Neurological Calm
Innate Energy
Peak Performance
Fine-tuning Vagus Nerve Health With AVNT™
Key research outcomes
Nurosym is backed by peer‑reviewed papers and clinically validated in various placebo‑controlled trials independently led by the world’s leading research institutions.
Studies consistently show measurable benefits in:
How It Works
NEURAL REGULATION & PLASTICITY
Nurosym resets healthy brain chemistry and strengthens neuroplasticity
AVNT™ leads to increased activity in brainstem centers that regulate norepinephrine - responsible for mood, focus, and learning (Zheng 2024)
Scientific Explanation
Your brain is an efficiency machine. Through neuroplasticity, it prunes away unused connections to save energy, meaning whichever circuits you activate most become your "default" setting. These circuts get activated by chemicals. If you’re constantly flooding your brain with cortisol (stress) your brain can "unplug" your capacity for calm because it thinks you’re in constant danger.
Nurosym overrides brain circuits to manually trigger chemical production like dopamine and serotonin. This shifts your brain’s resources back into focus and mood regulation. Each session retrains your brain to prioritize healthy chemistry over reactive stress patterns and release stored up mental and physical tension.
INFLAMMATORY CYTOKINES REDUCTION
Nurosym regulates inflammation and unblocks energy production
78% reduction in IL-6 harmful cytokines (Dasari 2023)
Scientific Explanation
Cytokines are tiny immune messengers that regulate our healing. When our nervous system is disrupted, cytokines levels explode and bombard nerves with false signals, leading to increased pain sensitivity.
When in high doses, pro-inflammatory cytokines (IL-6 and TNF-α) also cross the blood-brain barrier and disrupt mitochondrial function in cells, leading to tiredness and a weaker immune system.
Nurosym activates vagal anti-inflammatory pathways that suppress excessive immune signaling, leading to reduced pain levels and increased energy.
AUTONOMIC TONE BALANCE
Nurosym regulates HRV and vagal tone for optimal nervous system resilience
18% increase in HRV and 61% increase in vagal parasympathetic activity compared to placebo (PLOS ONE journals)
Scientific Explanation
RMSSD measures HRV (heart rate variability) and is the best indicator we have for nervous system resilience. A high level indicates your body’s psychophysiological self-repair mechanism is operating at its peak, and the brain is in sync with your heart, lungs, gut, and every other major organ.
Homeostasis, i.e. a system in balance, can lead to significant improvements in digestion and motility, cognitive abilities, accelerated recovery, increased physical capacity, and prolonged endurance.
How does Nurosym Work
The Mechanisms of Nurosym Neuromodulation
Nurosym sends patented electrical impulses to the brain via the Vagus Nerve, which leads to:
61% increase in Vagus Nerve Activity & 18% Improved Heart Rate Variability
The parasympathetic nervous system is the body’s internal relaxation & rest mechanism. HRV is an indicator of Vagus Nerve activity. Improving these parameters of HRV indicates targeted stimulation of the vagus nerve and activation of specific self-repair mechanisms of body & mind. In a clinical trial, a one-hour session of Nurosym favourably altered all three parameters of Heart Rate Variability (HRV), when compared to a placebo. Figure (a) shows High Frequency HRV is significantly increased ('p=0.001). Figure (b) shows Low-Frequency HRV is significantly decreased ('P=0.001). Figure (c) shows the ratio of LF to HF is significantly decreased (*p=0.002).
35% reduction in anxious thoughts
Studies have demonstrated that pre-existing symptoms such as anxious thoughts further heighten the risk of symptoms associated with chronic inflammation. Research on the Nurosym neuromodulation system has shown that it activates the vagus nerve, leading to a reduction in anxious thoughts and stress responses. This targeted stimulation of the vagus nerve increases vagal tone and inhibits cytokine production in the inflammatory process. Both are important mechanisms for anxious thoughts management and resilience. The figure illustrates changes in anxiety across three timepoints: pre-intervention (D0), post-intervention (D10) (D0 vs D10, p < 0.001), and 1-month follow-up after accomplished therapy (D0 vs Follow-up, p < 0.001).
48% reduced Fatigue & increased Energy
Nurosym neuromodulation has demonstrated a beneficial effect on fatigue by modulating the autonomic nervous system, leading to enhanced energy levels and reduced sensations of exhaustion. In the study, patients reported sustained improvements even one week after discontinuing the therapy, indicating prolonged relief from fatigue-related symptoms.(Figure) Fatigue was assessed using the Pichot fatigue scale scores during therapy (D0: day 0, D5: day 5 and D10: day 10). The results revealed a substantial reduction in fatigue, registering approximately 48% improvement (D0 vs. D10, p < 0.0001) after Nurosym neuromodulation therapy.
31% improvement in Sleep Scores
In individuals with sleep onset difficulties, the sympathetic branch of the autonomic nervous system may exhibit heightened activity compared to the parasympathetic branch, resulting in increased agitation. The study demonstrated that Nurosym neuromodulation enhances parasympathetic activity, which in turn mitigates agitation and improves sleep scores. (Figure) Changes in sleep (PSQI Sleep Disturbance Score) across three timepoints: pre-intervention, 2-weeks, and 4-weeks (*p < 0.05).
80% reduction in digestive issues
The vagus nerve serves as the primary communication highway between your brain and your gastrointestinal tract. When chronic inflammation or lingering post-viral interference disrupts this critical vagal-gut axis, it can trigger severe, persistent digestive problems and gut dysfunction.
In clinical evaluations of Nurosym neuromodulation, patients receiving Auricular Vagal Neuromodulation Therapy experienced a dramatic 80% reduction in the frequency of their gastrointestinal symptoms.
The figure presents the significant decrease in the frequency of reported digestive issues before and after the targeted neuromodulation therapy.
78% reduction in inflammatory markers
Inflammation throughout the body and brain contributes to disease development, progression, ageing, and mental health problems. In a randomised controlled trial of Nurosym neuromodulation, inflammatory cytokines were significantly lower in the group that received Auricular Vagal Neuromodulation Therapy (AVNT) compared to the placebo group at the end of 3 months.(Figure) The figure presents the changes in the IL-6 inflammatory biomarker compared to placebo.
61% improved Brain Fog, Gastrointestinal Function & Pain (Post-viral Fatigue Symptoms)
A growing body of research suggests that vagus nerve regulation plays a crucial role in managing chronic inflammation. Nurosym, through the stimulation of afferent vagus nerve fibres, has been shown to influence higher brain structures. This modulation may help alleviate symptoms connected to Post-viral Fatigue Syndrome such as chronic fatigue, pain, and brain fog.(Figure ) A very significant improvement in Post-viral Fatigue symptoms was observed after 10 neuromodulation therapy sessions. (D0 vs. D10: p < 0.0001).
45% improvement in Depressive States & Improved Mood
Disruption of signals in the afferent fibres of the vagus nerve can directly or indirectly induce brain disorders, including depressive states. Nurosym neuromodulation significantly decreased depressive state scores and improved mood within just 5 days of therapy, with continued improvement observed after 10 days.(Figure) The figure shows the evolution of the Beck depression scale (D0: day 0, D5: day 5 and D10: day 10). The results showed a noticeable improvement in mood, registering approximately 45% on the Beck Depression Scale (p<0.05).
11% improvement in Attention Deficiency Symptoms
Individuals with attention deficits, including those diagnosed with ADHD, often exhibit low heart rate variability (HRV) measurements, indicating reduced vagus nerve activity and diminished parasympathetic tone. Nurosym neuromodulation counteracts the persistent sympathetic "fight-or-flight" overdrive, thereby enhancing cognitive function.(Figure) Changes in attention were assessed using the Flanker Inhibitory Control and Attention assay across three timepoints: pre-intervention, post-intervention, and 1-month follow-up. After Nurosym therapy, significant gains were detected from pre-intervention to post-intervention (p < 0.01) and from pre-intervention to follow-up (p < 0.001).
40% reduction in postural heart rate abnormalities
People who suffer from postural heart rate abnormalities or tachycardia have diminished size vagus nerves. Research team discovered that postural heart rate abnormalities symptoms were significantly lessened in people receiving Nurosym — 15 beats less per minute compared to the placebo group. Additionally, the active group showed lower levels of anti-autonomic autoantibodies (specifically α1-AR and β1-AR)(Figure) Comparison of Orthostatic Tachycardia between Nurosym neuromodulation and placebo stimulation after a 2-Month. The figure illustrates the changes in heart rate upon standing.
28% reduction in Oxidative Stress (Reactive Oxygen Species)
Biologically, the vagus nerve inhibits oxidative stress, inflammation and sympathetic activity (and associated hypoxia). Nurosym led to a significant decrease in reactive oxygen species (ROS) (p = 0.004), while placebo stimulation did not cause a significant change (p = 0.10).(Figure) Change in median DCF values from admission to discharge in the Nurosym group compared to the placebo group (p < 0.005).
29% improvement in Reading and Learning
Researchers have demonstrated a direct link between vagus nerve stimulation and the activation of learning centres in the brain. This discovery has led to the evaluation of Nurosym neuromodulation, which has been shown to enhance cognitive retention in both healthy individuals and those with injured nervous systems.(Figure) Nurosym neuromodulation paired with training significantly (*p < 0.05) improved speed performance on the Automaticity learning task compared to placebo controls. Nurosym neuromodulation also significantly (∗p < 0.05) improved percent correct on the Decoding learning task as compared to controls.
32% improvement in Memory Recall
The vagus nerve, through its physiological connections to various brain areas, plays a key role in modulating many behavioural processes related to memory. Nurosym research investigates enhancements in memory and neuroplasticity, linking cognitive function with the parasympathetic nervous system.(Figure A, B) Nurosym improves memory on learning tasks in comparison to placebo. (A) There was a significant benefit of Nurosym neuromodulation compared to placebo across all test questions. (B) This effect was driven by a significant benefit of Nurosym neuromodulation on memory questions.
85% reduction in Atrial Fibrillation Burden
The vagus nerve modulates the inflammatory response, thereby reducing the systemic inflammatory burden that contributes to the progression of various diseases, including atrial fibrillation. Leveraging this mechanism, Nurosym neuromodulation offers a non-invasive modality for regulating cardiac rhythm, effectively suppressing atrial fibrillation.(Figure) Comparison of atrial fibrillation (AF) burden between the two groups (Nurosym neuromodulation vs Placebo stimulation) is presented using interquartile range values. The p-value reflects the comparison of median AF burden levels at the 6-month mark, adjusted for baseline measurements.
19% improvement of Heart Muscle Function (Global Longitude Strain reduction)
Many studies have shown that drug treatments do not improve morbidity and mortality in patients after myocardial infarction. These patients often exhibit significant autonomic dysfunction, characterised by increased sympathetic nervous system activity and decreased parasympathetic (vagal) activity. The study found that Nurosym is effective by targeting cardiac inflammation and autonomic dysfunction. (Figure) Comparison of the effect of Nurosym neuromodulation on global longitudinal strain (GLS) during active versus placebo stimulation. Active neuromodulation resulted in a significant improvement in GLS (p = 0.001) compared to sham stimulation.
50% improvement in Blood Vessel Flexibility & improved Circulation (FMD)
The purpose of the study was to determine the influence of vagal innervation control of the resting diameter of large blood vessels using Nurosym neuromodulation. Nurosym has demonstrated a significant ability to enhance blood circulation and macrovascular endothelial function compared to a placebo.(Figure) Percent change in flow-mediated vasodilation (FMD) with Nurosym. "Before" and "after" refer to the brachial artery (BA) diameter and FMD test conducted pre- and post-Nurosym neuromodulation. The y-axis shows the percent change in BA diameter. The box shows the 25th–75th percentile, the middle line is the median, the dot is the mean, and the bars indicate the maximum and minimum values.
39% improvement in markers of Microcirculatory Function
Parasympathetic outflow utilises the circuit from the dorsal motor nucleus of the vagus nerve to regulate circulation. This improvement in blood circulation, or perfusion rate, is crucial for efficiently supplying oxygen and nutrients to tissues while removing waste products. The study using Nurosym indicated a trend towards enhanced microcirculatory function,(Figure) (A) Changes in blood perfusion measured over nail bed area, before and after Nurosym neuromodulation (B) and sham (placebo) stimulation (C). Markedly higher perfusion rate was seen after Nurosym neuromodulation
34% improvement on Cardio-Vagal Baroreflex Gain
The use of Nurosym may positively influence cardio-vagal baroreflex gain (BRS) in patients with chronic heart failure (CHF). BRS, a marker of autonomic function, is often impaired in CHF, contributing to poor outcomes. Enhancing BRS through Nurosym could improve parasympathetic tone, stabilise cardiovascular regulation, and potentially mitigate disease progression. (Figure) Acute AVNT significantly increased cardio-vagal baroreflex gain in the study population, demonstrating its potential to enhance autonomic cardiovascular regulation in patients with chronic heart failure.
10% Reduction in Blood Pressure
Nurosym reduced systolic blood pressure (SBP) by approximately 9.7% and diastolic blood pressure (DBP) by 10.2% over three months in young adults with Grade 1 hypertension. Additionally, it significantly reduced stress markers and stabilised cardiovascular function by reducing vascular resistance without altering heart rate. Patients also reported improved quality of life, highlighting the intervention’s broader benefits.
Nurosym Research at a Glance
Rigorous Research Methods And Safety Procedures
The human brain has over 86 billion neurons and we have developed technology to fire up specific ones that help us get better. Our core belief at Parasym is the future of medicine advances with high-precision bioelectricity, specifically by decoding the brain’s electrical language.
Nurosym is a CE-marked wearable device, FDA-designated as non-significant risk, and all clinical research is conducted under ICH-GCP guidelines—ensuring safety, regulatory compliance, and scientific integrity at every stage. Most of our trials follow gold-standard, double-blind, placebo-controlled designs in ethically approved, real-world settings.
Clinical Trials
A clinical trial is a rigorously controlled study involving human participants, designed to evaluate the safety, effectiveness, and physiological impact of an intervention. Nurosym has been studied in over 50 clinical trials – including randomised, placebo-controlled studies.
Good Clinical Practice (GCP)
A global standard for ethical and scientific quality in clinical research. Nurosym trials are conducted in accordance with ICH-GCP guidelines, ensuring robust data collection, participant rights, ethical oversight, reproducible scientific data, and transparency in reporting.
Blinded, Randomised, Placebo-Controlled Trials
A number of Nurosym studies have used placebo stimulation groups, allowing for robust comparison and minimisation of bias.
Heart Rate Variability (HRV)
A core biomarker used to assess autonomic tone and a hallmark of stress-related disorders. This mirrors best practices in pharmaceutical PK/PD studies for dynamic tracking of biological response.
Validated Biomarker & Outcome Measurement
Nurosym studies track outcomes like: - Inflammatory cytokines (e.g., IL-6) Oxidative stress (e.g., ROS levels) Cortisol levels Autoantibodies Functional scores (fatigue, anxiety, depression) And more These validated endpoints provide mechanistic insights and quantitative evidence for how AVNT™ improves physiological and psychological resilience.
- Inflammatory cytokines (e.g., IL-6)
- Oxidative stress (e.g., ROS levels)
- Cortisol levels
- Autoantibodies
- Functional scores (fatigue, anxiety, depression)
- And more
These validated endpoints provide mechanistic insights and quantitative evidence for how AVNT™ improves physiological and psychological resilience.
Whole-System Effects
Unlike therapies targeting a single pathway, Auricular Vagal Neuromodulation Therapy (AVNT™) engages central and peripheral neural circuits involved in inflammation, mood regulation, and immune signalling. This makes it suitable for broad-spectrum symptom relief in complex syndromes like post-viral fatigue and dysautonomia.
Sample Size and Statistical Power
Trials are statistically powered based on expected effect sizes observed in pilot cohorts. Many use within-subject designs for increased sensitivity, and apply appropriate ANOVA or mixed-model statistical analyses with corrections for multiple comparisons (e.g. Bonferroni, FDR).
Pharmacokinetic-style Study Design for Neuromodulation
Morning-use studies follow validated pharmacokinetic-style methodologies, measuring vagus nerve activity over defined time windows (e.g. 5 minutes, 2 hours, 2 months post-intervention)
Independent-led studies in collaboration with leading institutions
Our work is conducted in collaboration with leading research institutions who independently lead and fund the clinical trials across diverse clinical populations

Peer-reviewed studies
Scientific inquiry drives everything at Parasym. Our research strategy extends beyond individual conditions—we collaborate with leading health institutions to conduct rigorous, independent clinical trials evaluating the therapeutic potential of non-invasive vagal nerve stimulation across a spectrum of disorders.
We actively publish our findings in peer-reviewed medical journals in partnership with globally recognized researchers and HCPs. These publications contribute to the growing body of knowledge on autonomic dysfunction, chronic inflammation, and the field of bioelectronic medicine. Nurosym’s technology has been featured in over 50 peer-reviewed articles, including randomized controlled trials, mechanistic studies, and clinical reviews of auricular vagal stimulation.
Multiple clinical trials are currently in progress, with upcoming results. As new research is published, this section will be updated. Several manuscripts are also in development and will be submitted for peer review in the coming months.
Clinical Trials
This study provides evidence supporting the potential of t-VNS as a therapeutic intervention for Long COVID patients. tVNS activated brainstem centers that regulate norepinephrine and acetylcholine release, improving neuroplasticity and cognitive control. Benefits in attention, processing speed, memory, mood, and sleep suggest broad modulation of brain–body circuits. The delayed fatigue improvement points to downstream effects on neuroinflammatory pathways.
Effects Of Low Level Tragus Stimulation On Inflammation In Acute Decompensated Heart Failure
Low-level tragus stimulation (LLTS) reduced systemic inflammation and oxidative stress in patients admitted with acute decompensated heart failure with reduced ejection fraction.
Noninvasive Vagus Nerve Stimulation in Postural Tachycardia Syndrome
Low-level transcutaneous vagus nerve stimulation significantly attenuated orthostatic tachycardia in patients with postural tachycardia syndrome (POTS). It also reduced circulating antiadrenergic autoantibodies, lowered inflammatory cytokines, improved cardiac autonomic function (via HRV), and enhanced secretomotor autonomic function without device-related side effects
THE CHALLENGE
Not just mapping the nervous system. We’re learning to talk to it with scientific precision.
Neural Pathways and Potential Mechanisms Involved in Neuromodulation Using Low Level Tragus Stimulation
Scientific Explanation
At the heart of Nurosym’s mission has been one central challenge - how to send bioelectrical signals that reach and activate precisely the right brain centers—without disturbing the rest.
Nurosym’s clinical research programme is the result of partnerships with over 60 independent academic and medical institutions, including leading hospitals and university research centres across Europe and North America.
Studies were independently designed and led by clinical investigators, with Parasym providing the neuromodulation device and technical support only. This independence ensured objectivity, transparency, and scientific validity.
All trials were reviewed and approved by independent ethics committees or Institutional Review Boards (IRBs) in line with global regulatory standards. Nurosym’s classification as a non-significant risk (NSR) device under FDA guidelines helped streamline ethical oversight while maintaining participant safety.
Clinical protocols adhered to ICH-Good Clinical Practice (GCP) guidelines, ensuring that trials met the highest standards of data integrity, participant protection, and reproducibility.
Protocols included precise definitions for study populations, endpoints, blinding, randomisation, and statistical power. Many studies used sham (placebo) stimulation and blinded outcome assessment to ensure unbiased results.
Trials measured both subjective clinical outcomes (fatigue, anxiety, sleep, cognitive performance) and objective physiological markers, such as:
- Heart rate variability (HRV)
- Inflammatory cytokines (e.g. IL-6, TNF-α)
- Oxidative stress (e.g. ROS levels)
- Cortisol and autonomic biomarkers
- Orthostatic heart rate changes (for POTS)
Research was conducted in real-world settings, often with home-based use protocols, ensuring that findings reflect actual clinical use. Outcomes were evaluated at multiple timepoints to assess both immediate and sustained effects of vagal stimulation.
Nurosym has been classified as a non-significant risk neuromodulation device under FDA guidelines, allowing for human research to proceed with streamlined ethics approval and oversight due to its low-risk profile.
Nurosym is a certified medical device. This certification ensures the device meets strict EU standards for safety, performance, and clinical benefit.
All clinical trials involving Nurosym are conducted in accordance with ICH-GCP standards, ensuring rigorous protocol design, ethical integrity, data reliability, and participant safety.
Nurosym studies are built around randomised, double-blind, placebo-controlled protocols — the most rigorous format in clinical research. Sham stimulation is used to control for placebo effects, ensuring that outcomes are driven by true physiological changes, not perception.
Studies are conducted in clinically relevant populations, such as individuals with post-viral fatigue, postural heart rate abnormalities, atrial fibrillation, anxious states, and autonomic dysfunction. This ensures that results are meaningful, translational, and aligned with current clinical challenges.
Trials measure biochemical and inflammatory markers like IL-6, TNF-α, cortisol, and reactive oxygen species (ROS) to verify that Nurosym activates the cholinergic anti-inflammatory pathway — a key mechanism for restoring immune balance.
Clinical endpoints are based on quantifiable physiological data — including wearable or implantable monitors, heart rate variability (HRV), numerous biomarkers and validated symptom scores — rather than relying on subjective self-report alone.
Nurosym is evaluated under realistic, at-home usage conditions to ensure both efficacy and user compliance are assessed in settings that reflect day-to-day life — not just laboratory environments.
Studies are statistically powered and analysed using modern methods, including intention-to-treat analysis, mixed-effects models, and correction for multiple comparisons, ensuring confidence in the findings and reproducibility across populations.
Collaborations
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Learn moreReferences
1. Zheng et al 2024 / Zheng, Z. S., Simonian, N., Wang, J., & Rosario, E. R. (2024). Transcutaneous vagus nerve stimulation improves Long COVID symptoms in a female cohort: a pilot study. Frontiers in neurology, 15, 1393371. https://doi.org/10.3389/fneur.2024.1393371
2. Verbanck et al 2021 / Verbanck, P., Clarinval, A. M., Burton, F., Corazza, F., Nagant, C., & Cheron, G. (2021). Transcutaneous auricular vagus nerve stimulation (tVNS) can reverse the manifestations of the Long-COVID syndrome: A pilot study. Frontiers in Neurology and Neuroscience Research, 2, Article 100011. https://quintet.no/wp-content/uploads/2023/11/transcutaneous-auricular-vagus-nerve[…]ifestations-of-the-long-covid-syndrome-a-pilot-study-100011.pdf
3. Dolcini et al 2025 / Dolcini, G., Favretti, M., Franculli, D., Buoncuore, G., Pellegrino, G., Di Carlo, M., Sarzi-Puttini, P., Conti, F., Iannuccielli, C., & Di Franco, M. (2025). Vagal nerve stimulation and fibromyalgia: an additional therapeutic option. Clinical and experimental rheumatology, 43(6), 1095–1104. https://doi.org/10.55563/clinexprheumatol/johqvo
4. Mbikyo et al 2024 / Mbikyo, M. B., Wang, A., Ma, Q., Miao, L., Cui, N., Yang, Y., Fu, H., Sun, Y., & Li, Z. (2024). Low-Level Tragus Stimulation Attenuates Blood Pressure in Young Individuals With Hypertension: Results From a Small–Scale Single–Blind Controlled Randomized Clinical Trial. Journal of the American Heart Association, 13(19), e032269. https://doi.org/10.1161/JAHA.123.032269
5. Thakkar et al 2023 / Thakkar, V. J., Richardson, Z. A., Dang, A., & Centanni, T. M. (2023). The effect of non-invasive vagus nerve stimulation on memory recall in reading: A pilot study. Behavioural brain research, 438, 114164. https://doi.org/10.1016/j.bbr.2022.114164
6. Dasari et al 2023 / University of Oklahoma Health Sciences Center / Dasari, T. W., Akhtar, K. H., Amil, F., Zhao, Y. D., Sohinki, D., Po, S. (2023). Effects of low level tragus stimulation on inflammation in acute decompensated heart failure. Journal of Cardiac Failure. 29(4): 660–661. https://doi.org/10.1016/j.cardfail.2022.10.278
7. Jackowska et al 2022 / Jackowska, M., Koenig, J., Vasendova, V., & Jandackova, V. K. (2022). A two-week course of transcutaneous vagal nerve stimulation improves global sleep: Findings from a randomised trial in community-dwelling adults. Autonomic neuroscience : basic & clinical, 240, 102972. https://doi.org/10.1016/j.autneu.2022.102972
8. Stavrakis et al 2024 / University of Oklahoma Health Sciences Center / Stavrakis, S., Chakraborty, P., Farhat, K., Whyte, S., Morris, L., Abideen Asad, Z. U., Karfonta, B., Anjum, J., Matlock, H. G., Cai, X., & Yu, X. (2024). Noninvasive Vagus Nerve Stimulation in Postural Tachycardia Syndrome: A Randomized Clinical Trial. JACC. Clinical electrophysiology, 10(2), 346–355. https://doi.org/10.1016/j.jacep.2023.10.015

