Ambulatory Cardiology Research Articles

Elegibility for Sacubitril/Valsartan in italian clinical practice: insights from the OPTIMA-HF registry

Abstract Background/Introduction Guidelines strongly recommend patients with heart failure with reduced ejection fraction (HFrEF) be treated with multiple medications proven to improve clinical outcomes, as tolerated. Among them, angiotensin receptor blocker/neprylisin inhibitor (ARNi) are the foundation of neuro-hormonal blockade in patients with HFrEF, however the degree to which gaps in this medication use and dosing persist in outpatient practice is unclear. Purpose To assess the proportion of patients with HFrEF who are eligible for ARNi based on the PARADIGM-HF trial criteria and the association between eligibility and baseline characteristics. Methods The OPTIMA-HF (Optimization of Therapy in the Italian Management of Heart Failure) registry included outpatients in Italy with chronic HFrEF receiving at least 1 oral medication for management of HF. Patients were characterized by baseline use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB)/ARNI, beta-blocker, mineralocorticoid receptor antagonist (MRA) and sodium glucose co-transporter II inhibitor (SGLT2i). Patient-level factors associated with medication use were examined. Results Outpatients with HFrEF from 29 ambulatory cardiology practices and university hospitals in the OPTIMA-HF registry recruited between January 2022 and September 2023 were included. Of 1291 patients, 1018 (79%) met the PARADIGM-HF criteria and 949 of them (93%) were on ARNi. Of the enrolled patients, 342 (27%) were not on ARNi, however only 129 (38%) did not met the PARADIGM-HF inclusion criteria for ARNi prescription. Reasons for not meeting PARADIGM-HF criteria were no beta-blocker background therapy (22%), hyperkalemia (4%), hypotension (15%), chronic kidney disease (65%) and hyperkalemia (79%). In a logistic regression model not being on ARNi was associated with older age, chronic kidney disease, not being on cardiac resynchronization therapy, lower systolic blood pressure, lower BMI, and higher PAPs (Figure), representing the picture of a more fragile patient net of compliance with the PARADIGM-HF criteria. Conclusions Among outpatients with HFrEF in the OPTIMA-HF Registry, 79% met the PARADIGM-HF criteria. Strategies to improve guideline-directed use of HFrEF medications remain urgently needed, and these findings may inform targeted approaches to optimize outpatient medical therapy.

Guideline-directed medical therapy patterns in heart failure with reduced ejection fraction: the OPTIMA-HF registry

Abstract Background/Introduction European guidelines strongly recommend an optimized pharmacological treatment in patients with heart failure with reduced ejection fraction (HFrEF) with a fast introduction of the four-pillars. Purpose Aim of the Optimization of Therapy in the Italian Management of Heart Failure [OpTIMa-HF] Registry was to collect data on HF patients to describe the current Italian population of HF patients with a specific focus on HFrEF treatment adherence and prescription rates, according to the most recent European Guidelines. Methods OPTIMA-HF is an observational, cross-sectional, multicenter, real-life study conducted in two different clinical settings: HF outpatients’ clinics of Italian University Hospitals and territorial Italian Cardiology outpatients’ services, that enrolled patients with chronic HFrEF receiving at least 1 oral medication for management of HF. Patients were characterized by baseline use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNI), beta-blocker, mineralocorticoid receptor antagonist (MRA) and sodium glucose co-transporter II inhibitor (SGLT2i). Patient-level factors associated with medication use were examined. Results Overall, 1390 patients from 29 ambulatory cardiology practices and university hospitals were included. Mean age was 69.5 ± 11.9 years, 24% were female, and median EF was 33 (28-37). Among enrolled patients, 72.2% were prescribed ARNI, 17.1% ACEI/ARB, 95% beta-blocker, 75.5% MRA and 63% SGLT2i therapy (Figure 1). Despite high prescription rates for each single class, a still not sufficient number of patients was on treatment with all four pillars, in particular 40.4% considering the presence ARNI and 6.2%. When medications were prescribed, few patients were receiving target doses of ACEI/ARB (31.7%), ARNI (16%), and beta-blocker (33.3%), whereas a higher proportion were receiving target doses of MRA therapy (38%), and all were receiving target dose for SGLT2i. Among patients eligible for all classes of medication, only 1.1% were simultaneously receiving target doses of ACE/ARB/ARNI, beta-blocker, MRA and SGLT2i. Prescription rates did not significantly differ between the type of center (University Hospital vs. territorial Cardiology outpatients’ services). As regards patients not on treatment with any of the four pillars, a small but still present amount of patients had no contraindications to these drugs (Figure 1). Conclusions In this contemporary outpatient HFrEF Italian registry, significant high prescription rates of the four-pillars were observed, however therapy combination rate is still not sufficient and drugs' titration need to be implemented to receive the greatest benefits from an optimized treatment. Strategies to improve guideline-directed use of HFrEF medications remain urgently needed, and these findings may inform targeted approaches to optimize outpatient medical therapy.

Ambulatory Cardiology or General Internal Medicine Assessment Prior to Scheduled Major Vascular Surgery is Associated with Improved Outcomes.

To characterize the association between ambulatory cardiology or general internal medicine (GIM) assessment prior to surgery and outcomes following scheduled major vascular surgery. Cardiovascular risk assessment and management prior to high-risk surgery remains an evolving area of care. This is population-based retrospective cohort study of all adults who underwent scheduled major vascular surgery in Ontario, Canada, April 1, 2004-March 31, 2019. Patients who had an ambulatory cardiology and/or GIM assessment within 6 months prior to surgery were compared to those who did not. The primary outcome was 30-day mortality. Secondary outcomes included: composite of 30-day mortality, myocardial infarction or stroke; 30-day cardiovascular death; 1-year mortality; composite of 1-year mortality, myocardial infarction or stroke; and 1-year cardiovascular death. Cox proportional hazard regression using inverse probability of treatment weighting (IPTW) was used to mitigate confounding by indication. Among 50,228 patients, 20,484 (40.8%) underwent an ambulatory assessment prior to surgery: 11,074 (54.1%) with cardiology, 8,071 (39.4%) with GIM and 1,339 (6.5%) with both. Compared to patients who did not, those who underwent an assessment had a higher Revised Cardiac Risk Index (N with Index over 2= 4,989[24.4%] vs. 4,587[15.4%], P<0.001) and more frequent pre-operative cardiac testing (N=7,772[37.9%] vs. 6,113[20.6%], P<0.001) but, lower 30-day mortality (N=551[2.7%] vs. 970[3.3%], P<0.001). After application of IPTW, cardiology or GIM assessment prior to surgery remained associated with a lower 30-day mortality (weighted Hazard Ratio [95%CI] = 0.73 [0.65-0.82]) and a lower rate of all secondary outcomes. Major vascular surgery patients assessed by a cardiology or GIM physician prior to surgery have better outcomes than those who are not. Further research is needed to better understand potential mechanisms of benefit.

CONTROL RATE OF THE OFFICE BLOOD PRESSURE AND ECHOCARDIOGRAPHIC DATA FOR TARGET ORGAN DAMAGE IN ONE AMBULATORY CARDIOLOGICAL PRACTICE IN BULGARIA

Objective: After the COVID 19 pandemic, the regular examinations of the patients with arterial hypertension were restarted in the ambulatory cardiological practice. 297 visits were done in one such outpatient clinic in the city center of Sofia, Bulgaria during the first 9 month of 2023. The aim of or study was to estimate the control rate of the office blood pressure and the hypertension mediated target organ damage, evaluated with echocardiography. Design and method: The patients were with mean age 62 years/18-87/.193 were women and 106 men. They were examined by cardiologist, an ECG was performed, and their office blood pressure was measured according to the ESH recommendations.Only 25 patients underwent 24 hours ABPM. According to the regulations of the National Health Care Fund, the patients with arterial hypertension should be referred for echocardiography every 2 years, so we analyzed the results, entered in their medical records. Results: 52% of the subjects were with good control of the office blood pressure/below 140/90 mm Hg/ and this percentage is comparable with the results from the recent real world data trails in Bulgaria. 71% of them fulfill the criteria for grade 1 diastolic dysfunction with E/A less than 1. 64% of the patients were with left ventricular hypertrophy, defined as left ventricular wall thickness greater than 11 mm. And 64% of them had LA diameter greater than 40 mm. Conclusions: Despite of the decent control of the office blood pressure almost 2/3 of the patients had data for hypertension mediated target organ damage from their routine echocardiography. This may be a result of the delay of the initiation of the therapy or more probably of the insufficient time under control That is why we must strongly encourage wider implementation of ABPM and home BP monitoring in ambulatory cardiology practice in Bulgaria.

Enhanced Safety and Efficiency of Ambulatory Cardiology Admissions: A Quality Improvement Initiative.

Pediatric cardiac patients have experienced evolving illnesses progressing to instability while awaiting inpatient admission from ambulatory settings. Admission delays and communication breakdowns increase the risk for tenuous patients. This quality improvement initiative aimed to improve safety and efficiency for patients admitted from an ambulatory Clinic to the Acute Cardiac Care Unit (ACCU) using standardized communication and admission processes within one year. An admission process map, in-clinic nurse monitoring, and communication pathways were developed and implemented. A standardized team handoff occurred via virtual huddle using illness severity, patient summary, action list, situational awareness, and synthesis. Escalation of care events and timeliness were compared pre- and postimplementation. There was a reduction of transfers to the intensive care unit within 24 hours of ACCU admission from 9.2% to 3.8% (P = 0.26), intensive care unit evaluations (without transfer) from 5.6% to 0% (P = 0.06), and arrests from 3.7% to 0% (P = 0.16). After the pilot, clinic nurses monitored 100% of at-risk patients. Overall mean time from admission decision to virtual huddle decreased from 81 to 61 minutes and mean time to admission from 144 to 115 minutes, with 41% (n = 33) arriving ≤ 60 minutes (goal). The COVID-19 pandemic negatively affected admission timeliness while safety metrics remained optimized. Implementing a standardized admission process between the Clinic and ACCU enhanced safety by reducing admission wait time and escalation of care post-admission. Sustainable, reliable handoff processes, in-clinic monitoring, and standardized admission processes were established. The pandemic hindered admission efficiency without compromising safety.

Increasing rates of screening and treatment of iron deficiency in ambulatory patients with heart failure with reduced ejection fraction: a quality improvement cohort study

IntroductionIron deficiency anaemia (IDA) is common in patients with heart failure (HF) and is associated with advanced HF and increased mortality. Intravenous iron supplementation increases exercise tolerance, improves quality of...

Abstract 12485: Cardiovascular Disease Risk, Cognitive Function, and Serum Biomarkers in Older Women Participating in a Lifestyle Intervention

Background: Cardiovascular disease (CVD), including atherosclerotic CVD (ASCVD) and stroke, increase risk of cognitive dysfunction. Serum biomarkers, including brain-derived neurotrophic factor (BDNF), vascular endothelial growth factor (VEGF), and insulin-like growth factor 1 (IGF-1) may be associated with elevated CVD risk and are also emerging as early indicators of cognitive dysfunction. Yet, few studies have investigated associations among all three: CVD risk, cognitive function, and serum biomarkers. Aims: We examined associations between CVD risk, cognitive function, and serum biomarkers in older women with CVD. Methods: Baseline data from an ongoing lifestyle intervention trial for the prevention of cognitive decline in older women with CVD (NCT04556305) were analyzed. Women ( N =253) aged ≥65 years were recruited from ambulatory cardiology clinics. At baseline, CVD risk factors, including blood pressure, body mass index (BMI), waist circumference, and step test (cardiorespiratory fitness) were assessed. ASCVD and CHA 2 DS 2 -VASc scores were calculated to estimate clinical ASCVD and stroke risk, respectively. Serum biomarkers included BDNF, VEGF, and IGF-1. Neurocognitive tests for global cognition, including episodic memory, executive function, semantic memory, and working memory domains, were administered. Linear regression models adjusted for age, education, and race or ethnicity were used to evaluate associations of individual CVD risk factors, ASCVD and CHA 2 DS 2 -VASc scores with cognitive function and serum biomarkers, separately. Results: Of CVD risk factors, waist circumference and BMI were associated with cognition: waist circumference with global cognition, episodic memory, and executive function ( β = -.14 - -.20); BMI with executive function ( β = -.13). ASCVD and CHA2DS2-VASc scores were associated with semantic memory ( β = -.23 and -.16, respectively). Only the ASCVD risk score was associated with BDNF ( β = .18) and VEGF ( β = .24) levels. Conclusion: In older women with CVD, body composition and CVD risk scores appear to be correlated with cognitive function. Future studies should explore associations prospectively and consider serum biomarkers as mediators of the relation of CVD risk to cognitive dysfunction.

Abstract 13006: Telemedicine Disparities in Ambulatory Cardiology Patients in a Large Academic Health System

Introduction: Although the COVID-19 pandemic prompted rapid expansion of telemedicine, the effect of system-wide digital health strategies on vulnerable populations remains to be understood. Given video visits offer several advantages over audio-only visits, telemedicine encounters are typically preferentially scheduled as video visits; however, access complexities may lead to audio-only encounters and exacerbate the digital divide. Aim: We aimed to identify sociodemographic characteristics associated with telemedicine visit modality in the outpatient cardiology population in a large academic health center. Methods: We assessed all outpatient cardiology telemedicine visits from 1/1/2020-12/31/2021 via the Johns Hopkins Telemedicine Equity Dashboard, which sources its data from the electronic medical record. Our primary outcome was visit modality, with an adverse outcome defined as video-to-audio visit conversion. The first telemedicine encounter for each unique patient was included (accounting for 85% of all telemedicine encounters during study period). We assessed predictors of video-to-audio visit conversion using simple and multivariate logistic regression with relevant pre-determined sociodemographic variables (see Figure ). Results: There were 47,961 total telemedicine encounters, spread between 39,381 unique patients. Odds of conversion from video to audio-only visit increased with age, with the highest odds of conversion to audio-only visit in patients age 75+. Non-White race, Medicaid, Medicare and self-pay insurance status, and higher social deprivation index (SDI) quintile were also associated with increased odds of audio-only modality. Conclusion: Current telemedicine strategies would benefit from further analysis and targeted intervention to develop a more equitable digital care delivery system, particularly for patients that are older, non-White, do not have private insurance, and live in areas with higher SDI.

Abstract 18874: Beyond the Beat: Predicting Frailty in Cardiovascular Patients Using Heart Rate Variability

Introduction: Frailty is the increased vulnerability to health issues due to age-related changes in body composition, mobility, and autonomic control. Heart rate variability (HRV) measures the oscillations between consecutive heartbeats. The LF/HF (low frequency/high frequency) ratio, a parameter of HRV, reflects the complex balance between sympathetic and parasympathetic control and cardiac autonomic regulation. Previous studies have linked the LF/HF ratio with frailty. Our goal was to determine if this association holds true in patients with cardiovascular disease (CVD) and if the LF/HF ratio can be used as a surrogate marker of frailty in these patients. Methods: A cross-sectional study was conducted at McGill University's Jewish General Hospital, involving adult patients at the ambulatory cardiology clinic. Resting HRV was evaluated for 2 minutes and 30 seconds using the Elite HRV CorSense monitor. Patients with electrical pacing, atrial fibrillation, or other arrhythmias during the visit were excluded. Frailty was assessed using the clinical frailty scale (CFS), with a CFS ≥ 5 indicating frailty. Routine comprehensive history and physical examinations were performed. Results: The cohort included 155 patients (66.9 ± 13 years, 68 females). Frailty prevalence was 15% (78.6 ± 10 years, 12 females), with a median LF/HF ratio of 0.37. The non-frail population (64.8 ± 12 years, 56 females) showed a significantly higher LF/HF ratio of 1.01 (p&lt;0.001). This difference was driven by a decrease in LF power in the frail group (78.3 ms 2 ) compared to the non-frail group (231.9 ms 2 , p=0.01). The LF/HF ratio correlated with frailty, decreasing by 0.437 for each unit increase in CFS (p&lt;0.001). An LF/HF ratio of 0.37 best predicted frailty (54% sensitivity, 82% specificity, 0.77 ROC). Adjustment for age, sex, and comorbidities did not alter the association between LF/HF ratio and frailty. Conclusions: The LF/HF ratio exhibits an inverse correlation with frailty, making it a predictive tool for identifying CVD patients who may benefit from further frailty evaluation. Additionally, HRV parameters show potential for monitoring frailty and guiding interventions. However, additional research is needed to assess their practical implementation fully.

Abstract 12575: Diagnoses Associated With Telemedicine Use in Cardiology Clinics During the COVID-19 Pandemic

Introduction: The COVID-19 pandemic led to widespread adoption of telemedicine, which has persisted in healthcare delivery. We aimed to characterize telemedicine use in ambulatory cardiology clinics over 2 years following onset of the COVID-19 pandemic. Question: What diagnoses are associated with telemedicine use in cardiology appointments? Methods: In this retrospective cohort study, demographic and encounter data of all cardiology clinic and telemedicine visits in the University of California Los Angeles (UCLA) Health System from 3/16/2020 to 6/27/2022 were obtained. Encounters were included if they were conducted by physicians, complete with ICD-10 codes, and not missing demographic data. Mixed effects logistic regression was used to model the association of diagnosis class (based on ICD-10 codes) with whether encounter was scheduled as telemedicine, adjusting for age, sex, race, ethnicity, social vulnerability index, date, and zip code. Results: The analysis included 72,878 patients (49.8% women, age 61.5 ± 17.2 years, 57.2% white, 12.5% Hispanic, 82.6% with zip code in a UCLA Health service area) over 248,373 encounters. Each patient had a median of 2 encounters (range 1-82). Of all encounters, 27,894 (11.2%) were scheduled as telemedicine. Telemedicine was more likely used in management of chronic conditions, especially metabolic disorders (adjusted OR [aOR] 2.26, 95% CI 2.10-2.44) and cardiomyopathies (aOR 2.10, 95% CI 1.93-2.28), than for evaluation of undifferentiated signs/symptoms. Telemedicine was less likely used for general exam/screening (aOR 0.52, 95% CI 0.46-0.58) and heart transplant (aOR 0.51, 95% CI 0.50-0.64; Table ). Conclusion: In this study, the most established use case for telemedicine in cardiology was care of chronic cardiac diagnoses among non-transplant patients. Ongoing maintenance of chronic cardiovascular conditions through telemedicine may be a sustainable healthcare delivery model post COVID-19 pandemic.

Deep Learning–Enabled Assessment of Left Heart Structure and Function Predicts Cardiovascular Outcomes

BackgroundDeep learning interpretation of echocardiographic images may facilitate automated assessment of cardiac structure and function. ObjectivesWe developed a deep learning model to interpret echocardiograms and examined the association of deep learning–derived echocardiographic measures with incident outcomes. MethodsWe trained and validated a 3-dimensional convolutional neural network model for echocardiographic view classification and quantification of left atrial dimension, left ventricular wall thickness, chamber diameter, and ejection fraction. The training sample comprised 64,028 echocardiograms (n = 27,135) from a retrospective multi-institutional ambulatory cardiology electronic health record sample. Validation was performed in a separate longitudinal primary care sample and an external health care system data set. Cox models evaluated the association of model-derived left heart measures with incident outcomes. ResultsDeep learning discriminated echocardiographic views (area under the receiver operating curve >0.97 for parasternal long axis, apical 4-chamber, and apical 2-chamber views vs human expert annotation) and quantified standard left heart measures (R2 range = 0.53 to 0.91 vs study report values). Model performance was similar in 2 external validation samples. Model-derived left heart measures predicted incident heart failure, atrial fibrillation, myocardial infarction, and death. A 1-SD lower model-left ventricular ejection fraction was associated with 43% greater risk of heart failure (HR: 1.43; 95% CI: 1.23-1.66) and 17% greater risk of death (HR: 1.17; 95% CI: 1.06-1.30). Similar results were observed for other model-derived left heart measures. ConclusionsDeep learning echocardiographic interpretation accurately quantified standard measures of left heart structure and function, which in turn were associated with future clinical outcomes. Deep learning may enable automated echocardiogram interpretation and disease prediction at scale.

Cardiology Encounters for Underrepresented Racial and Ethnic Groups with Human Immunodeficiency Virus and Borderline Cardiovascular Disease Risk.

Underrepresented racial and ethnic groups (UREGs) with HIV have a higher risk of cardiovascular disease (CVD) compared with the general population. Referral to a cardiovascular specialist improves CVD risk factor management in high-risk individuals. However, patient and provider factors impacting the likelihood of UREGs with HIV to have an encounter with a cardiologist are unknown. We evaluated a cohort of UREGs with HIV and borderline CVD risk (10-year risk ≥ 5% by the pooled cohort equations or ≥ 7.5% by Framingham risk score). Participants received HIV-related care from 2014-2020 at four academic medical centers in the United States (U.S.). Adjusted Cox proportional hazards regression was used to estimate the association of patient and provider characteristics with time to first ambulatory cardiology encounter. A total of 2,039 people with HIV (PWH) and borderline CVD risk were identified. The median age was 45years (IQR: 36-50); 52% were female; and 94% were Black. Of these participants, 283 (14%) had an ambulatory visit with a cardiologist (17% of women vs. 11% of men, p < .001). In fully adjusted models, older age, higher body mass index (BMI), atrial fibrillation, multimorbidity, urban residence, and no recent insurance were associated with a greater likelihood of an encounter with a cardiologist. In UREGs with HIV and borderline CVD risk, the strongest determinants of a cardiology encounter were diagnosed CVD, insurance type, and urban residence. Future research is needed to determine the extent to which these encounters impact CVD care practices and outcomes in this population. ClinicalTrials.gov Identifier: NCT04025125.

Clinical Outcomes of Telehealth in Patients With Coronary Artery Disease and Heart Failure During the COVID-19 Pandemic

The COVID-19 pandemic necessitated a rapid adoption of telehealth (TH); however, its safety in subspecialty clinical practice remains uncertain. To assess the clinical outcomes associated with TH use in patients with coronary artery disease and/or heart failure during the initial phase of the COVID-19 pandemic, eligible adult patients who saw cardiologists from March 1, 2020, to August 31, 2020 (TH period) were identified. Patients were divided into two 3-month subcohorts (TH1, TH2) and compared with corresponding 2019 prepandemic subcohorts. The primary outcome was cardiovascular (CV) events within 3 months after index visits. Secondary analysis was CV events in patients aged ≥75 years within 3-month follow-up associated with TH use. Multivariable logistic regression was used to evaluate the association between TH use and CV outcomes. The study cohort included 6,485 TH and 7,557 prepandemic patients. The mean age was 70 years, with 40% of patients aged ≥75 years and 35% women. TH visits accounted for 0% of visits during the prepandemic period, compared with 68% during the TH period. Telephone visits comprised ≥92% of all TH encounters. Compared with the prepandemic period, patients seen during the TH period had fewer overall CV events (adjusted odds ratio 0.78, 95% confidence interval 0.67 to 0.90). Patients aged ≥75 years had similar findings (adjusted odds ratio 0.70, 95% confidence interval 0.55 to 0.89). Additional analysis of CV outcome events within 6 months after index visits showed similar findings. In conclusion, TH largely by way of telephone encounters can be safely incorporated into the ambulatory cardiology practice regardless of age.

Abstract 12353: Clinical Outcomes of Telehealth in Coronary Artery Disease and Heart Failure Patients During Covid-19 Pandemic

Introduction: The COVID-19 pandemic necessitated a rapid adoption of telehealth (TH). Few studies have assessed the safety of TH in subspecialty clinical practice. This study aimed to assess the clinical outcomes of TH use in patients with coronary artery disease (CAD) and/or heart failure (HF) during the initial phase of the COVID-19 pandemic as care delivery model shifted. Methods: This retrospective cohort study assessed continuously enrolled members in an integrated healthcare delivery system in the United States. Adult patients with CAD and/or HF with outpatient cardiology encounters from 3/1/2020 to 8/31/2020 (TH period) were identified via EHR using ICD-10 codes. Accounting for the dynamic shift in the proportion of TH use, patients were divided into two 3-month sub-cohorts (March-May, June-August) and compared with corresponding periods in 2019 (pre-pandemic period). The primary endpoint was outcome events including ED visits and hospitalization for any cardiovascular (CV) cause within 3 months follow-up. The secondary endpoint was cardiovascular events over 6 months of follow-up. Multivariable logistic regression was used to evaluate the association between TH use and CV outcomes. Results: The study cohort included 6485 patients with outpatient cardiology encounters during the TH period and 7557 patients during the pre-pandemic period. The mean age was 70 years, with 40% of patients being aged ≥ 75 and 35% being female. TH visits accounted for 0% of visits during the pre-pandemic period, compared to 68% during the TH period. Telephone visits comprised ≥ 92% of all TH encounters. Compared to the pre-pandemic period, patients seen during the TH period had fewer CV events 3 months after the index visits (aOR 0.77, 95%CI 0.66-0.89) and 6 months after the index visits (aOR 0.78, 95%CI 0.69-0.87). Subgroup analysis evaluating patients aged ≥75 showed similar findings. Conclusions: TH particularly via telephone visits accounted for a large share of ambulatory cardiology encounters during the initial phase of the COVID-19 pandemic. No increase in CV events was detected with the use of TH, suggesting that TH can be safely incorporated into ambulatory cardiology practice.

Abstract 12636: Association Between Pre-Operative Specialist Assessment and Adverse Outcomes Among Patients Scheduled for Major Vascular Surgery

Background: The impact of pre-operative specialist assessment on outcomes following high-risk vascular surgery remains uncertain. Our objective was to characterize the association between pre-operative cardiology or general internal medicine (GIM) assessment and post-operative outcomes following scheduled major vascular surgery. Methods: This is a population-based cohort study of all adult scheduled major vascular surgery patients in Ontario, Canada (April 1, 2004-March 31, 2019). Those who underwent an ambulatory cardiology and/or GIM assessment within 6 months prior to surgery were compared to those who did not. The primary outcome was 30-day mortality. Secondary outcomes included 30-day mortality, myocardial infarction or stroke; 30-day cardiovascular death; 1-year mortality; 1-year mortality, myocardial infarction or stroke; and 1-year cardiovascular death. Multivariable cox proportional hazard regression using inverse probability of treatment weighting (IPTW) was used to mitigate confounding by indication. Results: Among 50,228 scheduled major vascular surgery patients, 20,484 underwent pre-operative ambulatory specialist assessment: 11,074 (54.1%) with cardiology, 8,071 (39.4%) with GIM and 1,339 (6.5%) with both. Patients who underwent cardiology or GIM assessment had a higher Revised Cardiac Risk Index (N with Index over 2= 4,989 [24.4%] vs. 4,587 [15.4%], p&lt;0.001) and more frequent pre-operative cardiac testing (N=7,772 [37.9%] vs. 6,113 [20.6%], p&lt;0.001) but had lower crude 30-day mortality (N=551 [2.7%] vs. 970 [3.3%], p&lt;0.001). After application of IPTW, pre-operative specialist assessment remained associated with a lower rate of 30-day mortality (Hazard Ratio [95%CI] = 0.73 [0.65-0.82]) and a lower rate of all secondary outcomes (Figure). Conclusion: Pre-operative ambulatory cardiology or GIM assessment is associated with improved outcomes following scheduled major vascular surgery

Characteristics Associated with Burnout among Cardiologists in an Academic Medical Setting: Baseline Survey Results from a Communication Coaching RCT.

Objectives: Clinician burnout poses risks not just to clinicians but also to patients and the health system. Cardiologists might be especially prone to burnout due to performing high-risk procedures, having to discuss serious news, and treating diseases that incur significant morbidity and mortality. Few have attempted to examine which cardiologists might be at higher risk of burnout. Knowing at-risk cardiologists can help frame resilience interventions. Methods: We enrolled 41 cardiologists across five ambulatory cardiology clinics into a randomized controlled trial where we assessed the Maslach Burnout Inventory at baseline. We used bivariate analyses to assess associations between cardiologist demographics and burnout. Results: Cardiologists reported low burnout for depersonalization and personal accomplishment and moderate levels for emotional exhaustion. Female cardiologists reported emotional exhaustion scores in the “low” range (M = 12.3; SD = 10.06), compared to male cardiologists whose score was in the “moderate” range 19.6 (SD = 9.59; p = 0.113). Cardiologists who had greater than 15 years in practice reported higher mean scores of emotional exhaustion, indicating moderate burnout (M = 20.0, SD = 10.63), compared to those with less than 15 years in practice (M = 16.6, SD = 9.10; p = 0.271). Conclusions: In this sample, unlike prior studies, male cardiologists reported more burnout. Consistent with prior work, mid-level cardiologists might be at highest risk of emotional exhaustion.

Primary palliative care for heart failure provided within ambulatory cardiology: A randomized pilot trial

BackgroundHeart failure is characterized by physical and emotional symptoms and decreased quality of life (QoL). Palliative care can reduce burdens of serious illness but often is limited to inpatient or academic settings. ObjectivesTo develop and test the Primary Education for Nurses in Palliative care-HF (PENPal-HF) intervention, training outpatient cardiology nurses to address symptom burden, patient priorities for care and QoL, and advance care planning as part of quarterly HF visits. MethodsWe conducted a pilot randomized clinical trial for adults with NYHA Stage III or IV HF and ≥ 2 hospitalizations in the past 12 months, recruited from a community-based cardiology clinic. Participants were randomized 2:1, PENPal-HF plus usual care versus usual care alone. Primary outcomes were feasibility and acceptability. ResultsWe randomized 30 adults with Stage III HF – 20 to PENPal-HF and 10 to usual care. Most in the intervention group (71%) and in the control group (62%) completed the study through the final outcome assessment in week 56; 5 participants died. Of 20 participants in the intervention, 14 (70%) remained in the study through the end of intervention visits; 11 (55%) completed all visits. Most intervention participants (93.75%) agreed or strongly agreed that they were satisfied with their care, and 87.5% agreed or strongly agreed that all people with HF should receive the intervention. Most intervention group participants (93.75%) reported a perceived improvement in physical symptoms, mood, and/or QoL. ConclusionsThis pilot study suggests that nurse-led primary palliative care in outpatient cardiology settings is promising. Research is warranted to determine efficacy and effectiveness.

Proposal for an Ambulatory Heart Failure Management Curriculum for Cardiology Residency Training Programs

BackgroundThe suboptimal implementation of guideline-directed medical therapy (GDMT) for heart failure (HF) patients has been linked with poor clinical outcomes. Little is known about the potential role of cardiology residency training programs in improving trainees’ (ie, future cardiologists’) ability to utilize GDMT. MethodsIn this survey-based study, we examined the degree of exposure to ambulatory HF patient management among cardiology trainees in Canada. All cardiology residency program directors (n = 15; 100% response rate) completed our survey. ResultsAlthough 9 programs (60%) mandated ≥ 3 ambulatory cardiology rotations, only 3 (20%) required ≥ 2 ambulatory HF rotations. When HF rotations were provided, only 7 programs (47%) offered moderate or higher exposure to ambulatory nontransplant HF patients (defined as ≥ 5 clinics/rotations). This element was independent of program- and institution-specific characteristics. All institutions had a multidisciplinary HF clinic, and the majority (13 [87%]) had access to an inpatient HF service, a consultative HF service, and/or a specialist pharmacist. Furthermore, 13 program directors (87%) agreed on the importance of adopting HF training curriculum and their program’s readiness to implement such a module. ConclusionsThe current state of HF training among cardiology residencies is suboptimal and in need of improvement. Most programs have access to a HF clinic, a specialist pharmacist, or an inpatient consultative service, which would facilitate adoption of a HF management curriculum that focuses on practical and experiential aspects of GDMT optimization. This program, which is under development, will be offered to training programs nationwide, to enable trainees to manage this growing and increasingly complex patient population.

Echocardiographic determinants of ventricular arrhythmia in sickle cell disease

Unexplained sudden death remains a leading cause of death in sickle cell disease (SCD) adults. Ventricular arrhythmia is a well-known risk factor for sudden death but its prevalence and determinants in SCD remain understudied. The aim of this study was to identify echocardiographic predictors of ventricular arrhythmia in SCD. From January 2019 to March 2021, SCD adults referred to ambulatory cardiology department for possible cardiac involvement were prospectively included (Drepacoeur cohort). Patients that had 24-hours ECG monitoring (24 h-Holter) and thransthoracic echocardiography (TTE) on the same day were analysed. The primary end point was the occurrence of ventricular arrhythmia (sustained or non-sustained ventricular tachycardia (VT), more than 500 premature ventricular contractions (PVC) on 24 h-Holter, or history of VT ablation). Overall, 90 patients were included and 54 (60%) analysed. Mean age was 47.6 ± 11.6 years (range 21–69), 53% were male. Heart function was mainly preserved with a mean left ventricular ejection fraction (LVEF) of 57.9 ± 4.9% and a mean global longitudinal strain (GLS) of −18 ± 2.8%. Mean tricuspid regurgitation velocity was 2.6 ± 0.4 m/s. Ventricular arrhythmia was observed in 13 (24.1%) patients (4 non-sustained VT, 9 with more than 500 PVC and 1 history of VT ablation). Ventricular arrhythmia was associated with lower GLS (−15.8 ± 1.8% vs. −19 ± 2.7%, P < 0.001), lower tricuspid annular plane systolic excursion (TAPSE 23 ± 5.7 mm vs. 26.9 ± 4.6 mm, P = 0.02) and more dilated right ventricle assessed by tricuspid annulus diameter (38.2 ± 6.1 mm vs. 34.2 ± 4.5 mm, P = 0.02). In multivariate analysis, GLS was independently associated with ventricular arrhythmia (OR = 2.1, 95% CI [1,3; 3,3], P = 0.004) with a moderate exponential correlation with PVC load on 24 h-Holter (R = 0.5, P < 0.001). In SCD adults with preserved LVEF, GLS was the only independent echocardiographic predictor of ventricular arrhythmia.

Genetic testing in ambulatory cardiology clinics reveals high rate of findings with clinical management implications

Cardiovascular disease (CVD) is the leading cause of death in adults in the United States, yet the benefits of genetic testing are not universally accepted. We developed the "HeartCare" panel of genes associated with CVD, evaluating high-penetrance Mendelian conditions, coronary artery disease (CAD) polygenic risk, LPA gene polymorphisms, and specific pharmacogenetic (PGx) variants. We enrolled 709 individuals from cardiology clinics at Baylor College of Medicine, and samples were analyzed in a CAP/CLIA-certified laboratory. Results were returned to the ordering physician and uploaded to the electronic medical record. Notably, 32% of patients had a genetic finding with clinical management implications, even after excluding PGx results, including 9% who were molecularly diagnosed with a Mendelian condition. Among surveyed physicians, 84% reported medical management changes based on these results, including specialist referrals, cardiac tests, and medication changes. LPA polymorphisms and high polygenic risk of CAD were found in 20% and 9% of patients, respectively, leading to diet, lifestyle, and other changes. Warfarin and simvastatin pharmacogenetic variants were present in roughly half of the cohort. Our results support the use of genetic information in routine cardiovascular health management and provide a roadmap for accompanying research.