Cardiology Consultation Research Articles

Clinical characteristics of patients with raised BNP referred from primary care to an outpatient heart failure with potential heart failure using NICE guidelines

Abstract Introduction UK NICE guidelines (1) mandate the referral of patients with potential heart failure (signs, symptoms and raised BNP) for specialist opinion including diagnostic echocardiography. We have analysed the demographic and clinical characteristics of 233 consecutive referrals over a nine month period of such patients from primary care to our outpatient cardiology service. Purpose To identify any differences between those who are subsequently identified as having reduced LV systolic function (HFrEF) and those with preserved LV systolic function. We have further explored any potential differences between those with moderately raised (>440 <2000ng/L) and those with grossly raised levels (>2000ng/L) of BNP as NICE guidance proposes a difference in urgency of assessment for these two patient cohorts. Methods All patients had diagnostic echocardiography following the British Society of Echocardiography guidelines (2) and were clinically assessed by a consultant cardiologist and specialist heart failure nurse. Results Of the 233 patients, 64 (27%) were identified as having HFrEF with the remaining 169 having preserved LV systolic function. In patients with HFrEF the majority had grossly raised BNP (62.5%) whereas with preserved LV systolic function the majority had moderately raised BNP (70.5%); Table 1. Within the referred population, demographics and clinical characteristics were broadly similar for patients with HFrEF and those with preserved LV systolic function for age and cardiovascular comorbidities (IHD, diabetes mellitus, hypertension) but were different for gender and heart rhythm. Patients with HFrEF and moderately raised BNP were twice as likely to be in sinus rhythm (75%) than those with grossly raised BNP (37.5%). In patients with moderately raised BNP those with preserved LV systolic function were more likely to be in AF than those with HFrEF (41% v. 25%). No gender difference was seen in patients with preserved LV systolic function whereas patients with HFrEF were twice as likely to be male; Table 2. Conclusions 1. The majority of patients with raised BNP and potential heart failure referred from primary care do not have HFrEF (72.5%) 2. Regardless of their LV systolic function those patients with the highest BNP levels are more likely to be in AF 3. Of patients with a raised BNP and HFrEF twice as many are male whereas no gender difference is seen in those with a raised BNP and preserved LV systolic 4. Whilst the mean age of both groups (preserved and reduced LV systolic function) is the same, in both groups those with grossly raised BNP are on average 5 years older than those with moderately raised BNP.

Factors influencing low-density-lipoprotein cholesterol after acute coronary syndrome and effectiveness of intensive teleconsultation monitoring, the teleobjectif cohort study

Abstract Context: Low-density lipoprotein cholesterol (LDL-c) plays a key role in the development and progression of atherosclerotic cardiovascular disease (ASCVD). Despite the availability of effective lipid-lowering treatments, patients who have experienced an acute coronary syndrome (ACS) continue to face a high risk of recurrent cardiovascular events and mortality. Achieving the recommended LDL-c target of <0.55 g/L in secondary cardiovascular prevention remains a significant challenge, with fewer than 30% of patients reaching this goal. Aim To investigate the factors influencing LDL-c control after ACS and the effectiveness of intensive teleconsultation monitoring to control LDL-c, even in sub-groups where control is poorest. Methods This bi-centric prospective cohort study conducted between december 2019 and december 2021 compared a group that received standard follow-up after an ACS with an interventional group that received regular follow-up by teleconsultation in addition of usual care to optimize lipid-lowering treatment. A subgroup analysis was carried out to examine the effect of teleconsultation in subpopulations known to be significantly associated with better or worse LDL-c control in the usual care group or described in the literature. Results 1602 patients met the inclusion criteria for our study (814 in the usual care group and 788 in the teleconsultation group). Baseline characteristics were similar between groups. In the usual care group, factors influencing lipid control included gender, diabetes, cardiology consultation, distance to the nearest cardiologist, social deprivation and initial LDL-C levels. Teleconsultation significantly improved LDL-C target attainment compared to usual care (74.7% vs. 26.6%, p<0.001 with multivariate analysis OR 5.06 [4.21 ; 6.07]), particularly benefiting geographically and socially disadvantaged patients. Conclusion Teleconsultation significantly improves lipid control in acute coronary syndrome patients compared to usual care. This universal intervention, particularly beneficial for geographically and socially disadvantaged patients, highlights the potential of telemedicine in enhancing cardiovascular management.analysis in usual care groupTeleconsultation effect in sub-groups

Real world data after the implementation of coronary computed tomography angiography in Swedish primary care to rule out coronary artery disease, a cross-sectional study based on pre-test probability

Abstract Background In primary care, most patients with of non-acute chest pain will neither receive a heart related diagnosis nor be referred to a cardiologist. Studies indicate a better cardiovascular prognosis in chest pain patients referred to Coronary Computed Tomography Angiography (CCTA) as compared to risk stratification solely based on risk prediction instruments(1). CCTA is recommended since 2019 for low to intermediate cardiovascular (CV) risk patients(2). In the study setting, the primary care has implemented CCTA as first line test for patients with suspected obstructive coronary artery disease (CAD) and a Pre-Test Probability (PTP) of <15% and any CV risk factor, with PTP mandatorily entered in the referral letters. Purpose To study the outcome of CCTA based on referred PTP values categorised into <5%, 5-15% and >15%. We hypothesized that the presence of significant stenosis would be on par with the mean PTP. Methods In this cross-sectional retrospective cohort study, all consecutive clinical referrals for a CCTA from primary health care centres with a catchment area of ~470 000 inhabitants in the country of Sweden between 1 June 2021 and 7 Dec. 2022, with PTP estimates and completed CCTA were included. CCTA findings were stratified as normal, atheromatosis, or significant stenosis (≥50% coronary lumen obstruction). Patient baseline characteristics routinely registered on the day of CCTA was retrieved from a nationwide quality registry, SWEDEHEART(3). Pearsons’s Chi2 and one-way ANOVA was used to test differences in group distributions. Results During the study period, 381 patients with a PTP had obtained CCTA, of which 75% (n=286) had PTP <15%. The mean age was 60 years (standard deviation [SD] 11), 70% were female, 30% were prescribed lipid-lowering medication and 47% anti-hypertensives (Table 1). In total, the mean PTP was 12.4% (SD 8.7) and in 18% a suspected significant stenosis was identified. (Figure 1). Among patients referred with PTP 5-15%, the presence of suspected significant stenosis was 12% and cardiology consultation was less frequently described than for PTP <5 or ≥15% (14% vs 33% vs 44%, p < 0.001). Conclusions This study indicates that PTP is an efficient means to select patients for CCTA in primary care. In total, about 1/5 had a suspected significant stenosis, which often requires further investigations, and about 4/5 could be reassured that symptoms were not due to coronary artery disease. In 31% atheromatosis was identified, potentially facilitating counselling on CV prevention. We conclude that CCTA is a clinically effective option for primary care physicians to rule out CAD in patients with low PTP.Figure 1Table 1

Myocarditis prognostic score: a new risk assessment tool in patients with myocarditis

Abstract Background Myocarditis is an inflammatory disease of the myocardium with multiple causes and evolutions. The aim of our study was to design a prognostic multiparametric score in patients with myocarditis, to identify those at higher risk of adverse cardiovascular events (AE). Methods A prospective study was performed enrolling 98 patients with myocarditis: 72 M, 26 F; median age 27 [IQR 20–40]. Patients were divided into 2 groups: complicated (CM) and uncomplicated myocarditis (UM). Six months after hospital admission, cardiac magnetic resonance (CMR) and cardiological consultation were repeated. AE (death, hospitalization for heart failure, heart transplant, ICD implantation, heart failure development) were evaluated at 6 months and after 3 years. Results We found 67 UM and 31 CM. AE were significantly higher in patients with complicated myocarditis. We found a significant correlation between AE and reduced left ventricular ejection fraction (LVEF) at hospital admission, increased GLS, septal LGE at CMR, longer persistence time of increased troponin, LGE extension progression or persistence 6-month CMR. A myocarditis prognostic score was developed on the basis of these parameters. A score ≥ 5 showed higher sensitivity (100%) and specificity (87%) - AUC 1, to identify AE in patients with myocarditis. A score between 3 and 4 showed high sensitivity but low specificity. A score ≤ 2 was associated with low probability of events. Conclusion Our study confirms the high probability of AE in patients with CM and it suggests a myocarditis prognostic score to identify patients at higher risk of AE.

Time taken for cardiology care and one-year results for primary care physicians' referrals for cardiology consultation in heart failure patients: clinical implications for heart failure management

Abstract Background and Purpose The clinical trajectory of patients with heart failure (HF) is characterised by frequent episodes of decompensation requiring urgent medical assistance, hospitalisations, and an increased risk of mortality. HF clinical guidelines recommend early visits by health professionals after hospital discharge, yet little evidence exists regarding the associations between delayed medical attention and outcomes in HF patients. To assess the clinical impact of the time taken to receive cardiology care for referrals from primary care physicians (PCPs) to a cardiology department in HF patients, we selected 6,859 HF patients who visited the cardiology service at least once between 2010 and 2021. Methods Using an interrupted time series regression model, we analysed the impact of integrating e-consultations into the healthcare model (implemented in 2013) and evaluated the time taken to receive cardiology care, as well as all-cause, cardiovascular (CV), and HF-related hospital admissions and mortality. The primary objective of this analysis was to examine the associations between delays in cardiology care following a PCP referral and 1-year outcomes (HF-related, cardiovascular, and total hospitalisations; and HF-related, cardiovascular, and total mortality). Results Almost 50% were women, and the mean age was 77.8 years. Arterial hypertension (79.6%), diabetes (34%), atrial fibrillation (51.4%), ischemic heart disease (20.4%), and cerebrovascular disease were the most prevalent comorbidities. The mean time from PCP referral to cardiology consultation in the overall population was 22.3 days: <8 days in 53.9%, 8-14 days in 17.1%, 15-30 days in 15.9%, and >30 days in 13.0% of patients, respectively. One year after cardiology consultation, 68.6% of patients required assistance in an Emergency Department; 22.5% were hospitalised for any cause, 14.9% for cardiovascular reasons, and 9.2% for HF-related issues. Moreover, total mortality at 1-year was 8.6%, comprising 4.3% cardiovascular mortality and 1.3% HF-related deaths. Multivariate analysis of the relationship between the time taken to receive cardiology care and 1-year outcomes revealed a significant increased risk associated with a longer delay in cardiology assistance, particularly evident in the subgroup of patients with previous hospital admissions due to worsening HF (see Table). Conclusions Throughout the follow-up period, a reduced time taken to receive care was independently associated with better 1-year outcomes. We believe that our experience can contribute to the development of a more efficient ambulatory care pathway for HF patients, especially those at high risk, such as those with a history of hospitalisation due to worsening events. Our findings further support the clinical guideline recommendation for early contact by health professionals following hospital discharge, extending it to include PCP referrals for cardiology consultations.

Active surveillance for cardiac complications after major noncardiac surgery: implications on resource utilization and safety in high-risk patients

Abstract Background The 2022 ESC guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery recommend that high-risk patients should undergo active surveillance for cardiac complications, including perioperative myocardial infarction/injury (PMI), following major noncardiac surgery. Unfortunately, little is known about the resource use and safety of active surveillance compared to a control cohort (i.e. without active surveillance). Objective To quantify the impact of active surveillance for cardiac complications, by perioperative cardiac troponin (cTn) measurements and a systematic PMI work-up on working days, on resource usage and safety. Methods We did a retrospective comparison of non-randomised pre- vs post-implementation of an active surveillance program for cardiac complications in patients at elevated cardiovascular risk undergoing noncardiac surgery at two hospitals in Switzerland. The two cohorts' resource use and safety were compared. Resource use encompassed perioperative cTn measurements, ECGs, cardiac imaging, cardiology consultations as well as coronary angiography (CAG) and revascularisation procedures. Safety was assessed based on the number of "seemingly normal CAG" and complications arising from CAG and revascularisation procedures. Results A total of 13’147 patients, 10’346 in the active surveillance cohort and 2’805 in the standard-of-care (SOC) cohort, were eligible for this analysis. Patient characteristics between both cohorts were comparable (e.g. median age of 74 vs 73 and 44.8% vs 43% female, respectively). Patients in the active surveillance cohort underwent significantly more perioperative cTn measurements (86.4% vs 3.5%, respectively), postoperative ECGs (13.5% vs 5.7%), postoperative cardiac consultations (5.9% vs 2.4%), postoperative transthoracic echocardiogram (TTE) (7.5% vs 6.1%), postoperative myocardial perfusion imaging (MPI) (1.2% vs 0.6%), and postoperative CAG (0.8% vs 0.4%, all p <0.05). The increased resource use led to a substantial increase in detected cardiac complications within the first 48h after surgery: active surveillance 1’207 (12%) (95%CI 11%-12%) vs SOC 68 (2.4%) (95%CI 1.9%-3.1%). The active surveillance cohort generated an overall cardiac management cost of 236 Euros (95%CI 223–250) per patient vs 133 Euros (95%CI 110–160) per patient in the SOC cohort, resulting in an incremental cost for the active surveillance of 103 Euros (95%CI 110–160) per patient. Thereby the cost of detecting one additional cardiac complication within 48h was 989 Euros. Concerning safety, no significant differences in the number of "seemingly normal CAG" (6.4% vs 15%, p=0.1) and complications due to CAG and revascularisation (0.6% vs 5.1%, p=0.08) were observed. Conclusion The active surveillance for cardiac complications is safe when compared to a standard-of-care cohort while 989 Euros per additional detected cardiac complication seems reasonably priced.Resource-utilization tableOverview

Pregnancy in women with congenital heart disease : new insights into neonatal risk predictioc

Abstract Background Advances in managing adult congenital heart disease (ACHD) have led to an increased number of women with CHD reaching childbearing age. This demographic shift underscores the need for improved understanding and prediction of complications during pregnancy in this specific ACHD population. Despite progress in maternal cardiac risk assessment, the prediction of neonatal outcomes for ACHD pregnancies remains underdeveloped. Therefore, the aims of this study are (1) to assess neonatal outcomes in a CHD women population, (2) to identify their predictive factors and (3) to propose a new risk score for predicting neonatal complications. Methods This registry study included all women born between 1975 and 1996 diagnosed with ACHD who underwent at least one cardiology consultation for ACHD in Cliniques Universitaires Saint-Luc. A multivariate analysis was performed to identify predictors of neonatal complications and these were incorporated into a new risk index. Its validity was assessed using bootstrap method. This score was then compared with scores adapted from the ZAHARA and CARPREG studies for offspring events prediction. Results Analysis of 491 pregnancies revealed 31.4% of neonatal complications. Four significant predictors of adverse neonatal outcomes were identified: cardiac treatment during pregnancy (OR 14.9, 95%CI [4.6-64.3]), hypertensive disorders of pregnancy (OR 10.4, 95%CI [3.4-39.5]), smoking during pregnancy (OR 10.3, 95% CI [3.0-44.9]), and pre-pregnancy BMI < 18.5 kg/m² (OR 6.2, 95% CI [2.6-16.5]). The risk model demonstrated an AUC of 0.70 (95% CI [0.65-0.75), which remained stable after bootstrap validation. This model significantly outperformed the scores adapted from ZAHARA and CARPREG data. Based on the regression coefficients, a risk score was subsequently developed comprising 5 risk categories. Conclusion One third of ACHD pregnancies are complicated by poor neonatal outcome. These complications are determined by 4 independent factors relating to the cardiac and non-cardiac status of the patients, which have been incorporated into a risk score. Our study is one of the first to propose a predictive risk score of neonatal outcomes in ACHD pregancies, and paves the way for other validation and confirmation studies.Offspring scores: performance comparisonNew risk score for neonatal outcome

Concordance between cardiological interventions and artificial intelligence recommendations for patients presenting with chest pain, based on consultations from the emergency department to cardiology

Abstract Introduction The management of chest pain in emergency departments is a critical challenge. The integration of advanced artificial intelligence (AI) tools, such as pre-trained generative systems like ChatGPT, may present an opportunity to optimize this diagnostic process. This study investigates the effectiveness of AI in recommending diagnostic tests for patients presenting with chest pain, evaluating its concordance with clinical decisions by experienced cardiologists. Methods Retrospective observational study where 102 cases of patients with chest pain treated in the ED and assessed by Cardiology between January and March 2023 were reviewed. Chest pain was classified into high, medium and low probability. Data from emergency department to cardiology consultations were presented to ChatGPT, asking which diagnostic test it would recommend: conventional ergometry, coronary CT, imaging stress test, coronary angiography, or discharge. Various concordance indices, such as Simple Match and Tanimoto, among others, were used to evaluate the consensus between ChatGPT recommendations and cardiologists' decisions (table 2). Results Out of the 102 cases collected, 54% presented with high, 35% with medium and 11% with low probability chest pain. Table 1 summarizes the different proposals between the cardiologist and the AI. For patients with high probability chest pain, coronary angiography was the most commonly requested test, with a positive concordance of 77% according to the Simple Match index and 72% as per the Tanimoto coefficient. For other tests such as ergometry or imaging stress test, there were a 77% and 74% agreement, respectively, in not performing these tests, and there was an almost unanimous agreement (close to 100%) against discharging patients without conducting tests. Medium probability chest pain was more frequent and complex in its management. The decision to perform a coronary angiography agreed in 70% according to the Simple Match index and 72% with Tanimoto. The decision not to discharge patients directly without conducting tests showed a higher agreement at 89%. Other results were less precise. For low probability chest pain, there was a notable concordance (90%) in the decision not to perform diagnostic tests, such as imaging stress test, according to the Simple Match index. Conclusions - The AI achieves a notable concordance with cardiologists' decisions in the diagnostic approach of chest pain, particularly for patients with high probability chest pain, where the coronary angiography demonstrated good agreement. - Although AI cannot fully replace the clinical judgment of cardiologists in cases based on self-reported information, its utility as a supportive tool underscores the potential for its careful integration with medical expertise to enhance the diagnostic process. This implies the need for the development of specialized AI tools to better assist cardiologists in patient diagnosis.Table 1Table 2

Electronic consultation from primary care to a cardiology department improves outcomes in patients with cancer

Abstract Background The number of cancer patients with known cardiovascular (CV) disease is increasing due to improved cancer prognosis. Purpose The objective of this study is to assess the long-term results of cancer patients referred to a cardiology department by primary care using electronic consultation (e-consultation). Methods We analysed the patients with previous diagnosis of cancer referred to a cardiology department (CD) from 2010 to 2021 (n=6.889), selected from a total of 68.518 patients (61.629 without cancer), and compared two assistance models: in-person practice (from 2010 to 2012) and e-consultation (from 2013 to 2021). In the first period, all the patients referred by primary care physicians (PCPs) were seen in an in-person consultation and in the e-consultation model the cardiologist reviewed the electronic records (e-consultation) and decided to solve without any visit or, if it was necessary, with an in-person consultation. The outcomes between both periods were analysed using an interrupted time series regression model: 1) delay time to cardiology assistance; 2) all-cause and cardiovascular hospital admissions, and 3) all-cause and cardiovascular mortality during the first year after the initial consultation or e-consultation to the CD. Results Among cancer patients referred to cardiology consultation, the introduction of e-consultation decreased waiting times to cardiology care by 51,8% (95% CI: 51,7%-51,9%) (Fig 1). Over 60% of referrals were resolved in less than 8 days, with this proportion significantly higher after the e-consultation program was introduced (p<0,001). Furthermore, we observed a reduction in the one-year rate of outcomes, with an incidence rate ratio (iRR) [IC 95%] of 0,75 [0,73-0,77] for CV-related hospitalizations (Fig 2b), 0,43 [0,42-0,44] for all-cause hospitalization (Fig 2a), and 0,87 [0,86-0,88] for all-cause mortality. In the multivariate analysis, the delay in receiving cardiology care was significantly associated with an independent increase in 1-year mortality (OR [95% CI] 1,39 [1,06-1,83]) and hospital admission (OR [95% CI] 1,25 [1,02-1,52]). Furthermore, the implementation of the e-consult model was associated with a reduction in hospital admission rates (OR [95% CI] 0,19 [0,14-0,25]). Conclusions In comparison to the in-person consultation period, an outpatient care program that incorporates e-consultation for cancer patients significantly reduced waiting times for cardiology care and shown to be safe, associated with lower rates of hospital admissions.Figure 1Figure 2

Introducing online narrated video animations to facilitate patients' understanding of cardiac procedures in a high-volume tertiary centre

Abstract Introduction Discussions about the benefits and risks of invasive procedures, including their alternatives, are an integral part of certain patient consultations in Cardiology. However, patients absorb only a fraction of the information shared during a single encounter, often due to time constraints, leading to an incomplete understanding. Video animation tools were designed to better facilitate communication and consolidate patient (and family members) understanding in advance of their procedure. Purpose We are a high-volume tertiary cardiac centre, and we aimed to assess real-world patient feedback having introduced an online cardiac video animation tool into our organisation. Methods In July 2022, we obtained unlimited patient access to a digital tool that offers short, multi-language narrated video animations covering the breadth of cardiac procedures (cardiac intervention, electrophysiology, structural and cardiac surgery). It is accessible on any device, including a desktop, laptop, or mobile phone. Specifically, we purchased password protected access to 31 video animations in three local languages. Web-links and QR codes for each video animation were designed. These were shared with patients and family members during different stages of the patients’ journey through the hospital. We sampled qualitative feedback from a cohort of patients attending pre-assessment clinic, measured on our electronic patient record via a 3-point Likert scale. Results As illustrated in Figure 1, we adapted our patient pathway to integrate use of this resource in the patient journey by 1) notifying patients during their out-patient cardiologist consultation; 2) emailing video links integrated within an e-consent process; 3) introducing video links as QR codes in patient letters; 4) reminding patients during their nurse-led pre-assessment clinic; 5) via hospital poster advertisements; 6) and on the front page of the hospital website. Since its introduction 18 months ago, 20,607 animation views have occurred, with 90% watched to completion. The three most popular animations were "angiogram/angioplasty" (4135), atrial fibrillation ablation (1415), and TAVI (1243). From July 2022 to December 2023, 1,878 patients have attended our nurse led pre-assessment clinic, and we sampled qualitative feedback from about 20% (342 patients). As demonstrated in Figure 2, 84% of patients felt the procedural video animations were quite helpful/very helpful. The remaining 16% found it "not helpful", with anecdotal reasons being "inability to access the technology", "feeling already adequately informed", or "not wanting to know". Conclusion In our high-volume tertiary centre, online narrated video animations discussing cardiac procedures were successfully implemented into our patient pathway and deemed helpful by the majority of our patients.Fig1.Process map of the patient journeyFig2.Patients’ feedback regarding video

Fine Tuning ECG Interpretation for Young Athletes: ECG Screening Using Z-score-based Analysis

BackgroundElectrocardiograms (ECGs) in athletes commonly reveal findings related to physiologic adaptations to exercise, that may be difficult to discern from true underlying cardiovascular abnormalities. North American and European societies have published consensus statements for normal, borderline, and abnormal ECG findings for athletes, but these criteria are not based on established correlation with disease states. Additionally, data comparing ECG findings in athletes to non-athlete control subjects are lacking. Our objective was to compare the ECGs of collegiate athletes and non-athlete controls using Z-scores for digital ECG variables to better identify significant differences between the groups and to evaluate the ECG variables in athletes falling outside the normal range.MethodsValues for 102 digital ECG variables on 7206 subjects aged 17–22 years, including 672 athletes, from Hawaii Pacific Health, University of Hawaii, and Rady Children’s Hospital San Diego were obtained through retrospective review. Age and sex-specific Z-scores for ECG variables were derived from normal subjects and used to assess the range of values for specific ECG variables in young athletes. Athletes with abnormal ECGs were referred to cardiology consultation and/or echocardiogram.ResultsAthletes had slower heart rate, longer PR interval, more rightward QRS axis, longer QRS duration but shorter QTc duration, larger amplitude and area of T waves, prevalent R’ waves in V1, and higher values of variables traditionally associated with left ventricular hypertrophy (LVH): amplitudes of S waves (leads V1-V2), Q waves (V6, III) and R waves (II, V5, V6). Z-scores of these ECG variables in 558 (83%) of the athletes fell within − 2.5 and 2.5 range derived from the normal population dataset, and 60 (8.9%) athletes had a Z-score outside the − 3 to 3 range. While 191 (28.4%) athletes met traditional voltage criteria for diagnosis of LVH on ECG, only 53 athletes (7.9%) had Z-scores outside the range of -2.5 to 2.5 for both S amplitude in leads V1-V2 and R amplitude in leads V5-6. Only one athlete was diagnosed with hypertrophic cardiomyopathy with a Z-score of R wave in V6 of 2.34 and T wave in V6 of -5.94.ConclusionThe use of Z-scores derived from a normal population may provide more precise screening to define cardiac abnormalities in young athletes and reduce unnecessary secondary testing, restrictions and concern.

Delay in cardiology consultation after primary care physician referrals in heart failure: Clinical implications.

To investigate the association between the elapsed time to cardiology care following a primary care physician (PCP) referral and 1year outcomes among patients with heart failure (HF). Data from electronic medical records at our institution encompassing all PCP referrals to cardiology consultation from 2010 to 2021 (N=68518) were analysed. Of these, 6379 patients had a prior diagnosis of HF. Using a Cox regression model for hospitalization and mortality outcomes, the association between delay time in cardiology care post-PCP referral and 1year outcomes was examined, adjusting for age, gender and comorbidities. A significant increase in 1year mortality rates with delayed cardiology care was observed for each day: all-cause (0.25%), cardiovascular (CV) (0.13%) and HF (0.11%). In multivariate analysis, continuous delay to consultation was independently associated with higher risk of all-cause [hazard ratio (HR): 1.02; 95% confidence interval (CI) (1.01-1.02); P<0.01], CV [1.01 (1.00-1.02); P<0.01] and HF mortality (HR: 1.01; 95% CI 1.00-1.03; P<0.01). Patients attended in the 25th quartile of time delay (<2days) had significantly lower mortality and HF readmission rates [1.21 (1.10-1.33); P<0.01] as compared with patients in the 75th quartile (>14days). Delay in cardiology assistance following a PCP referral among patients previously diagnosed with HF was associated with increased in all-cause, CV, and HF mortality at 1year.

8059 An Interesting Case Of Hypogonadism Likely Caused By Cushing's Syndrome

Abstract Disclosure: R. Ripa: None. J. Su: None. R. Patel: None. Introduction: Cushing’s Syndrome is a rare endocrine disorder that comprises a multitude of symptoms caused by hypercortisolism. Given non-specific symptoms, the disease can often be overlooked for more common diseases, such as diabetes, obesity, and even hypogonadism. Hypogonadism is a clinical disorder defined by decreased functional activity of the gonads. The diagnosis can often be challenging in developed males, who present with hypogonadotropic hypogonadism without an obvious cause. Here we present a case of a male who presented with hypogonadism symptoms for at least 5 years before being diagnosed with Cushing’s syndrome. Case Presentation: 58-year-old Caucasian male with a medical history of hypertension, cardiomyopathy and a BMI of 23, presented with decreased libido and erectile dysfunction. He was started on testosterone therapy three years prior, however it was discontinued due to heart failure. Without testosterone replacement, lab work was notable for: low free and total testosterone, 21.4 and 50.6 ng/dL, respectively, inappropriately normal findings of LH, FSH (1.0 and 4.9 IU/L, respectively), as well as unremarkable findings of GH, Prolactin, TSH, pituitary MRI and testes ultrasound, leading to a suspicion of hypogonadism. Due to persistent symptoms of hypogonadism and low testosterone, clomiphene was started but later changed to testosterone therapy after cardiology consultation. Shortly after, he began reporting facial flushing, associated with facial roundedness and elevated blood pressure. Upon further work up, hyperaldosteronism and pheochromocytoma testing was negative and his baseline cortisol was 21.9 mcg/dL with a low adrenocorticotropic hormone (ACTH), &amp;lt;5 pg/mL. Further, dexamethasone suppression testing showed suboptimally suppressed cortisol (14.4 mcg/dL). An abdomen MRI with and without contrast revealed a 2.3 cm adrenal adenoma, confirming an adrenal source of Cushing’s syndrome, and he underwent an adrenalectomy. Post-procedure, his cortisol and ACTH levels normalized to 10.5 mcg/dL and 39 pg/mL, respectively, showing a revival of his hypothalamic - pituitary - adrenal axis. Unfortunately, however, his free and total testosterone levels continued to remain low (38.9 and 152 ng/dL, respectively) and he was continued on testosterone therapy. Discussion: Our patient initially presented with decreased libido, and low testosterone levels and was treated for hypogonadism, as he did not have typical Cushing’s symptoms. Due to eventual weight gain and facial edema, it was only then that work up was pursued showing hypercortisolism release, leading to a proper diagnosis of Cushing’s syndrome. Hypercortisolism can affect all parts of the body, including hormones, muscles, joints and bones. When presenting in the initial stages and with mild symptoms, the diagnosis of hypercortisolism is often challenging and can go undetected for many years. Presentation: 6/2/2024

Cardiac Radiation Exposure and Incident Cancer: challenges and opportunities.

Use of radiological procedures has enormously advanced cardiology. People with heart disease are exposed to ionizing radiation. Exposure to ionizing radiation increases lifetime cancer risk with a dose-proportional hazard according to the linear no-threshold model adopted for radioprotection purposes. In the United States, the average citizen accumulates a median annual medical radiation exposure of 2.29 millisievert (mSv) per year per capita as of the radiologic year 2016, corresponding to the dose exposure of 115 chest X-rays. Cardiology studies often involve high exposures per procedure accounting for approximately 30% to 50% of cumulative medical radiation exposures. Malignancy is more incident in the most radiosensitive organs receiving the largest organ dose from cardiac interventions and cardiovascular imaging testing, such as the lung, bone marrow, and female breast. The latency period between radiation exposure and cancer is thought to be at least 2 years for leukemia and 5 years for all solid cancers, and differences are more likely to emerge in cardiology studies with longer follow-up and inclusion of non-cardiovascular endpoints such as cancer incidence. In cardiological studies, excess cancers are observed 3 to 12 years following exposure, with longer follow-up times showing greater differences in cancer incidence. The presumed associated excess cancer risk needs greater study. These exposures provide a unique opportunity to expand our knowledge of the relationship between exposure to ionizing radiation and cancer risk. Future trials comparing interventional fluoroscopy versus optimal medical therapy or open surgery should include a cancer incidence endpoint.

Cardiology Consult for the General Pediatrician after Cardiac Manifestations from a SARS-CoV-2 Infection.

The novel Coronavirus Disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, created a need for evidence-based guidelines for the evaluation, management, and follow-up after infection. Data have become rapidly available, creating a challenge for medical providers to stay abreast of the ever-evolving recommendations. This document, written collaboratively by pediatric cardiovascular experts, pediatricians, and sports medicine specialists, is focused on SARS-- CoV-2-related pediatric cardiac manifestations. It aims to provide a systemic review of high-yield literature related to all cardiovascular entities as a tool for primary pediatric clinicians to utilize as they consider the cardiac consequences of acute SARS-CoV-2 infection, MIS-C, vaccine-related myocarditis, return-to-play, and long COVID-19 syndrome.

In-Hospital Outcomes of Patients with Non-ST Elevation Myocardial Infarction Undergoing Early Invasive Percutaneous Coronary Intervention

Methodology: A cross-sectional study was conducted in the Adult Cardiology Department at the National Institute of Cardiovascular Diseases (NICVD) in Karachi, Pakistan, from August 2019 to February 2020. The study included 165 patients, both male and female, aged 40 to 75 years, who presented with NSTEMI and underwent early invasive PCI. All patients were either admitted through the emergency department or referred from outpatient services at NICVD. Comprehensive medical assessments were performed, and relevant medical history and clinical details were documented. PCI procedures were conducted under the supervision of experienced consultant cardiologists with over five years of procedural expertise. The primary outcomes evaluated were the incidence of cardiogenic shock, heart failure, and in-hospital mortality. Results: Of the 165 patients included in the study, 125 (75.8%) were male, with a mean age of 56.6±7.72 years and a mean BMI of 26.5±3.8 kg/m². Hypertension was prevalent in 100 (60.6%) patients, while 78 (47.3%) had diabetes mellitus. A history of smoking was reported in 70 (42.4%) patients. Heart failure emerged as the most common in-hospital adverse outcome, occurring in 25 (15.2%) patients, followed by cardiogenic shock in 9 (5.5%) patients, and in-hospital mortality in 20 (12.1%) patients. Conclusion: Among patients undergoing early invasive PCI following NSTEMI, heart failure was the most frequent adverse in-hospital outcome, followed by mortality and cardiogenic shock. These findings underscore the importance of vigilant monitoring and management of high-risk NSTEMI patients during the early stages of PCI intervention.

Diagnostic Challenges and Outcomes in Transient Loss of Consciousness: A Retrospective Analysis

Abstract Background Transient loss of consciousness (T-LOC) is a common presenting complaint, posing significant diagnostic challenges. This study explores outcomes for T-LOC. Methods Using the Hospital Inpatient Enquiry System, data on patients with T-LOC were collected at a large academic teaching hospital over six months, including demographics, length of stay (LOS), diagnostic tests, and discharge diagnoses. Results A total of 160 T-LOC patient visits were analysed, divided into three age cohorts: under 65 (n=66), 65-74 (n=38), and over 75 (n=56). Of the 94 patients aged over 65 (58.75% of the sample), mean age was 76.07 years; 47% were female. Diagnostics varied by age, with higher rates of computed tomography of the brain (87.23%) and lying-standing blood pressure (37.23%) in those over 65. Conversely, those over 65 were less likely to receive electrocardiograms (86.17% vs. 96.97%), telemetry (51.06% vs. 59.09%), magnetic resonance imaging of the brain (21.28% vs. 25.76%), transthoracic echocardiograms (14.89% vs. 25.76%), and exercise stress tests (3.19% vs. 10.61%) compared to those under 65. Carotid ultrasound and electroencephalography were infrequently performed across all age groups. Patients aged over 75 were most likely to have a diagnosis (78.57% vs 60.53% in 65-74 and 60.61% in under 65). Orthostatic hypotension was the most common diagnosis 8.51% (8/94) of those over 65. 33.13% (53/160) of patients had no diagnosis documented. LOS increased with age: averaging 6 days (range 1-19) for those under 64, 7.45 days (range 1-36) for those 65-74, and 9.09 days (range 1-64) for those over 75. Older adults were less likely to receive cardiology (19.15%) and neurology consultations (11.70%) compared to those under 65 (27.27% and 36.36%, respectively). Conclusion A considerable number of patients lacked a diagnosis, highlighting the diagnostic complexities of T-LOC. The development of a specialist syncope assessment pathway is underway to improve diagnostics, potentially reducing unnecessary tests and hospital stays.

Association of a Novel Electronic Form for Preoperative Cardiac Risk Assessment With Reduction in Cardiac Consultations and Testing: Retrospective Cohort Study.

Preoperative cardiac risk assessment is an integral part of preoperative evaluation; however, there is significant variation among providers, leading to inappropriate referrals for cardiology consultation or excessive low-value cardiac testing. We implemented a novel electronic medical record (EMR) form in our preoperative clinics to decrease variation. This study aimed to investigate the impact of the EMR form on the preoperative utilization of cardiology consultation and cardiac diagnostic testing (echocardiograms, stress tests, and cardiac catheterization) and evaluate postoperative outcomes. A retrospective cohort study was conducted. Patients who underwent outpatient preoperative evaluation prior to an elective surgery over 2 years were divided into 2 cohorts: from July 1, 2021, to June 30, 2022 (pre-EMR form implementation), and from July 1, 2022, to June 30, 2023 (post-EMR form implementation). Demographics, comorbidities, resource utilization, and surgical characteristics were analyzed. Propensity score matching was used to adjust for differences between the 2 cohorts. The primary outcomes were the utilization of preoperative cardiology consultation, cardiac testing, and 30-day postoperative major adverse cardiac events (MACE). A total of 25,484 patients met the inclusion criteria. Propensity score matching yielded 11,645 well-matched pairs. The post-EMR form, matched cohort had lower cardiology consultation (pre-EMR form: n=2698, 23.2% vs post-EMR form: n=2088, 17.9%; P<.001) and echocardiogram (pre-EMR form: n=808, 6.9% vs post-EMR form: n=591, 5.1%; P<.001) utilization. There were no significant differences in the 30-day postoperative outcomes, including MACE (all P>.05). While patients with "possible indications" for cardiology consultation had higher MACE rates, the consultations did not reduce MACE risk. Most algorithm end points, except for active cardiac conditions, had MACE rates <1%. In this cohort study, preoperative cardiac risk assessment using a novel EMR form was associated with a significant decrease in cardiology consultation and testing utilization, with no adverse impact on postoperative outcomes. Adopting this approach may assist perioperative medicine clinicians and anesthesiologists in efficiently decreasing unnecessary preoperative resource utilization without compromising patient safety or quality of care.

Beyond lung cancer screening, an opportunity for early detection of chronic obstructive pulmonary disease and cardiovascular diseases.

Lung cancer screening programs concern smokers at risk for cardiovascular diseases (CVDs) and chronic obstructive pulmonary disease (COPD). The LUMASCAN (LUng Cancer Screening, MArkers and low-dose computed tomography SCANner) study aimed to evaluate the acceptability and feasibility of screening for these 3 diseases in a community population with centralized organization and to determine low-dose computed tomography (CT) markers associated with each disease. This cohort enrolled participants meeting National Comprehensive Cancer Network criteria (v1.2014) in an organized lung cancer-screening program including low-dose CT scans; spirometry; evaluations of coronary artery calcifications (CACs); and a smoking cessation plan at inclusion, 1, and 2 years; then telephone follow-up. Outcomes were the participation rate and the proportion of participants affected by lung cancer, obstructive lung disease, or CVD events. Logistic-regression models were used to identify radiological factors associated with each disease. Between 2016 and 2019, a total of 302 participants were enrolled: 61% men; median age 58.8 years; 77% active smoker; 11% diabetes; 38% hypertension; and 27% taking lipid-lowering agents. Inclusion, 1-year, and 2-year participation rates were 99%, 81%, 79%, respectively. After a median follow-up of 5.81 years, screenings detected 12 (4%) lung cancer, 9 of 12 via low-dose CT (78% localized) and 3 of 12 during follow-up (all stage IV), 83 (27%) unknown obstructive lung disease, and 131 (43.4%) moderate to severe CACs warranting a cardiology consultation. Preexisting COPD and moderate to severe CACs were associated with major CVD events with odds ratios of 1.98 (95% confident interval [CI] = 1.00 to 3.88) and 3.27 (95% CI = 1.72 to 6.43), respectively. The LUMASCAN study demonstrated the feasibility of combined screening for lung cancer, COPD, and CVD in a community population. Its centralized organization enabled high participation and coordination of healthcare practitioners.

Radiation Oncology Opinions and Practice on Cardiotoxicity in Lung Cancer: A Cross-sectional Study by the International Cardio-oncology Society

AimsSymptomatic radiation cardiotoxicity affects up to 30% patients with lung cancer and several heart substructure doses are associated with reduced overall survival. A greater focus on minimising cardiotoxicity is now possible due to advancements in radiotherapy technology and the new discipline of cardio-oncology, but uptake of emerging data has not been ascertained. A global cross-sectional analysis of Radiation Oncologists who treat lung cancer was therefore conducted by the International Cardio-Oncology Society in order to establish the impact of recently published literature and guidelines on practice. Materials and methodsA bespoke questionnaire was designed following an extensive review of the literature and from recurring relevant themes presented at Radiation Oncology and Cardio-Oncology research meetings. Six question domains were retained following consensus discussions among the investigators, comprising 55 multiple choice stems: guidelines, cardiovascular assessment, cardiology investigations, radiotherapy planning strategies, primary prevention prescribing and local cardio-oncology service access. An invitation was sent to all Radiation Oncologists registered with ICOS and to Radiation Oncology colleagues of the investigators. ResultsIn total 118 participants were recruited and 92% were consultant physicians. The ICOS 2021 expert consensus statement was rated as the most useful position paper, followed by the joint ESC–ESTRO 2022 guideline. The majority (80%) of participants indicated that a detailed cardiovascular history was advisable. Although 69% of respondents deemed the availability of cardiac substructure auto-segmentation to be very/quite important, it was implemented by only a few, with the most common being the left anterior descending coronary artery V15. A distinct cardio-oncology service was available to 39% participants, while the remainder utilised general cardiology services. ConclusionThe uptake of recent guidelines on cardiovascular optimisation is good, but access to cardiology investigations and consultations, and auto-segmentation, represent barriers to modifying radiotherapy practices in lung cancer to reduce the risk of radiation cardiotoxicity.