"additional","affiliation":[{"name":"Cardiology Division Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kimberly A.","family":"Parks","sequence":"additional","affiliation":[{"name":"Cardiology Division Brigham and Womens Hospital Boston MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Demosthenes G.","family":"Katritsis","sequence":"additional","affiliation":[{"name":"Hygeia Hospital Athens Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4370-8135","authenticated-orcid":false,"given":"Stavros","family":"Stavrakis","sequence":"additional","affiliation":[{"name":"Heart Rhythm Institute University of Oklahoma Health Sciences Center Oklahoma City OK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5006-1547","authenticated-orcid":false,"given":"Antonis A.","family":"Armoundas","sequence":"additional","affiliation":[{"name":"Cardiovascular Research Center Massachusetts General Hospital Boston MA"},{"name":"Institute for Medical Engineering and Science Massachusetts Institute of TechnologyCambridge MA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_1_2_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0002-8703(03)00524-6"},{"key":"e_1_3_1_3_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2006.10.062"},{"key":"e_1_3_1_4_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacep.2015.01.005"},{"key":"e_1_3_1_5_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2010.09.034"},{"key":"e_1_3_1_6_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.111.018028"},{"key":"e_1_3_1_7_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2014.12.026"},{"key":"e_1_3_1_8_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacep.2019.11.008"},{"key":"e_1_3_1_9_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pcbi.1004011"},{"key":"e_1_3_1_10_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.medici.2017.04.004"},{"key":"e_1_3_1_11_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.110.977827"},{"key":"e_1_3_1_12_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0735-1097(02)01760-6"},{"key":"e_1_3_1_13_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCEP.113.000204"},{"key":"e_1_3_1_14_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1542-474X.2009.00341.x"},{"key":"e_1_3_1_15_2","doi-asserted-by":"publisher","DOI":"10.1093\/europace\/eus273"},{"key":"e_1_3_1_16_2","doi-asserted-by":"publisher","DOI":"10.1253\/circj.69.1368"},{"key":"e_1_3_1_17_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.hrthm.2015.11.019"},{"key":"e_1_3_1_18_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1540-8167.2012.02336.x"},{"key":"e_1_3_1_19_2","doi-asserted-by":"publisher","DOI":"10.1002\/ca.1089"},{"key":"e_1_3_1_20_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.111.033563"},{"key":"e_1_3_1_21_2","doi-asserted-by":"publisher","DOI":"10.1152\/ajpheart.00639.2013"},{"key":"e_1_3_1_22_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ahj.2013.06.023"},{"key":"e_1_3_1_23_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCEP.119.008186"},{"key":"e_1_3_1_24_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.hrthm.2012.03.014"},{"key":"e_1_3_1_25_2","doi-asserted-by":"publisher","DOI":"10.1253\/circj.CJ-15-0253"},{"key":"e_1_3_1_26_2","doi-asserted-by":"publisher","DOI":"10.1038\/s41598-019-50487-4"},{"key":"e_1_3_1_27_2","doi-asserted-by":"publisher","DOI":"10.1161\/01.CIR.77.1.110"},{"key":"e_1_3_1_28_2","doi-asserted-by":"publisher","DOI":"10.1161\/JAHA.114.001055"},{"key":"e_1_3_1_29_2","first-page":"87","article-title":"Is the normal heartbeat chaotic or homeostatic?","volume":"6","author":"Goldberger AL","year":"1991","unstructured":"Goldberger AL. 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