Cardiology Consultation Research Articles

The Utility and Educational Impact of a Virtual Webinar to Deliver an International Undergraduate Cardiovascular Conference.

IntroductionConferences are an important avenue for dissemination of knowledge, research and provide networking opportunities for career development. The COVID-19 pandemic has prompted adoption of virtual platforms for delivery of these conferences. The aim of the study was to determine the utility and educational impact of a student-led virtual webinar to deliver an undergraduate cardiovascular conference compared to a traditional in-person conference.MethodsWe conducted a two-day virtual conference using the Zoom platform in June 2021. The conference consisted of cardiology subspecialty lectures, and workshops were conducted by a junior doctor, senior cardiology trainees and consultants. The conference also outlaid a virtual poster hall and oral presentation session while networking opportunities were encouraged using breakout rooms and poster hall chat function. A 38-item self-administered online questionnaire was designed and disseminated at the end of the conference to all attending delegates. All data analysis and data visualisation strategies were conducted on R statistical programming.ResultsEight-hundred and forty students from 55 countries attended the event. Four hundred and ninety participants (58.5% response rate, 55.9% female) completed the questionnaire. Factors such as weekend conference (84.9%), student-led or organised (84.1%), environmental/sustainable (82.3%), appropriate level for me (81.5%) and comfort to present (80.8%) were deemed to be at least equal to traditional in-person conference. The conference also increased participants’ interest, their core cardiology knowledge and improved their critical analysis and basic echocardiography skills [median 4 (IQR 3–5) for all parameters]. Overall, participants also found it easy to use the virtual platform [median 5 (IQR 5–5)] and easier to ask questions compared to in-person conferences [median 5 (IQR 4–5) vs median 4 (IQR 3–5), p < 0.001].ConclusionOur virtual conference provided opportunities to students that the COVID-19 pandemic would have otherwise affected; however, its utility and educational impact will need to be assessed within its individual context of delivery.

Factors Influencing Thirty-Day Readmission Rate in Patients With Heart Failure Exacerbation.

BackgroundThe purpose of this study is to further investigate the leading causes of readmission at 30 days in heart failure exacerbation patients, along with associations to mortality and intensive care unit (ICU) admissions.MethodsA retrospective data analysis was performed on a total of 33,400 patients between January 1, 2016, and December 31, 2020. The primary endpoints were to determine whether guideline-directed medical therapy (GDMT), length of stay, and time to first diuretic affect readmission rates. Secondary endpoints include time to first chest X-ray, time to first echocardiogram, administration of intravenous fluids, diet, presence of cardiology consult, and ICU admission.ResultsPatients who received GDMT had decreased likelihood of mortality (odds ratio (OR): 0.518; 95% confidence interval (CI): 0.394 - 0.682; P < 0.001). Patients who had an echocardiogram done within 1 day of admission had less likelihood of death (OR: 0.606; 95% CI: 0.483 - 0.759; P < 0.001). In addition, patients who had a cardiac diet during their hospitalization were 0.632 times less likely to experience mortality (95% CI: 0.502 - 0.797; P < 0.001). Patients that received their first intravenous diuretic 2 h or more after admission were 1.290 times as likely to be readmitted within 30 days (95% CI: 1.018 - 1.634; P = 0.035). In addition, patients that did not receive intravenous diuretics were even more likely to be readmitted within 30 days (OR: 1.555; 95% CI: 1.237 - 1.955; P < 0.01). Patients who were treated with GDMT had a decreased chance of being readmitted within 30 days (OR: 0.781; 95% CI: 0.647 - 0.944; P = 0.01).ConclusionsThis study stresses the importance of initiating GDMT, cardiac diet, diuretics, and echocardiogram in timely manner.

Role of Myocardial Strain Imaging by Echocardiography for the Early Detection of Anthracyclines-Induced Cardiotoxicity.

SummaryObjectiveTo investigate the role of myocardial strain imaging by echocardiography is for detecting anthracycline-induced cardiotoxicity early.Patients and methodsFifty patients had transthoracic echocardiogram before, during, and after taking anthracyclines. GE Vivid E9 Ultrasound System was used for echocardiographic examination and myocardial strain imaging. All patients were assessed three times: on the first visit, before starting anthracycline medication; on the second visit, three months later; and on the third visit, six months later.ResultsCardiotoxicity occurred in 4 patients at the end of the research. There was a statistically significant association between percentage change in global longitudinal strain (GLS) and ejection fraction (EF) at 3 months p < 0.001 and 6 months p < 0.001. Change in the GLS at 3 months and 6 months had a sensitivity and specificity of 100%, 95.65%, and 100%, 89.13% respectively. Using receiver operating characteristic curve (ROC) for change in GLS showed that Area Under a Curve (AUC) = 1.000, sensitivity, specificity, positive predictive value, and negative predictive value all equals 100%.ConclusionStrain echocardiographic examination using GLS is a good predictor for early detection of left ventricle dysfunction caused by anthracyclines chemotherapy.

Collaborative advanced nurse practitioner (ANP) and senior cardiac physiologist (SCP) ECHO use in a community chest pain clinic: an audit of case management and clinical outcomes.

Abstract Funding Acknowledgements Type of funding sources: None. Background In the primary care setting chest pain is a common presenting complaint with an over diagnosis/suspicion of stable angina, however General Practitioners (GPs) lack access to a cardiac specialist in a timely fashion, as a result 31% of all ED chest pain patients are referred to the emergency department. The Integrated community chest pain clinic (ICCPC) provides an alternative pathway for GPs to refer patients with non-acute chest pain. This clinic is advanced nurse practitioner (ANP) led in partnership with a senior cardiac physiologist (SCP) to provide cardiac diagnostics. ESC guidelines recommend echocardiography (ECHO) as a level 1b recommendation for patients with suspected coronary artery disease for the assessment of chest pain. Purpose The aim of this study is to assess referral to and impact of SCP provided ECHO in an integrated community chest pain clinic. Methods A retrospective clinical audit of all patients who were referred for ECHO over a 15-month period was performed. Clinical indication for referral, case management and final diagnosis were evaluated, approved by the hospital audit department. Results A total of 89 patients were referred by the ANP to the SCP for ECHO, (18%) of total patient cohort. All patients presented with chest pain and the clinical reason for referral included abnormal ECG n=25 (28%), hypertension n=24 (26%), dyspnoea n=19 (21%) or new murmur n=6 (7%). Other referral rational n= 15 (18%) included elevated NT-proBNP and long covid. Seventy percent of all cases were managed by collaborative autonomy between the ANP and SCP and discharged to the general practitioner. Collaboration with the Consultant Cardiologist was required for n=26 (30%) of cases. Of these n=4 were discharged. Twenty-two or 24% of the total number of ECHOs performed showed notable abnormalities requiring further management. This included dilated aortic root n= 6, valve disease n=8, one of which was severe requiring surgical valve replacement and regional wall motion abnormalities n=5. Three patients exhibited significant myocardial disease including Hypertrophic cardiomyopathy, Hypertrophic obstructive cardiomyopathy and Hypertrophic Cardiomyopathy with Severe Asymmetrical Hypertrophy. Discussion The integrated community chest pain clinic provides the patient with non-acute chest pain access to and advanced nurse practitioner and senior cardiac physiologist outside the acute setting. The provision of SCP led ECHO provides a timely and useful diagnostic tool as per ESC guidelines. Most patients post ECHO were managed by the ANP in collaboration with the cardiac physiologist. Chest pain is not always due to coronary heart disease and patients with significant myocardial and valve disease were diagnosed and promptly managed in the community setting. Advanced practice nursing and cardiac physiologist led care with access to ECHO has proven vital for this patient cohort.

Referring Provider Opinions of Pediatric Cardiology Evaluations Performed by Nurse Practitioners.

In the setting of physician shortages, nurse practitioner (NP) roles have evolved, with increasing independence across most healthcare settings. We sought to characterize referring clinician perceptions of NP-performed outpatient pediatric cardiology consultations. We electronically distributed to pediatric and family medicine physicians and NPs in Arkansas our 11-item survey assessing the acceptability of pediatric cardiology consultations being completed by an NP under varying circumstances. Circumstances included seven common referral indications, and the scale offered five answer choices ranging from "definitely unacceptable" to "definitely acceptable". A total of 292 of 1756 (16.6% response rate) referring clinicians responded to the survey. Overall, 57% of responses indicated that NP-completed pediatric cardiology evaluations were either definitely or probably unacceptable. Acceptability was varied by referral indication and referring clinician characteristics. Unacceptability of NP-completed pediatric cardiology evaluations was greatest among family medicine physicians (81%), pediatricians (66%), and clinicians working in solo or two-physician practices (77%) or community hospitals/clinics (71%). If NP evaluation of a murmur included required review with a cardiologist, the unacceptability rate dropped from 50 to 24% (p < 0.0001). Unacceptability was higher in physicians who do not work with NPs (69%) compared to those who do (60%) (pp < 0.0001). Many referring physicians were willing to send patients ≥ 100 miles to ensure evaluation by a pediatric cardiologist. Most referring physicians find pediatric cardiology evaluations performed by NPs to be unacceptable. Requisite review with a cardiologist improved acceptability of NP evaluations. Many referring physicians would send patients much farther to guarantee evaluation by a cardiologist.

Type A Wellens’ syndrome - A critical electrocardiographic sign

Wellens’ syndrome was first described in 1982[1] and classified into type A and type B. Type A Wellens’ syndrome is characterized by biphasic T-waves in leads V2 and V3, and type B is characterized by deep symmetrical T-wave inversions in the same leads. The study reported that Wellens’ syndrome electrocardiographic (ECG) finding related to left anterior descending (LAD) total or near-total occlusion, which is also described as one of the ST-segment elevation myocardial infarction (STEMI) equivalent signs.[2] Cardiology consultation for possible coronary angiography is necessary for evaluating patients.[3] A 29-year-old male without underlying medical diseases was admitted to our emergency department due to intermittent retrosternal chest tightness for 1 week. His chest pain usually occurs after exertion, accompanied by nausea and dizziness, and subsides 10–15 min after rest. He did not notice other exacerbating or relieving factors. Thus, he visited our emergency department for a consultation. The patient is a nonsmoker with no family history of acute coronary syndrome. In the emergency department, his chest pain had already subsided. He was vitally stable. On physical examination, his cardiac auscultation revealed a regular heartbeat with no murmurs. His ECG performed in the emergency department showed sinus rhythm with biphasic T-waves in leads V2 and V3 without precordial Q waves [Figure 1], which is compatible with type A Wellens’ syndrome. As for his blood examination, his troponin I level is 3.2 ng/mL (normal range < 0.02 ng/mL) and creatine kinase-myocardial band mass is 8.5 ng/mL (normal range <5 ng/mL). He also had thrombocytosis with a platelet count of 993,000/μL.Figure 1: Patient’s initial ECG. ECG: ElectrocardiographicThe patient received aspirin, ticagrelor, and heparin for the myocardial infarction. He received urgent coronary angiography and the examination showed an 85% stenosis of the proximal LAD artery [Figure 2] that was successfully opened through angioplasty. Two drug-eluted stents were placed. After angioplasty, his ECG showed sinus rhythm with no Wellens’ pattern. In addition, he did not experience any chest pain attack after angioplasty. On admission, the patient was diagnosed with essential thrombocythemia through positive JAK-2 V617F mutation test and bone marrow biopsy.Figure 2: Patient’s coronary angiography showed LAD stenosis. (Left) Before the intervention. (Right) After the intervention. LAD: Left anterior descendingWellens’ syndrome is one of the STEMI equivalent ECG signs that need to be treated as acute myocardial infraction in the emergency department.[2] A previous study[1] showed that 75% of the patients with Wellens’ syndrome developed extensive anterior wall myocardial infarction a few weeks after admission. T-wave findings of Wellens’ syndrome are classified into two patterns. In type B, which comprises approximately 75% of cases, the T-wave is deeply inverted and the inverted T-wave is symmetric in contour. In type A, which comprises 25% of cases, the T-wave is biphasic in leads V2 and V3. Other ECG criteria included no loss of R rave or precordial Q waves. Considering noncoronary causes of T-wave inversions, the left ventricular hypertrophy and bundle branch block patterns should be readily recognized by their significant coexistent findings.[3] The characteristic ECG pattern often develops when the patient is not experiencing angina.[3] Patients with ET may present with vasomotor symptoms such as myocardial infarction or stroke. However, in this case, the patient was young and without any risk factors for myocardial infarction before diagnosis. Prompt recognition of the ECG pattern and early cardiology consultation are essential to prevent missing the diagnosis of myocardial infarction. Declaration of patient consent The authors certify that they have obtained appropriate patient consent form. In the form, the patient has given his consent for the images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Protocol for Home-Based Solution for Remote Atrial Fibrillation Screening to Prevent Recurrence Stroke (HUA-TUO AF Trial): a randomised controlled trial

IntroductionCurrent international guidelines recommend ECG monitoring after an ischaemic stroke to detect atrial fibrillation (AF) in order to prevent stroke recurrence. However, optimal strategies to detect AF and the downstream...

Elevated troponin in patients with acute gastrointestinal bleeding: prevalence, predictorsand outcomes.

Background: Cardiac troponin (cTn) can also be elevated in patients with non-cardiac illnesses. The utility of elevated cTn in patients with acute gastrointestinal bleeding (AGIB) is unclear. Methods: We retrospectively identified all patients admitted with AGIB who hadcTn ordered. We assessed the prevalence, predictors and mortality. Results: A total of 172 patients with AGIB were included in the study, of whom 17% had abnormal cTn. Predictors of elevated cTn were advanced age, lower BMI, coronary artery disease and chronic kidney disease. The abnormal cTn group had more cardiac consultation and procedures and longer length of stay. However, there was no difference in mortality between the two groups. Conclusion: Elevated cTn in patients with AGIB was associated with more cardiology consultation and downstream cardiac testing, greater delay to endoscopic evaluation and longer length of stay, without significantly affecting the mortality.

Frequency of Cardiovascular Problems in Patients with Benign Prostate Enlargement

Background: Males often suffer from the genitourinary disorder known as benign prostatic hyperplasia (BPH) also known as benign prostate enlargement (BPE). Various studies observed association between cardiac problems and benign prostate enlargement. Objective: To find out frequency of cardiovascular problems in patients with benign prostate enlargement Methodology: The current study was cross sectional carried out at the Urology Department, Fauji Foundation Hospital Peshawar Cantt. The study duration was twelve months from January 2021 to January 2022. All the collection of data was done by using pre-designed Performa. A consultant cardiologist assessed all the enrolled patients for the cardiovascular problems. All the data analysis was done by SPSS version 23. Results: In the current study, the frequency of hypertension was 28 (23.33%) patients. Out of 28 hypertensive patients, cardiovascular problems were observed in 13 (46.43%) patients. Decreased ejection fraction was observed in 4 (30.77%) patients, left ventricular hypertrophy in 3 (23.08%), left ventricular failure in 2 (15.38%), ischemic heart disease in 3 (23.08%) and non- significant ECG change was observed in only 1 (7.69%) patient. Conclusion: Our study concludes that the frequency of hypertension and cardiovascular problems are high in patients with benign prostate enlargement. To avoid unintended cardiovascular events, such individuals should be thoroughly evaluated. Keywords: Cardiovascular problems; Benign prostate enlargement; Morbidity

Utility of prehospital electrocardiogram interpretation in ST-segment elevation myocardial infarction utilizing computer interpretation and transmission for interventional cardiologist consultation.

ObjectivesWe examined the appropriateness of prehospital cardiac catheter laboratory activation (CCL‐A) in ST‐segment elevation myocardial infarction (STEMI) utilizing the University of Glasgow algorithm (UGA) and remote interventional cardiologist consultation.BackgroundThe incremental benefit of prehospital electrocardiogram (PH‐ECG) transmission on the diagnostic accuracy and appropriateness of CCL‐A has been examined in a small number of studies with conflicting results.MethodsWe identified consecutive PH‐ECG transmissions between June 2, 2010 and October 6, 2016. Blinded adjudication of ECGs, appropriateness of CCL‐A, and index diagnoses were performed using the fourth universal definition of MI. The primary outcome was the appropriate CCL‐A rate. Secondary outcomes included rates of false‐positive CCL‐A, inappropriate CCL‐A, and inappropriate CCL nonactivation.ResultsAmong 1088 PH‐ECG transmissions, there were 565 (52%) CCL‐As and 523 (48%) CCL nonactivations. The appropriate CCL‐A rate was 97% (550 of 565 CCL‐As), of which 4.9% (n = 27) were false‐positive. The inappropriate CCL‐A rate was 2.7% (15 of 565 CCL‐As) and the inappropriate CCL nonactivation rate was 3.6% (19 of 523 CCL nonactivations). Reasons for appropriate CCL nonactivation (n = 504) included nondiagnostic ST‐segment elevation (n = 128, 25%), bundle branch block (n = 132, 26%), repolarization abnormality (n = 61, 12%), artefact (n = 72, 14%), no ischemic symptoms (n = 32, 6.3%), severe comorbidities (n = 26, 5.2%), transient ST‐segment elevation (n = 20, 4.0%), and others.ConclusionsPH‐ECG interpretation utilizing UGA with interventional cardiologist consultation accurately identified STEMI with low rates of inappropriate and false‐positive CCL‐As, whereas using UGA alone would have almost doubled CCL‐As. The benefits of cardiologist consultation were identifying “masquerading” STEMI and avoiding unnecessary CCL‐As.

VITAL SIGNS GUIDED THERAPY AT THE CARDIAC CARE UNIT: INTERVENTIONS BY A CARDIOLOGY PHARMACIST

Objective: To identify the role of a cardiology pharmacist in ptimisation of cardiovascular treatment depending on vital signs including heart rate (HR) and blood pressure (BP) for patients with acute coronary syndrome (ACS) Design and method: A prospective interventional study conducted at the cardiac care unit (CCU) over 3 months (July-October 2021). A senior consultant cardiologist noticed frequent uncontrolled vital signs of patients at the CCU particularly those with ACS, therefore, he asked the cardiology pharmacist to observe the missed uncontrolled HR and BP without optimum treatment for all patients at the CCU after completing the daily morning round and make drug interventions collaboratively. The drug intervention for this group of patients was called ‘Vital Signs Guided Therapy’. Results: Among 147 patients who got drug interventions by the pharmacist over 3 months, 41 (28%) of patients included in the vital signs guided therapy cohort, the main diagnosis of the patients: ACS 88%, complete heart block 5%, atrial fibrillation 5%, and acute decompensated heart failure 2%. Mean HR (79 ± 15) beat per minute, systolic BP (136 ± 28) mmHg, and diastolic BP (86 ± 14) mmHg. HR control was done for 56% of patients and BP control for 61% of patients. Control of both HR and BP were done for 20% of the cohort. Types of drug interventions and ptimisation are shown in Figure 1. Conclusions: Team work; including a cardiology pharmacist, is essential for drug therapy ptimisation guided by vital signs for patients at CCU.

What's New in Orthopaedic Trauma.

What's New in Orthopaedic Trauma.

The latest cutoff value of high-sensitivity cardiac troponin I (access hs-TnI) for major adverse cardiac events during the perioperative period of coronary artery bypass grafting: a retrospective study from a single heart center

Abstract Objectives To investigate the latest cutoff value of high-sensitivity cardiac troponin I for major adverse cardiac events (MACEs) during the perioperative period of coronary artery bypass grafting (CABG). Methods A total of 200 patients, into MACEs and non-MACEs groups according to the occurrence of MACEs over a 12 day postoperative period underwent a complete baseline history survey, physical examination, 12-lead electrocardiogram (ECG), and laboratory examination during a preoperative cardiology consultation. Serum levels of hs-TnI, myohemoglobin, creatine kinase MB isoform (CK-MB), and B-type natriuretic peptide were assessed using a Beckman DXI800 automatic chemiluminescence immune analyzer. Results The 200 patients were classified into the MACEs (n=10) and non-MACEs (n=190) groups. Based on a receiver-operating characteristic analysis, the optimal 4–6 h postoperative hs-TnI, CK-MB, and MYO joint cut-off levels for predicting perioperative MACEs were 2,622.3 pg/mL, 17.9 ng/mL, and 190.2 ng/mL, respectively. The AUC was 0.779 (95% confidence interval: 0.622–0.937; p&lt;0.05) with a sensitivity of 80.0% and a specificity of 74.0%. When the hs-TnI, CK-MB, and MYO levels exceeded the joint cut-off levels, the incidence of MACEs was significantly increased during the perioperative period (Log rank p&lt;0.05). Cox regression analysis showed that dyslipidemia, left ventricular ejection fraction &lt;50%, hs-TnI level, and myohemoglobin level were the main risk factors for MACEs after CABG (p&lt;0.05). Conclusion An hs-TnI level of 2,622.3 pg/mL, CK-MB level of 17.9 ng/mL, and MYO level of 190.2 ng/mL were the cutoff values for predicting MACEs. Dyslipidemia, left ventricular ejection fraction &lt;50%, hs-TnI level, and myohemoglobin level were the main risk factors for MACEs after CABG.

Diagnostic yield of a portable electrocardiographic device versus 24-hours conventional holter monitoring in the diagnosis of arrhythmic events

Abstract Funding Acknowledgements Type of funding sources: None. Background The study of palpitations, presyncope or dizziness constitutes an important part of the cardiology consultations. These symptoms are nonspecific most of times, and with the usual diagnostic tools (24-hour Holter mainly) it is difficult to reach an accurate diagnosis, since episodes occur erratically once or a few times a month. The Kardia® electrocardiographic monitoring device is a diagnostic tool that allows the patient to self-perform ECG based on symptoms and send it for later review and interpretation by a cardiologist. Purpose We compared the diagnostic yield of the conventional 24-hour Holter monitor versus the Kardia® device in patients undergoing a cardiology study. Methods We conducted a prospective cohort study in 36 patients referred to the cardiology consultation due to palpitations or presyncope. In all of them, a 24-hour Holter was carried out, according to the usual protocol, and then a KardiaMobile® 6L device was given for a month. They received training to perform an ECG (six limb leads) and use the mobile application. The quantitative variables are expressed as means and standard deviation and the qualitative values as percentages. Results The study included 36 patients, of which 66.7% were women and 33.3% men, mean age of 44.2±14.3 years. The most frequent clinical symptom was palpitations (88.9%). Regarding the 24-hour Holter, only 22.2% of patients felt the symptoms for which they consulted during the day they wore it. Only in 19.4% the etiological diagnosis was reached through this method. Regarding the KardiaMobile® device, 72.2% of patients presented symptoms during the month of follow-up. Through the records obtained with this device, the diagnosis was reached in 52.8% of the cases, taking into account that if the patient reported having symptoms at the time the ECG was performed, if the ECG was normal, it was considered a diagnostic success, since the non-cardiological cause of the symptom was demonstrated. The diagnosis implied a therapeutic approach in 30.6% of cases: antiarrhythmic drugs were started in 8 patients, and 4 electrophysiological studies were indicated: in 3 patients for AVRNT ablation and in 1 patient for sustained ventricular tachycardias. Table1 shows a summary of the results. Conclusion Despite the limited number of patients, in our study, the 30-day recording with portable KardiaMobile® monitoring system showed statistically significant superiority (p &amp;lt;0.05) compared to the conventional 24-hour Holter monitor in the etiological diagnosis of palpitations and dizziness in a selected group of patients. It must be borne in mind that this is a relatively young population and the study needs to be extended to a larger number of patients to generalize these conclusions. The main limitation of the KardiaMobile® device is that it requires minimal skills in terms of using a smartphone, so this tool is not extensible to any patient profile.

Optimization of a care pathway before atrial fibrillation ablation with the integration of translational research into routine clinical care

Abstract Funding Acknowledgements Type of funding sources: None. Background The diagnostic work-up for atrial fibrillation (AF) catheter ablation is often complex and expensive. Improving the organization of this work-up may help to streamline patient journeys and to reduce administrative burden and costs. Additionally, reorganizing the existing work-up provides the opportunity to integrate (translational) research into routine clinical care, hereby contributing to improved patient selection and improved care for future patients. Purpose The aim of this project was to optimize a care pathway for patients considered for AF ablation, with the goals to improve the patient journey and simultaneously integrate research into the clinical process. Methods The Lean Six Sigma approach was used to map the pre-existing process, identify constraints in the process and formulate countermeasures. The impact of this pathway optimization was evaluated using four outcome measures: (1) efficient use of medical resources, defined as the percentage of patients receiving the pre-ablation work-up and eventually undergoing AF ablation, (2) number of hospital visits and consultations with a cardiologist, (3) pathway compliance, defined as the percentage of patients that completed the work-up with a maximum of 2 outpatient hospital visits, a maximum of 1 cardiologist consultation, laboratory results available, and a complete echocardiogram available, and (4) completeness of scientific data, defined as the availability of a predefined set of relevant variables (clinical indicators, medication, laboratory results and echocardiography derived data). Results Five root causes for constraints in the pre-existing work-up were identified and corresponding countermeasures were formulated (Figure 1). The impact of the countermeasures was studied for 33 patients before and 26 patients after pathway optimization. After optimization, efficient use of resources increased from 44% to 95% (p&amp;lt;0.01). The project resulted in fewer hospital visits per patient (3.2 ±1.2 versus 2.3 ±0.8, p=0.01) and fewer cardiologist consultations (1.8 ±0.7 versus 1.0 ±0.3, p&amp;lt;0.01). Pathway compliance increased significantly (3% versus 73%, p&amp;lt;0.01), an increase that was reflected in all separate components of overall pathway compliance (Figure 2, panel A). The percentage of available data for scientific research increased from 80% to 94% (p&amp;lt;0.01), resulting in a complete dataset in 73% of patients after, compared to only 15% of patients prior to the optimization project (p&amp;lt;0.01, Figure 2, panel B). Conclusions This optimization project resulted in a more efficient care pathway for patients considered for AF ablation. The structural integration of research into the care pathway may lay the foundations for further improvements of AF care in the future.

P313 TAKOTSUBO SYNDROME – FOCAL VARIANT

Abstract Takotsubo syndrome (TTS) is a cardiomyopathy induced by physical and/or emotional stress, characterised by transient changes of the regional motion generally extending beyond the territory distribution of one single coronary vessel. The classic form of TTS presents, in 43.7% of cases, with ST segment elevation and in about 80% with cardiac apical ballooning. In 1.5% of TTS cases, however, regional changes in motion are observed which may mimic an acute coronary syndrome. We describe the case of a 77–year–old woman with hypertension and hypercholesterolemia. The patient came to the ER due to polytrauma secondary to an accidental fall. During hospitalisation, the patient complained of a sudden onset of a retrosternal aching chest pain radiating to the back and right shoulder, associated with neurovegetative symptoms. An electrocardiogram showed a normofrequent sinus rhythm and T–negative waves in the infero–lateral region. Upon cardiology consultation, a transthoracic echocardiogram was performed showing a left ventricle with akinesia of the middle and apical segments of the inferolateral wall with compensatory hyperkinesis of the other segments. When an acute coronary syndrome was suspected, urgent coronary imaging was performed, showing coronary arteries without significant stenosis, while ventriculography confirmed the alterations in ventricular motion. Blood chemistry tests showed a phasic increase in myocardial necrosis enzymes and, in particular, in HS troponin values (max value 2714 ng/L). Therapy with an ace–inhibitor and a beta blocker was introduced; seriate echocardiographic controls showed a progressive normalisation of the alterations in motion. A TTS diagnosis was therefore made, according to InterTAK 2018 diagnostic criteria. This case is of particular interest as it is a prime example of a rare variant of TTS: the clinical presentation, the ECG alterations and the regional akinesia may lead to a clinical suspicion of ACS. A good knowledge of the TTS, including the focal variant, enables the cardiologist to make a correct diagnosis and to initiate suitable therapy.

P178 TYPE–A AORTIC DISSECTION IN MARFANOID HABITUS

Abstract Aortic dissection (AD) is the tearing of the tunica intima of the aortic wall with creation of a false lumen. Type–A AD, in which the intimal flaps originates in the aortic tract proximal to the left subclavian artery, is a surgical emergency because – if left untreated – it has mortality rates as high as 1–2% every hour, from the onset of symptoms. Certain collagenopathies, such as Marfan Syndrome, are a predisposing condition for AD. We describe the case of a 25–year–old man with Marfanoid habitus who came to the Emergency Room of our facility, with acute pulmonary oedema. He had been complaining about thoraco–abdominal pain, bloody mucus and worsening dyspnoea since the week before. Upon cardiology consultation, a transthoracic echocardiogram showed an aneurysm of the aortic root (70 mm) and the ascending aorta (90 mm), with dissection flap extended beneath the aortic valvular plane, with torrential aortic valve insufficiency and eccentric jet, a left ventricle severely dilated and a severe systolic dysfunction (EF 25%). On urgent CT angiography the dissection flap was observed to extend cranially to the right common carotid artery and caudally to the renal arteries. The patient then underwent cardiac surgery to replace the aortic valve with a mechanical prosthesis and the ascending aorta as per the Bentall procedure and to replace the aortic arch with reimplantation and debranching of the supra–aortic trunks. Four months after discharge, the patient presented again due to sustained ventricular tachycardia (SVT) which was interrupted by electric cardioversion. On this occasion, an ICD implant was indicated as a secondary prevention measure. After one month, recurrence of SVT was observed, which was successfully treated by the implanted ICD, and therefore indication was given for an electrophysiologic study and subsequent transcatheter radiofrequency ablation of the ventricular arrhythmia. The case presented is of particular interest as it highlights the crucial role of a rapid echocardiographic assessment focussed on making a diagnosis and directing treatment, despite a misleading clinical picture due to duration and atypicality of symptoms. It should also be stressed that an overall assessment of the patient, based on habitus and age, plays a major role in establishing a suspected diagnosis and guiding the patient towards the most appropriate treatment.

P306 COVID–19 RELATED PERICARDITIS. CLINICAL IMPLICATIONS AND ROLE OF CARDIAC REHABILITATION IN SUBSEQUENT LONG–COVID SYNDROME

Acute pericarditis is considered one of the cardiovascular complications of COVID–19.Aim of the StudyThe aim was to evaluate the prevalence and clinical implications of acute pericarditis diagnosed through the presence of pericardial effusion in patients with COVID–19.MethodsThe investigation is a retrospective observational study enrolling patients admitted to ICU of Madonna del Soccorso Hospital (San Benedetto del Tronto, Italy) because of a SARS–Cov2 induced severe acute respiratory syndrome. N.170 patients, admitted from 1st april 2020 to 30th april 2021, were enrolled. All patients presented a variable picture of bilateral ground glass opacifications at HR– Chest CT. Some patients underwent oro–tracheal intubation+invasive ventilation. All patients underwent cardiological consultation including a transthoracic bedside echocardiogram, using ultrasound E9–GE machine (Boston, MA, USA). Demographic, laboratory and clinical data were collected for all enrolled patients.The diagnosis of acute pericarditis was defined by different degrees of pericardial effusion. All patient were divided in two groups: 1) pericarditis group (A); 2) pericarditis–free group (B).ResultsOf 170 enrolled patient, 51 were females (30%) and 119 were males (70%). Median age for all patients was 67,6 + 13,3 (females: 70,5 + 16,2; males: 66,4 + 11,7). Of 170, n. 60 patients had a diagnosis of acute pericarditis (32,2%) and were included into Group A [age 69,2 + 12,6; 39 (65%) males aged 69,3 + 10,6, 21 (35%) females aged 69,1 + 16,0]. Of 60, only 6 had a pericardial effusion >10 mm (10%); the remaining group A–patients (90%) had a mild pericardial effusion (<10 mm). No patient had tamponade picture. Group B (pericarditis–free) included 110 patients, aged 66,7 + 13,7, 80 (72,7%) males aged 65,0 + 12,1, 30 (27,3%) females aged 71,4 + 16,6. Group A–patients had more days of intubation and a prolonged hospital stay compared with group B, with a significant difference (p < 0.02 and p < 0,03 rispectively). N. 21 of 60 group A patients underwent a 7 weeks of CARDIAC REHABILITATION (CR) because of a LONG–COVID picture. In these patient a 6MWT was performed before and after CR. A significant increase of the walked distance after CR was found (from 352 + 21 to 498 + 31 – p < 0.03 – delta=41%).ConclusionPericarditis is a frequent cardiovascular complication of COVID–19 (32,2% in our study) with clinical and prognostic implications. CR is essential for long–term recovery in these patients.

P179 DYSFUNCTION OF A MITRAL VALVE BIOPROTESIS FROM FLAIL OF A LEAFLET

Abstract Introduction The degeneration of biological valve prostheses is an irreversible process determined by intrinsic factors (calcification, thickening, fibrosis of the leaflets) or extrinsic (prosthesis–patient mismatch, malapposition, prosthetic detachment, thrombosis, endocarditis) that determine hemodynamic dysfunction with frequent need for surgical re–intervention . The average life span of a valve bioprosthesis is around ten years but in some cases premature dysfunction can occur. Clinical Case In September 2021, an 83–year–old woman who was symptomatic of progressively worsening dyspnea entered the emergency care unit of our hospital. In medical history: mitral valve replacement surgery using bioprosthesis in 2016, hypothyroidism in medical therapy. At the entrance, the patient appeared alert, attentive and oriented. Tachypnoic and dyspnoic at rest. Objectively ss 3/6 was appreciated on mitral focus, ss 2/6 on tricuspid focus. Signs of pulmonary congestion. PA 120/80 mmHg. HR 100 bpm, SpO2 88%. Laboratory tests showed increased NTproBNP values. On the ECG: sinus rhythm, HR 96 / min, atrioventricular conduction within limits, narrow QRS, widespread alterations in repolarization as from overload. The echocardiogram performed during the cardiological consultation showed normal biventricular size and contractility. The mitral biological prosthesis appeared in place with an increased transprosthetic gradient (mean Gp 7mmHg) and evidence of severe intraprosthetic regurgitation. There was also moderate to severe tricuspid insufficiency with PAPs estimated at 38 mmHg; the VCI was dilated and non–collapsing. Admitted to cardiac intensive care unit, trans–esophageal echocardiogram was performed which confirmed the finding of bioprosthesis dysfunction caused by severe mitral valve insufficiency in relation to eversion of the posterior leaflet. The patient remained in conditions of haemodynamic instability despite medical therapy with respiratory failure therefore after consulting cardiac surgery she was intubated and transferred for trans–catheter intervention of valve–in valve in emergency. Conclusions Transesophageal echocardiography represents the reference method in the evaluation of valve bioprostheses: in this case it allowed to highlight an unusual mechanism of mitral bioprosthesis dysfunction due to complete eversion of a leaflet.

Prevalence and outcomes of WPW pattern in the young: a report from a nationwide cardiac screening programme

Abstract Funding Acknowledgements Type of funding sources: None. Background Individuals with accessory pathways, also referred as the Wolff-Parkinson-White pattern (WPWp), are usually asymptomatic and fatal arrhythmias may be the first presentation. Risk stratification is recommended, with electrophysiological study (EPS) being the gold standard. Catheter ablation offers a widely available, curative option, and provides incentive for screening, particularly in high-risk populations such as athletes. Purpose We sought to assess the prevalence, real-world clinical practice and outcomes of WPWp in young individuals identified through a nationwide cardiac screening programme. Method Between 2008 and 2018, 113,209 consecutive individuals (14 to 35 years old, 38% female) underwent cardiac screening with a health questionnaire, 12-lead electrocardiogram (ECG) and cardiology consultation. Individuals with suspected cardiac disease were referred for further investigations as necessary. Clinical outcomes were obtained via an online questionnaire and matched de-identified records from the Office of National Statistics database. Individuals were classified as elite athletes, non-elite athletes and non-athletes. Results A total of 214 (0.2%) individuals were referred for secondary evaluation with a suspected WPWp (Figure 1). Clinical outcomes were unavailable for 30 (14%) individuals. Follow-up confirmed an additional 13 individuals with a WPWp who were deemed to have normal investigations at screening, of which 8 (61%) had reported cardiovascular symptoms on their HQ and, in retrospect, 4 (30%) demonstrated subtle WPWp on their ECG. A WPWp was confirmed in 187 individuals (0.2%), of which 149 (80%) individuals were considered non-athletes, 114 (61%) reported cardiovascular symptoms, 116 (62%) underwent risk stratification with an EPS and 95 (43%) underwent catheter ablation. Report of palpitation was significantly greater in non-athletes than athletes (p=0.034). In asymptomatic individuals, those engaging in sports at elite level were more likely to be referred for an EPS (p=0.04). Four adverse cardiac events were reported over a follow up period of 7.4 years (IQR 4.9 to 9.2), including 3 individuals (16 years, 20 years, 40 years) with life-threatening arrhythmic events (LAE) requiring cardioversion, and 1 individual (20 years) with sudden cardiac death. Of these 4 individuals, only 1 with a LAE had undergone risk stratification with EPS. Conclusions The incidence of SCD in this young screened population was 0.72 per 1000 person-years. Clinical practice was variable and EPS was not offered to a significant proportion of patients, despite inadequate non-invasive risk stratification. The indication to EPS was driven by the athletic status in the asymptomatic individuals. The WPW syndrome may manifest with subtle ECG changes, posing a diagnostic challenge to interpreting physicians.