Cardiology Community Research Articles

Translating the 2021 ESC heart failure guideline recommendations in daily practice: Results from a heart failure survey. A scientific statement of the ESC Council for Cardiology Practice and the Heart Failure Association of the ESC.

Real-world data show that guidelines are insufficiently implemented, and particularly guideline-directed medical therapies (GDMT) are underused in patients with heart failure and reduced ejection fraction (HFrEF) in clinical practice. The Council for Cardiology Practice and the Heart Failure Association of the European Society of Cardiology (ESC) developed a survey aiming to (i) evaluate the perspectives of the cardiology community on the 2021 ESC heart failure (HF) guidelines, (ii) pinpoint disparities in disease management, and (iii) propose strategies to enhance adherence to HF guidelines. A 22-question survey regarding the diagnosis and treatment of HFrEF was delivered between March and June 2022. Of 457 physicians, 54% were general cardiologists, 19.4% were HF specialists, 18.9% other cardiac specialists, and 7.7% non-cardiac specialists. For diagnosis, 52.1% employed echocardiography and natriuretic peptides (NPs), 33.2% primarily used echocardiography, and 14.7% predominantly relied on NPs. The first drug class initiated in HFrEF was angiotensin-converting enzyme inhibitors/angiotensin receptor-neprilysin inhibitor (ACEi/ARNi) (91.2%), beta-blockers (BB) (73.8%), mineralocorticoid receptor antagonists (MRAs) (53.4%), and sodium-glucose cotransporter 2 (SGLT2) inhibitors (48.1%). The combination ACEi/ARNi + MRA+ BB was preferred by 39.3% of physicians, ACEi/ARNi + SGLT2 inhibitors + BB by 33.3%, and ACEi/ARNi + BB by 22.2%. The time required to initiate and optimize GDMT was estimated to be <1 month by 8.3%, 1-3 months by 52%, 3-6 months by 31.8%, and >6 months by 7.9%. Compared to general cardiologists, HF specialists/academic cardiologists reported lower estimated time-to-initiation, and more commonly preferred a parallel initiation of GDMT rather than a sequential approach. Participants generally followed diagnostic and treatment guidelines, but variations in HFrEF management across care settings or HF specialties were noted. The survey may raise awareness and promote standardized HF care.

Surgical treatment of isolated tricuspid valve disease: indications, new evidence, and risk stratification

The tricuspid valve, long neglected as a passive structure and often termed the "forgotten valve", has recently gained attention from the international medical and cardiological community due to the association of tricuspid regurgitation with an unfavorable prognosis. Isolated tricuspid regurgitation represents a relatively unknown and variable condition, closely linked to the shape and function of the right ventricle and the state of the pulmonary circulation. Currently, guidelines are not clear regarding the optimal treatment strategy, the process of patient selection, and the surgical or transcatheter procedural timing, nor for predicting patient outcomes. Surgical procedures specifically aimed at correcting isolated tricuspid regurgitation, without other concomitant indications for open-heart surgery, have been considered complex and risky, with a high rate of postoperative complications and a poorly understood impact on patient survival and life expectancy. In this review, we will attempt to examine tricuspid valve pathology by analyzing preoperative assessment, essential for risk stratification, various surgical techniques, and outcomes.

Carotid Plaque Score is Associated with 10-year Major Adverse Cardiovascular Events in Low-Intermediate Risk Patients Referred to a General Cardiology Community Clinic.

Atherosclerotic carotid plaque assessments have not been integrated into routine clinical practice due to the time-consuming nature of both imaging and measurements. Plaque score, Rotterdam method, is simple, quick, and only requires 4-6 B-mode ultrasound images. The aim was to assess the benefit of plaque score in a community cardiology clinic to identify patients at risk for major adverse cardiovascular events (MACE). Patients ≥40 years presenting for risk assessment were given a carotid ultrasound. Exclusions included a history of vascular disease or MACE and being >75 years. Kaplan-Meier curves and hazard ratios were performed. The left and right common carotid artery (CCA), bulb, and internal carotid artery (ICA) were given 1 point per segment if plaque present (plaque score 0 to 6). Administrative data holdings at ICES were used for 10-year event follow-up. Of 8,472 patients, 60% were females (n = 5,121). Plaque was more prevalent in males (64% vs 53.9%; P <0.0001). The 10-year MACE cumulative incidence estimate was 6.37% with 276 events (males 6.9 % vs females 6.0%; P = 0.004). Having both maximal CCA IMT <1.00 mm and plaque score = 0, was associated with less events. A plaque score <2 was associated with a low 10-year event rate (4.1%) compared to 2-4 (8.7%) and 5-6 (20%). A plaque score ≥2 can re-stratify low-intermediate risk patients to a higher risk for events. Plaque score may be used as a quick assessment in a cardiology office to guide treatment management of patients.

STereotactic Arrhythmia Radioablation and its place in modern cardiac ElectroPhysiology: Results of an EHRA Survey

Abstract Background Stereotactic arrhythmia radioablation (STAR) is an emerging treatment option for recurrent ventricular tachycardia/fibrillation (VT/VF) in particular in structural heart disease (SHD). However, the current role and envisioned future role of STAR is in clinical practice as viewed by Cardiologists is unknown. Objective To assess the current role of STAR, barriers to its use, and expected future role, within the cardiology community. Methods An online survey was created with the support of the EHRA Scientific Initiatives committee and distributed via newsletters and social media. The survey consisted of 20 multiple-choice questions with a focus on baseline demographics, awareness / access, current use, and the future role of STAR. Results A total of 129 international participants completed the survey, mean age was 43±11 years, 25 (16.4%) were female. Ninety-one (59.9%) participants were cardiac electrophysiologists while 13 (8.6%) were general cardiologists. Nine participants (7%) were unaware of STAR as a therapeutic option. Sixty-four (49.6%) had access to STAR while 62 (48.1%) had treated / referred a patient for treatment. Median number of patients treated was 4 (range 1-100). Common primary indications for STAR were recurrent VT/VF in SDH (45%), recurrent VT/VF without SHD (7.8%) or PVC (3.9%). Based on their knowledge, 49% and 59% of survey participants responded they would consider performing / referring a patient for STAR, respectively. Reported main advantages of STAR were efficacy in the treatment of arrhythmias not amenable to conventional treatment (49%), non-invasive treatment approach with overall low expected acute and short-term procedural risk (23%) and possible higher efficacy than other available treatment options (23%). Survey respondents named one or more previous catheter ablations (CA) or contraindication for CA (79%), diagnosis of SHD (78%), recurrent monomorphic VT with &amp;gt;3 episodes within the preceding 3 months (68%), optimal antiarrhythmic medication (61%) or electrical storm (59%) as prerequisites for the use of STAR. Most respondents foresee a future clinical role for STAR in the treatment of VT/VF with or without underlying SHD (72% and 75%, respectively). Although, only a minority expected a first-line indication for it in with or without SHD (7% and 5%, respectively) and STAR was viewed rather as a bail-out option (48% and 35%, respectively). Conclusions STAR is a new option for the treatment of recurrent VT that appears to gain acceptance within the EP community. Randomized-controlled trials and an EHRA consensus document are critical to further define efficacy, patient populations, as well as the appropriate clinical use for the treatment of VT.Central figureFuture role of STAR

Advances in Clinical Cardiology 2023: A Summary of Key Clinical Trials.

Over the course of 2023, numerous key clinical trials with valuable contributions to clinical cardiology were published or presented at major international conferences. This review seeks to summarise these trials and reflect on their clinical context. The authors collated and reviewed clinical trials presented at major cardiology conferences during 2023 including the American College of Cardiology (ACC), European Association for Percutaneous Cardiovascular Interventions (EuroPCR), European Society of Cardiology (ESC), Transcatheter Cardiovascular Therapeutics (TCT), American Heart Association (AHA), European Heart Rhythm Association (EHRA), Society for Cardiovascular Angiography and Interventions (SCAI), TVT-The Heart Summit (TVT) and Cardiovascular Research Technologies (CRT). Trials with a broad relevance to the cardiology community and those with potential to change current practice were included. A total of 80 key cardiology clinical trials were identified for inclusion. Key trials in acute coronary syndrome (ACS) and antiplatelet management such as HOST-IDEA, T-PASS and STOP-DAPT3 were included in addition to several pivotal interventional trials such as ORBITA 2, MULTISTARS-AMI, ILUMIEN-IV, OCTIVUS and OCTOBER. Additionally, several trials evaluated new stent design and technology such as BIOSTEMI, PARTHENOPE and TRANSFORM. Structural intervention trials included long-term data from PARTNER 3, new data on the durability of transcatheter aortic valve intervention (TAVI), in addition to major new trials regarding transcatheter tricuspid valve intervention from TRISCEND II. Heart failure (HF) and prevention covered several key studies including DAPA-MI, STEP-HF, ADVOR, DICTATE HF and CAMEO-DAPA. In cardiac devices and electrophysiology, several trial exploring novel ablation strategies in atrial fibrillation (AF) such as PULSED AF and ADVENT were presented with further data evaluating the efficacy of anticoagulation in subclinical AF in NOAH-AFNET 6, FRAIL AF and AZALEA-TIMI 71. This article presents a summary of key clinical cardiology trials published and presented during the past year and should be of interest to both practising clinicians and researchers.

Review of international clinical guidelines for the management of hypertension in patients with diabetes mellitus?

Arterial hypertension (AH) is one of the leading problems of cardiological communities around the world. In patients with diabetes mellitus (DM), hypertension occurs 2 times more often than in the general population, being mutually aggravating diseases and leading risk factors for coronary heart disease, stroke, congestive heart failure and chronic kidney disease, which lead to disability and increased cardiovascular mortality. Various cardiological and endocrinological communities pay special attention to the management of hypertension in patients with DM, taking into account comorbidity. The present review examines modern approaches to the management of hypertension in DM patients based on current international clinical recommendations. Most of the current practical guidelines and clinical recommendations emphasize the need for early combined antihypertensive therapy for diabetes, which is due to the complex multifactorial pathogenesis and a more severe course of hypertension in disorders of carbohydrate metabolism. The main groups of antihypertensive drugs recommended for diabetes include: angiotensin converting enzyme inhibitors/angiotensin receptor blockers, thiazide/thiazide-like diuretics, calcium antagonists.

The IN-HF Registry: the history and the scientific production for the Italian cardiology community

The Italian Network on Congestive Heart Failure (IN-CHF) project, later known as IN-HF Online, was launched in 1995 to provide the Italian cardiology community with a digital tool, standardized across the country, for managing outpatients with heart failure (HF), that enabled the creation of a database for clinical, educational and scientific purposes. During its almost three decades of activity, this observational research program has achieved highly positive scientific results. Indeed, IN-HF fostered professional relationships among individuals working in different centers, established a cultural network for the care of HF patients, periodically updated on the scientific advances, and allowed the assessment of several clinical, epidemiological, and prognostic features. These findings have been published in numerous national and international journals, as summarized in the present overview.

Changes in hemodynamic parameters and atrial fibrillation risk in patients after permanent pacemaker implantation

Data on the development of left ventricular dysfunction after permanent pacemaker implantation are available. According to data from the DAVID (The Dual Chamber and VVI Implantable Defibrillator) study, it was shown that DDDR-paced patients had significantly more fatal events and HF deterioration cases requiring hospitalization. Similar were the results of the MOde Selection Trial (MOST), which poses serious questions to the cardiology community. For that reason it is important to understand how PPM implantation changes the hemodynamic parameters of the heart and what consequences this may have. On the one hand, asynchronous contraction of the paced heart and increase in AF risk with advancing age require active screening of asymptomatic paroxysms of tachyarrhythmias to promptly adjust therapy. On the other hand, minimizing the rate of ventricular pacing through proper programming of the devices should not be overlooked. Recently, various biomarkers have been validated to select high-risk patients in which the therapeutic strategy can be modulated on time.

Stereotactic arrhythmia radioablation and its implications for modern cardiac electrophysiology: results of an EHRA survey.

Stereotactic arrhythmia radioablation (STAR) is a treatment option for recurrent ventricular tachycardia/fibrillation (VT/VF) in patients with structural heart disease (SHD). The current and future role of STAR as viewed by cardiologists is unknown. The study aimed to assess the current role, barriers to application, and expected future role of STAR. An online survey consisting of 20 questions on baseline demographics, awareness/access, current use, and the future role of STAR was conducted. A total of 129 international participants completed the survey [mean age 43 ± 11 years, 25 (16.4%) female]. Ninety-one (59.9%) participants were electrophysiologists. Nine participants (7%) were unaware of STAR as a therapeutic option. Sixty-four (49.6%) had access to STAR, while 62 (48.1%) had treated/referred a patient for treatment. Common primary indications for STAR were recurrent VT/VF in SHD (45%), recurrent VT/VF without SHD (7.8%), or premature ventricular contraction (3.9%). Reported main advantages of STAR were efficacy in the treatment of arrhythmias not amenable to conventional treatment (49%) and non-invasive treatment approach with overall low expected acute and short-term procedural risk (23%). Most respondents have foreseen a future clinical role of STAR in the treatment of VT/VF with or without underlying SHD (72% and 75%, respectively), although only a minority expected a first-line indication for it (7% and 5%, respectively). Stereotactic arrhythmia radioablation as a novel treatment option of recurrent VT appears to gain acceptance within the cardiology community. Further trials are critical to further define efficacy, patient populations, as well as the appropriate clinical use for the treatment of VT.

Systematic Review of Literature Citing the ISCHEMIA Trial.

Optimal therapy for patients with chronic coronary artery disease (CCD) has long been a topic under investigation and a subject of debate. Seeking to clarify appropriate management, the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial compared medical management versus coronary angiography for patients with stable ischemic heart disease. Its reception in the medical community has been met with both acclaim and criticism. In light of such disparate views of this trial, a systematic review of the literature citing the ISCHEMIA trial was performed. All articles citing the ISCHEMIA trial on PubMed as of July 21, 2023, were compiled and underwent qualitative analysis. A total of 430 articles were evaluated; 109 (25.3%) did not offer substantial commentary on ISCHEMIA and cite it as background evidence for further study. Of the commentary articles, the majority (224, 52.1%) gave balanced, honest appraisals of the ISCHEMIA trial. A total of 46 (10.7%) strongly praised the trial while another 39 (9.1%) were strongly critical of the results. Almost three-quarters of the literature citing the ISCHEMIA trial was commentary in nature, with roughly equal distribution across the spectrum of praise and criticism. Despite being one of the largest studies on CCD and coronary revascularization ever conducted, the impact of ISCHEMIA on the cardiology community appears to be mixed.

Current frailty knowledge, awareness, and practices among physicians following the 2022 European consensus document on Frailty in Cardiology.

Aging-related cardiovascular disease and frailty burdens are anticipated to rise with global aging. In response to directions from major cardiovascular societies, we investigated frailty knowledge, awareness, and practices among cardiologists as key stakeholders in this emerging paradigm a year after the European Frailty in Cardiology consensus document was published. We launched a prospective multinational web-based survey via social networks to broad cardiology communities representing multiple World Health Organization regions, including Western Pacific and Southeast Asia regions. Overall, 578 respondents [38.2% female; ages 35-49 years (55.2%) and 50-64 years (34.4%)] across subspecialties, including interventionists (43.3%), general cardiologists (30.6%), and heart failure specialists (HFSs) (10.9%), were surveyed. Nearly half had read the consensus document (38.9%). Non-interventionists had better perceived knowledge of frailty assessment instruments (fully or vaguely aware, 57.2% vs. 45%, adj. P = 0.0002), exercise programmes (well aware, 12.9% vs. 6.0%, adj. P = 0.001), and engaged more in multidisciplinary team care (frequently or occasionally, 52.6% vs. 41%, adj. P = 0.002) than interventionists. Heart failure specialists more often addressed pre-procedural frailty (frequently or occasionally, 43.5% vs. 28.2%, P = 0.004) and polypharmacy (frequently or occasionally, 85.5% vs. 71%, adj. P = 0.014) and had consistently better composite knowledge (39.3% vs. 21.6%, adj. P = 0.001) and practice responses (21% vs. 11.1%, adj. P = 0.018) than non-HFSs. Respondents with better knowledge responses also had better frailty practices (40.3% vs. 3.6%, adj. P < 0.001). Distinct response differences suggest that future strategies strengthening frailty principles should address practices peculiar to subspecialties, such as pre-procedural frailty strategies for interventionists and rehabilitation interventions for HFSs.

ANMCO Position paper - 2023 ANMCO States General: Towards a modern Cardiological Community Care

Over the last two decades, cardiovascular diseases have become the leading cause of chronic disease morbidity and mortality in Italy. Therefore, the chronic cardiovascular care landscape has evolved rapidly in an era of unprecedented demand. Furthermore, the COVID-19 pandemic has highlighted significant deficiencies in existing health and social care systems, especially in the management of chronic cardiovascular disease. In this scenario, the National Reform for Recovery and Resilience (PNRR) may represent a unique opportunity for the development of a new integrated care system between hospital and community. The Italian Association of Hospital Cardiologists (ANMCO) recognizes the need for a statement on the integrated cardiological community care to guide health professionals caring for people with chronic cardiovascular conditions. The aim of the present statement is to outline the evidence for a modern integrated cardiological community care identifying challenges and offering advice for a future transdisciplinary and multi-organizational approach to ensure best practice in the management of chronic cardiovascular disease.

Chronic kidney disease and atrial fibrillation: approaches to the choice of antiarrhythmic therapy

In clinical practice, impaired renal function is often combined with cardiovascular diseases, in particular with atrial fibrillation. As you know, the kidneys perform many functions, including excretory, metabolic and endocrine. The cardiorenal axis is regulated in such a way that an imbalance results in both cardiac and renal remodeling. Therefore, the pathophysiological relationships between the kidneys and the heart are of great clinical importance. Considering the need to create the basis for personalized patient-oriented care, documents on the position of a number of associations and societies dedicated to the treatment of patients with atrial fibrillation and chronic kidney disease are currently presented. Treatment of atrial fibrillation includes prophylactic anticoagulation and pharmacological therapy aimed at maintaining sinus rhythm or correcting the frequency of ventricular responses. At the same time, when choosing the optimal dose of oral direct anticoagulant drugs, there are a number of discrepancies in published regulatory documents of various cardiological and nephrological communities. It should be noted that in recent years there has been no significant improvement in the clinical pharmacology of arrhythmias. Existing pharmacological approaches for the correction of arrhythmias in patients with atrial fibrillation and chronic kidney disease are limited by their limited effectiveness and the possibility of developing dangerous effects, including the proarrhythmic effect against ventricular arrhythmias and organ-toxic complications. The use of catheter and surgical ablation is inhibited by the complexity, cost and high relapse rate in patients with chronic kidney disease. It seems that antiarrhythmic drugs are not given enough attention compared to anticoagulant therapy, especially in patients with atrial fibrillation and chronic kidney disease. This review article discusses approaches to the choice of antiarrhythmic therapy in this category of patients.

A virtual heart failure ward in a rural demography

Abstract Background Lincolnshire is a large rural county in the UK with wide economic variation, social deprivation, poor communication infrastructure and no large urban centre of population. As a result of these factors we have a significant incidence of heart failure and a variation in access to services. As part of a county wide initiative to improve the care of patients with heart failure and to reduce acute reduce admissions to hospital we introduced a virtual heart failure ward in January 2022. The ward is overseen by the community cardiology heart failure specialist nurses and led by a cardiology Advanced Clinical Practitioner (ACP) - a multi-professional worker educated to Level 7 with the ability to prescribe and request procedures/ investigations. Governance is from the acute cardiology team via multi-disciplinary meetings. Patients who are decompensating that historically would have required admission can be 'admitted' to the ward and patients who have been admitted to the acute hospital can also be admitted/ stepped down to facilitate discharge. The ward is supported by a 7/7 (expanded from 5/7 to support the project) specialist nursing team, weekly ward rounds, telemedicine (multi-provider app), remote monitoring (oximetry/ weight/ BP), outpatient IV furosemide, specialist heart failure rehabilitation (F2F and remote) and supports a seamless service between primary, community and secondary care. Results In the first 13-months N=213 patients were treated via the virtual ward. N=137 (64%) 'step up, N=75 (35%) step down, N=1 (self-referral), see figure one. N=194 patients were discharged. N=25 (12%) were admitted for escalation of care, see figure two. In the first year, we estimate that the virtual ward released 1,147 acute bed days (1,033 admission prevention and 114 early discharge) and delivered a cost reduction of approximately to £1m. An external audit team has identified a 10% reduction in heart failure admissions to the acute hospital. PROMS (patient recorded outcome measures) show high patient satisfaction and staff have found the enhanced 7/7 service beneficial and rewarding. Discussion Our experience of implementing a virtual heart failure ward in a rural demography has been exceedingly positive. We have observed significant reductions in admissions, facilitated early discharged from hospital with high patient and staff satisfaction. this intervention has also delivered a substantial cost saving to the wider health economy.Step Up/ Step DownDischarge Destinations

Abstract 18955: Post Webinar Survey Responses Regarding Maternity and Legal Rights for Cardiologists

Introduction/Background: Women are under-represented in cardiology and cardiology subspecialties. Work life challenges are often a stated reason why women do not choose cardiology. Pregnancy and motherhood represent a time of significant challenges to women in cardiology due to lack of support and discrimination. The American Heart Association (AHA)Women in Cardiology (WIC) Committee recently held a case-based webinar to increase awareness about the issues, discuss available resources for support, and understand laws protecting women against discrimination. Goals/Aims: The goal of the survey was to understand the current landscape of perceived institutional support during the maternity period and gauge awareness of the laws protecting women against discrimination. Methods/Approach: After the webinar, an email survey was sent to all those who registered on behalf of the AHAWIC Committee within 7days of the event. Results/Data: There were 189registrants for the webinar, of which 29(15%)responded to the survey. Of those who responded, 72%were female, 48%were &lt;40years of age, 33%of the attendees were mothers, and 20%reported fertility issues. Almost all respondents reported working in a hospital-based practice (90%),59%were attending physicians and 38%were trainees. Only 28%reported that their work environment was very supportive of mothers and only 31%were aware of maternal legal rights in the workplace. After the webinar, 76%planned to learn or implement new maternal rights related policies in their workplace (Figure 1). Conclusions: Pregnancy and motherhood represent a challenging time in the career of a female cardiologist or trainee. Perceived support in the workplace is low. Very few women know their legal rights, but a majority had a plan to learn more after the webinar. This survey highlights opportunities for the cardiology community and national societies to help support women cardiologists.

Abstract 16043: Impact of Left Ventricular Global Longitudinal Strain on the Outcomes of Patients With Moderate Aortic Stenosis and Moderate Aortic Insufficiency

Background: Reduced left ventricular global longitudinal strain (GLS) is associated with worse outcomes in patients with severe aortic stenosis (AS). Its role in predicting outcomes in moderate AS is now being reported. We aim to investigate the prognostic value of GLS in patients with moderate AS and moderate aortic insufficiency (AI). Methods: We conducted a retrospective review of 1576 patients with a diagnosis of AS and AI at a community cardiology practice. We reviewed the echocardiographic data and included 254 patients with moderate AS and moderate AI. They were retrospectively followed for 1 year from the time they initially had the echocardiography findings to note the occurrence of shortness of breath (SOB), heart failure (HF) hospitalization, or mortality during the 1 year period. Results: Out of the 254 patients that were studied, 121 patients (47.64%) had GLS ≤16%. Demographics and comorbidities such as age, sex, hypertension, diabetes mellitus (DM), obesity, and atrial fibrillation were balanced in both arms. Patients with GLS ≤16% had significantly higher SOB (50.41% vs. 32.33%, p=0.003) and HF hospitalization (17.36% vs. 9.02%, p=0.049) during 1-year follow-up. 1-year mortality was higher in GLS ≤16% arm but not statistically significant (5.79% vs. 1.5%, p=0.065). After adjusting for patient characteristics using logistic regression, GLS ≤16% was independently associated with higher odds of SOB (aOR 2.139, 95CI 1.28-3.59, p=0.004) but not for HF hospitalization (aOR 2.022, 95CI 0.94-4.35, p=0.072) and 1-year mortality (aOR 4.165, 95CI 0.78-22.12, p=0.094). Conclusions: GLS ≤16% is associated with an increased likelihood of SOB in patients with moderate AS and moderate AI. HF hospitalization and 1-year mortality were not statistically significant, but there is a clear trend towards worse outcomes in patients with GLS ≤16%. If future studies reproduce similar results and outcomes, it may be time to rethink the timing of aortic valve intervention.

Abstract 13694: Impact of an Interdisciplinary Heart Failure Clinic on Achieving Guideline-Directed Medical Therapy in the Community

Background: Guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) is underutilized despite proven benefits. Strategies to implement GDMT are needed, especially in the era of sodium-glucose cotransporter-2 inhibitors (SGLT2is). Research Question: What is the impact of embedded interdisciplinary heart failure (HF) clinics on HFrEF GDMT prescribing within community cardiology practices? Goal: Compare GDMT prescribing for HFrEF patients followed in community cardiology practices with or without the added support of embedded interdisciplinary HF clinics. Methods: This retrospective chart review of four community-based cardiology practices in North Carolina identified 2,121 patients ≥ 18 years old with a diagnosis of HFrEF (EF ≤ 40%) who had encounters from January 1 to December 31, 2022. Patients were categorized based on whether their encounters included an HF clinic provider. Patients seen in HF clinic also had access to embedded clinical pharmacists and centralized social work support. Chi square test of independence was used to assess differences between groups. Results: Significantly more patients who attended HF clinic (n=1050) compared to those receiving usual care alone (n=1071) were female (36% vs 30%, p&lt;0.01), African American (39% vs 30%, p&lt;0.01), and had systolic BP &lt; 100 mmHg (12% vs 7%, p&lt;0.01). Mean age (67.8 ± 2.4 years), rates of potassium &gt; 5 mEq/L (10%), and rates of GFR &lt; 30 mL/min/1.73m 2 (12%) were similar between groups. HF clinic patients had significantly higher rates of angiotensin receptor/neprilysin inhibitors (ARNis) (72% vs 46%, p&lt;0.01), ACEi/ARB/ARNis combined (86% vs 77%, p&lt;0.01), SGLT2is (61% vs 20%, p&lt;0.01), and mineralocorticoid receptor antagonists (45% vs 32%, p&lt;0.01) prescribed compared to usual care alone. HF beta blocker prescribing was similar between groups (88% vs 89%, p=NS). Conclusion: Patients receiving care in interdisciplinary HF clinics within community cardiology practices had significantly higher rates of HFrEF GDMT prescribing for 3 of the 4 drug classes. Specialized HF clinics can provide patients additional support and resources to achieve GDMT.

Pretreatment antithrombotic strategies in non-ST elevation acute coronary syndromes in contemporaneous clinical practice

BackgroundPretreatment antithrombotic strategies in non-ST elevation acute coronary syndromes (NSTE-ACS) during hospitalization is still a matter of contention within the cardiology community. Our aim was to analyze in-hospital and one-year follow-up outcomes of patients with NSTE-ACS pretreated with dual antiplatelet therapy (DAPT) versus single antiplatelet therapy (SAPT). MethodsA retrospective study was carried out with NSTE-ACS patients who planned to undergo an invasive strategy and were included in the Portuguese Registry of ACS between 2018 and 2021. A composite primary outcome (in-hospital re-infarction, stroke, heart failure, hemorrhage, death) was compared regarding antiplatelet strategy (DAPT versus SAPT). Secondary outcomes were defined as one-year all-cause mortality and one-year cardiovascular rehospitalization. ResultsA total of 1469 patients were included, with a mean age of 66 ± 12 years, and 73.9 % were male. The DAPT regime was used in 38.2 % of patients and SAPT in 61.8 % of patients. NSTE myocardial infarction was the most frequent presentation (88.5 %). Revascularization was performed within 24 h in 55.2% of patients. Time until revascularization >24 h occurred in 44.8% of patients, with 16.5% of these between [24 h–48 h], 10.6% in [48 h–72 h] and 17.6% > 72 h. The primary outcome was more frequently observed in the SAPT group (10.4 %, p = 0.033), mainly driven by more ischemic events. Time until revascularization >72 h and the SAPT regime were independent predictors of the primary outcome (OR 3.09, p = 0.005, and OR 2.03, p = 0.008, respectively). ConclusionNSTE-ACS patients pretreated with SAPT had worse in-hospital outcomes. This difference can probably be explained by time until revascularization delay.

Cardiopulmonary exercise testing criteria for advanced therapies in patients with heart failure.

Many cardiology associations endorse the role of the cardiopulmonary exercise test (CPET) to define the severity of impairment of functional capacity in individuals with heart failure with reduced ejection fraction (HFrEF) and when evaluating the need for advanced therapies for these patients. The focus of the CPET within the cardiology community has been on peak volume of oxygen uptake (VO2). However, several CPET variables are associated with outcomes in individuals with and without chronic disease and can inform clinical decisions in individuals with HFrEF. In this manuscript, we will review the normal cardiopulmonary response to a graded exercise test and review current guideline recommendations relative to CPET in patients with HFrEF.

Risk Stratification in Pediatric Wolff-Parkinson-White: Practice Variation Among Pediatric Cardiologists and Electrophysiologists.

Published guidelines provide recommendations for risk stratification in pediatric Wolff-Parkinson-White (WPW). There are no data on provider concordance with these guidelines. We hypothesized that significant practice variation exists between pediatric cardiologists (PC) and electrophysiologists (EP). The records of all patients, age 8 to 21 years, with a new ECG diagnosis of WPW between 1/1/2013 and 12/31/2018, from a single center, were retrospectively reviewed. Subjects were categorized on the basis of symptoms and resting ECG findings as one of the following: asymptomatic intermittent WPW, asymptomatic persistent WPW, or symptomatic WPW. The performance and results of diagnostic testing, including Holter monitor, event monitor, exercise stress test (EST), and electrophysiology study (EPS), were recorded. The primary outcome was concordance with published guidelines. A secondary outcome was documentation of a discussion of sudden cardiac death (SCD) risk. 615 patient encounters were analyzed in 231 patients with newly diagnosed WPW pattern on ECG (56% male; mean age at diagnosis 13.9 ± 2.5 years). EP were observed to have a significantly higher rate of guideline concordance than PC (95% vs. 71%, p < 0.001). There was significant practice variation between PC and EP in the documentation of a discussion of SCD risk: 96% in EP vs. 39% in PC (p < 0.001). Significant practice variation exists in the non-invasive and invasive risk stratification of pediatric WPW, with lower concordance to published guidelines amongst PC, when compared to EP. This report highlights the need to promote awareness of current WPW guidelines in the pediatric cardiology community at large.