Ambulatory Cardiology Research Articles

Cardiologists' charting varied by risk factor, and was often discordant with patient report

Objective To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report. Study Design and Setting A total of 68 Ontario cardiologists and 789 of their ambulatory cardiology patients were randomly selected. Cardiac risk factor data were systematically extracted from medical charts, and a survey was mailed to participants to assess risk factor concordance. Results With regard to completeness of risk factor documentation, 90.4% of charts contained a report of hypertension, 87.2% of diabetes, 80.5% of dyslipidemia, 78.6% of smoking behavior, 73.0% of other comorbidities, 48.7% of family history of heart disease, and 45.9% of body mass index or obesity. Using Cohen's ĸ, there was a concordance of 87.7% between physician charts and patient self-report of diabetes, 69.5% for obesity, 56.8% for smoking status, 49% for hypertension, and 48.4% for family history. Conclusion Two of four major cardiac risk factors (hypertension and diabetes) were recorded in 90% of patient records; however, arguably the most important reversible risk factors for cardiac disease (dyslipidemia and smoking) were only reported 80% of the time. The results suggest that physician chart report may not be the criterion standard for quality assessment in cardiac risk factor reporting.

Acoustic Cardiography Augments Prolonged QRS Duration for Detecting Left Ventricular Dysfunction

Prolonged QRS duration has been used as a marker for left ventricular (LV) systolic dysfunction (SD) and is used in the evaluation of patients presenting with known or suspected heart failure. The goal of this study was to compare the abilities of QRS duration and simultaneous digital ECG and heart sounds, that is acoustic cardiographic, parameters to identify patients with LV dysfunction. Our learning population consisted of 171 patients with possible chronic compensated or mildly decompensated heart failure who presented to an ambulatory cardiology clinic for echocardiographic examination. We defined LVSD as a LV ejection fraction < 50%, and estimated LV filling pressures from diastolic measurements. These patients also had acoustic cardiographic recordings from which we obtained a variety of individual ECG and acoustic cardiographic parameters. We used the product of four of these parameters to obtain a diagnostic score for LV dysfunction. We then compared the diagnostic performances of QRS duration and the score on a test population of patients who presented to an emergency department with possible heart failure. In the learning population, the sensitivities/specificities of QRS duration > or =120 ms and the score for prediction of LVSD were 51%/92% and 77%/90%, respectively. In the test population, the score remained superior to QRS duration for detecting LVSD as well as acute decompensated heart failure. Improved identification of LVSD and clinical heart failure can be achieved with a cost-effective bedside screening tool with the simple combination of simultaneously acquired digital ECG and heart sound data.

Heart Attacks, Heart Rate, and Gel Electrodes: the invention of ambulatory cardiology

Ambulatory cardiology began in 1959 in a department of pathology to answer a question raised at the autopsy table: are high heart rates in apparently healthy individuals a risk factor for developing coronary artery disease? This question led to the development of a miniature monitor and a new kind of electrode, which enabled clinicians to measure EKG signals during activity and over prolonged periods of time. These electrodes are now used universally for diagnosis and for monitoring the heart during a myriad of different activities and circumstances. The story of the development of the monitor and electrodes illustrates the ways in which ideas and discovery lead to applications and advances in medicine.

High-Dose Atorvastatin vs Usual-Dose Simvastatin for Secondary Prevention After Myocardial Infarction&lt;SUBTITLE&gt;The IDEAL Study: A Randomized Controlled Trial&lt;/SUBTITLE&gt;

Evidence suggests that more intensive lowering of low-density lipoprotein cholesterol (LDL-C) than is commonly applied clinically will provide further benefit in stable coronary artery disease. To compare the effects of 2 strategies of lipid lowering on the risk of cardiovascular disease among patients with a previous myocardial infarction (MI). The IDEAL study, a prospective, randomized, open-label, blinded end-point evaluation trial conducted at 190 ambulatory cardiology care and specialist practices in northern Europe between March 1999 and March 2005 with a median follow-up of 4.8 years, which enrolled 8888 patients aged 80 years or younger with a history of acute MI. Patients were randomly assigned to receive a high dose of atorvastatin (80 mg/d; n = 4439), or usual-dose simvastatin (20 mg/d; n = 4449). Occurrence of a major coronary event, defined as coronary death, confirmed nonfatal acute MI, or cardiac arrest with resuscitation. During treatment, mean LDL-C levels were 104 (SE, 0.3) mg/dL in the simvastatin group and 81 (SE, 0.3) mg/dL in the atorvastatin group. A major coronary event occurred in 463 simvastatin patients (10.4%) and in 411 atorvastatin patients (9.3%) (hazard ratio [HR], 0.89; 95% CI, 0.78-1.01; P = .07). Nonfatal acute MI occurred in 321 (7.2%) and 267 (6.0%) in the 2 groups (HR, 0.83; 95% CI, 0.71-0.98; P = .02), but no differences were seen in the 2 other components of the primary end point. Major cardiovascular events occurred in 608 and 533 in the 2 groups, respectively (HR, 0.87; 95% CI, 0.77-0.98; P = .02). Occurrence of any coronary event was reported in 1059 simvastatin and 898 atorvastatin patients (HR, 0.84; 95% CI, 0.76-0.91; P<.001). Noncardiovascular death occurred in 156 (3.5%) and 143 (3.2%) in the 2 groups (HR, 0.92; 95% CI, 0.73-1.15; P = .47). Death from any cause occurred in 374 (8.4%) in the simvastatin group and 366 (8.2%) in the atorvastatin group (HR, 0.98; 95% CI, 0.85-1.13; P = .81). Patients in the atorvastatin group had higher rates of drug discontinuation due to nonserious adverse events; transaminase elevation resulted in 43 (1.0%) vs 5 (0.1%) withdrawals (P<.001). Serious myopathy and rhabdomyolysis were rare in both groups. In this study of patients with previous MI, intensive lowering of LDL-C did not result in a significant reduction in the primary outcome of major coronary events, but did reduce the risk of other composite secondary end points and nonfatal acute MI. There were no differences in cardiovascular or all-cause mortality. Patients with MI may benefit from intensive lowering of LDL-C without an increase in noncardiovascular mortality or other serious adverse reactions.Trial Registration ClinicalTrials.gov Identifier: NCT00159835.

ACC/AHA Key Data Elements and Definitions for Measuring the Clinical Management and Outcomes of Patients With Chronic Heart Failure

Table of Contents 1. Uses for HF Data Standards 1892 2. Balance Between Focus and Comprehensiveness 1893 3. Balance Between “Primary” and “Summary” Data Elements 1893 4. Variety of Disease States Leading to HF 1893 5. Acute and Chronic Care, Inpatient and Outpatient Care Venues 1893 6. Therapy for HF 1893 7. Outcomes Assessment for HF 1893 1. III. HF Clinical Data Standards Elements and Definitions 1893 The American College of Cardiology (ACC) and the American Heart Association (AHA) recognize …

Causal Effect of Ambulatory Specialty Care on Mortality Following Myocardial Infarction: A Comparison of Propensity Score and Instrumental Variable Analyses

The quality and outcomes of care provided by primary care physicians and specialists are increasingly important issues in health policy research. Estimating the effect of specialty care on patient outcomes however is complicated by the observational nature of the studies. Patients treated by specialists are often different in terms of observed and unobserved characteristics that can bias estimates of specialty effects. We illustrate and compare two different analytic approaches, propensity scores and instrumental variables, to infer the causal effect of cardiology care in the ambulatory setting on 18-month mortality among 5467 elderly patients who survived at least 3 months after being hospitalized for a myocardial infarction in New York state during 1994 and 1995. Using both approaches we found reductions in 18-month mortality associated with ambulatory cardiology care. However, reasonable deviations from the assumptions underlying each method led to estimated differences in mortality ranging from a 6% absolute reduction in mortality to a 2% increase among patients who received cardiology care. Choosing an analytic strategy depends on both available data and the policy question of interest. We believe that comparative analyses such as this one, with extensive assessment of the assumptions underlying each method, can provide valuable insights into important policy questions reliant on the analysis of observational data.

Variation in Patient Utilities for Outcomes of the Management of Chronic Stable Angina

Objective. —Although practice guidelines sometimes make recommendations based on symptom severity, they rarely account for how patients feel about their symptoms. To investigate the possible importance of patient preferences in treatment of ischemic heart disease, we assessed attitudes toward symptoms in patients with angina pectoris. Design. —Case series. Setting. —Ambulatory cardiology clinics at two tertiary care medical centers. Patients. —A total of 220 subjects were selected from 589 patients with chronic stable angina referred from cardiologists to achieve patient samples balanced for sex, race, and angina severity. Main Outcome Measures. —We measured patients' attitudes toward their angina using the rating scale, time trade-off, and standard gamble utility metrics. Reliability of measurements was evaluated by repeating the assessments 2 weeks later on 50 willing patients. Results. —While the mean responses followed the expected patterns (those with more severe Canadian Cardiovascular Society scores chose lower utilities), attitudes toward symptoms varied substantially among patients with similarly severe angina. For example, there was a 33% chance that a patient with class II angina had a time trade-off utility that was lower (ie, more bothered by symptoms) than a patient with more severe angina (class III/IV). This variation in utilities was not due to random error in the assessments. Conclusions. —Angina patients with similar functional limitation vary considerably in their tolerance for their symptoms, as measured by utilities. Our findings suggest that guidelines for the management of ischemic heart disease should be based on the preferences of the individual patient rather than on symptom severity alone. (JAMA. 1995;273:1185-1190)

Variation in patient utilities for outcomes of the management of chronic stable angina. Implications for clinical practice guidelines. Ischemic Heart Disease Patient Outcomes Research Team

Although practice guidelines sometimes make recommendations based on symptom severity, they rarely account for how patients feel about their symptoms. To investigate the possible importance of patient preferences in treatment of ischemic heart disease, we assessed attitudes toward symptoms in patients with angina pectoris. Case series. Ambulatory cardiology clinics at two tertiary care medical centers. A total of 220 subjects were selected from 589 patients with chronic stable angina referred from cardiologists to achieve patients samples balanced for sex, race, and angina severity. We measured patients' attitudes toward their angina using the rating scale, time trade-off, and standard gamble utility metrics. Reliability of measurements was evaluated by repeating the assessments 2 weeks later on 50 willing patients. While the mean responses followed the expected patterns (those with more severe Canadian Cardiovascular Society scores chose lower utilities), attitudes toward symptoms varied substantially among patients with similarly severe angina. For example, there was a 33% chance that a patient with class II angina had a time trade-off utility that was lower (ie, more bothered by symptoms) than a patient with more severe angina (class III/IV). This variation in utilities was not due to random error in the assessments. Angina patients with similar functional limitation vary considerably in their tolerance for their symptoms, as measured by utilities. Our findings suggest that guidelines for the management of ischemic heart disease should be based on the preferences of the individual patient rather than on symptom severity alone.

Using a Computer Database to Increase Efficiency in the Practice Setting

A computerized database is an invaluable tool for planning and managing patient care. The design and function of two databases for an ambulatory cardiology setting are discussed in this article. Information about patients with hyperlipidemia and with permanent pace-makers was entered into the custom-designed databases. The benefits of using computers for record keeping, such as improved organization and efficiency, are also addressed.

Panic Disorder in Cardiac Outpatients

The prevalence of and nature of panic disorder were investigated in an ambulatory cardiology practice. Questionnaires about panic symptoms were mailed to 414 patients, and possible or definite panic disorder was found in 104 of the 310 respondents. Interviews with 52 of the 104 patients substantiated diagnoses of panic disorder, for a prevalence of 9.2% of the total sample population of 414. Comparison of patients grouped by duration of panic disorder revealed that long-duration panic disorder had its onset before age 30 and followed a chronic course. Short-duration panic disorder developed at an older age following the appearance of cardiac disease.