Outpatient Cardiology Research Articles

Validation of Psychometric Properties of Partners in Health Scale for Heart Failure.

Background: Congestive heart failure (CHF) is a complex chronic disease, and it is associated with a second comorbid condition in more than half of cases. Self-management programs can be specific to CHF or generic for chronic diseases. Several tools have been validated for CHF. Presently, there are no established generic instruments that are validated for measuring self-management in CHF. Objective: This study aims to evaluate the internal reliability and construct validity (psychometric properties) of the Partners in Health (PIH) scale for patients with congestive heart failure, a generic chronic disease self-management tool. Methods: The study included 210 adult CHF patients [120 with heart failure with reduced ejection fraction (HfrEF), 90 with preserved ejection fraction (HfpEF)], from Community Cardiology Outpatients in West Melbourne, Australia, who were treated in community cardiology and were included between May 2022 and Jan 2024. The screened patient population were diagnosed with CHF and were eligible for an SGLT-2 inhibitor. Cohort analysis used the Bayesian confirmatory factor analysis to evaluate the a priori four-factor structure. Omega coefficients and 95% credible intervals (CI) were used to assess internal reliability. Results: In the CHF (HFrEF) and preserved ejection fraction (HFpEF) cohorts, participants' mean [standard deviation (SD)] age was 66.8 (13.5) and 71.3 (9.76) years. Description of study sociodemographics highlighted that 88% and 52% of patients were male, there was a BMI > 50% in both cohorts, eGFR > 60 mL/min were 59% and 74%, and LVEF < 40% and > 50% were 99% and 100%, respectively. Model fit for the hypothesised model was adequate (posterior predictive p = 0.073) and all hypothesised factor loadings were substantial (>0.6) and significant (p < 0.001). Omega coefficients (95% CI) for the PIH subscales of Knowledge, Partnership, Management and Coping were 0.84 (0.79-0.88), 0.79 (0.73-0.84), 0.89 (0.85-0.91) and 0.84 (0.79-0.88), respectively. Conclusion: This study is original in confirming the dimensionality, known-group validity, and reliability of the PIH scale for measuring generic self-management in outpatients with CHF syndrome.

Transthoracic cardiac ultrasonic shear wave elastography for detecting myocardial stiffness in healthy and hypertrophic cardiomyopathy individuals

Objective: To explore the feasibility of transthoracic cardiac shear wave elastography (SWE) for non-invasive quantitative measurement of myocardial stiffness in healthy volunteers (HV) and hypertrophic cardiomyopathy (HCM) patients, and analyze the relationship between myocardial shear wave velocity (SWV) and left ventricular diastolic function. Methods: A total of 16 HV who underwent health check-ups and 5 HCM patients who visited the Cardiology Outpatient Clinic at Fujian Medical University Affiliated Union Hospital from September 2022 to October 2023 were prospectively recruited. The SWE technique was used to measure SWV of the basal segment of the interventricular septum, including left ventricular long-axis myocardial shear wave velocity (LA-SWV) and short-axis myocardial shear wave velocity (SA-SWV). The intraclass correlation coefficient (ICC) was employed to evaluate the intra-observer and inter-observer consistency of SWV measurements. Spearman's correlation analysis was performed to evaluate the correlation between baseline characteristics, echocardiography parameters and SWV. Quantitative data were expressed as median (interquartile range) [M (Q1, Q3)]. Results: The HV group had the age of 34.5 (24.0, 51.0) years, including 8 males (50%); the HCM group had the age of 34.0 (27.0, 46.0) years, including 3 males (60%). The intra-observer and inter-observer ICC (95%CI) for LA-SWV measurements were 0.806 (0.592-0.907) and 0.785 (0.471-0.949), respectively, indicating high consistency; the intra-observer and inter-observer ICC (95%CI) for SA-SWV measurements were 0.746 (0.359-0.862) and 0.602 (0.245-0.834), indicating moderate consistency. LA-SWV [1.74 (1.65, 1.77) vs 1.25 (1.22, 1.33) m/s, P<0.001] and SA-SWV [1.98 (1.96, 2.15) vs 1.52(1.46, 1.55) m/s, P<0.001] were significantly higher in HCM group than those in HV group. There was no significant correlation between SWV and gender, age or body mass index (all P>0.05). In the left ventricular long-axis view, interventricular septal end-diastolic thickness (IVSDT) (r=0.749, P<0.001), early diastolic mitral valve flow velocity/early diastolic mitral annular peak motion velocity (E/e') (r=0.669, P<0.001), and left ventricular mass index (LVMI) (r=0.679, P<0.001) were positively correlated with LA-SWV, while e' (r=-0.545, P<0.001) and late diastolic mitral annular peak motion velocity (r=-0.489, P=0.021) were negatively correlated with LA-SWV. In the left ventricular short-axis view, IVSDT (r=0.784, P<0.001), E/e' (r=0.657, P<0.001), and LVMI (r=0.660, P<0.001) were positively correlated with SA-SWV, while e' was negatively correlated with SA-SWV (r=-0.658, P<0.001). Conclusions: The use of SWE technique to measure myocardial SWV can be applied to assess the stiffness differences between normal myocardium and HCM myocardium. Additionally, SWV is correlated with left ventricular diastolic function indices and can effectively evaluate the diastolic dysfunction of the left ventricle caused by HCM.

The role of pre-existing left-sided valvular heart disease in the prognosis of patients with acute myocardial infarction.

Acute myocardial infarction (AMI) and valvular heart disease (VHD) are the leading causes of cardiovascular morbidity and mortality. The epidemiology of VHD has changed in recent decades with an aging population, increasing risk factors for cardiovascular disease and migration, all of which have a significant implifications for healthcare systems. Due to common pathophysiological mechanisms and risk factors, AMI and VHD often coexist. These patients have more complicated clinical characteristics, in-hospital course and outcomes, and are less likely to receive guideline-directed therapy. Because of the reciprocal negative pathophysiological influence, these patients need to be referred to VHD specialists and further discussed within the Heart team to assess the need for earlier intervention. Since the results of the number of studies show that one third of the patients are referred to the heart teams either too early or too late, there is a need to better define the communication networks between the treating physicians, including internists, general practitioners, outpatient cardiologists and heart teams, after the discharge of patients with pre-existing VHD and AMI.

Reliability, internal consistency, and validity of the World Health Organization disability assessment schedule (WHODAS) 2.0 among adults with heart failure

BackgroundHeart failure (HF) imposes significant disability. The World Health Organization Disability Assessment Schedule (WHODAS) 2.0 is a generic instrument that measures disability. Although it has been used in HF, no previous study has investigated its measurement properties in this group. ObjectiveTo assess the test-retest reliability, internal consistency, convergent, and discriminant validity of WHODAS 2.0 in individuals with HF. MethodsWe conducted a cross-sectional study that included individuals with HF treated at the outpatient cardiology center. Data included sociodemographic and clinical (e.g., New York Heart Association - NYHA) characteristics, estimated functional capacity (Duke Activity Status Index - DASI), quality of life (Minnesota Living with Heart Failure Questionnaire - MLHFQ), and disability (the WHODAS 2.0 36-item version). We assessed associations, using Pearson's correlation coefficient or the Kruskal-Wallis test, between the WHODAS 2.0 scores and the MLHFQ, DASI, and NYHA. The WHODAS 2.0 results were collected again seven days after the initial assessment for reliability (intraclass correlation coefficient - ICC). ResultsParticipants were 100 people with HF (M age = 57.8 ± 14 years, 57 % men), of whom 84 % were literate. The WHODAS 2.0 was reliable (ICC = 0.789) and had good internal consistency (Cronbach's alpha >0.7 in all domains). Convergent validity was observed through moderate correlations with DASI and MLHFQ and discriminant validity with statistically different results according to NYHA classes. ConclusionWHODAS 2.0 is a reliable, consistent, and valid instrument for measuring disability in individuals with HF. Further research is needed to evaluate other properties, such as its responsiveness to interventions.

Abstract 4112591: Delayed Migration of a Valve-in-Valve Transcatheter Aortic Valve Replacement

Introduction: Migration of a transcatheter aortic valve replacement (TAVR) is a rare, life-threatening complication that typically occurs during or shortly after the procedure. We present a unique case of an exceptionally rare, delayed migration of a valve-in-valve TAVR three years post-procedure that was subsequently treated with surgical explantation of the TAVR prosthesis and surgical aortic valve replacement (SAVR). Clinical Case: A 64-year-old male presented to an outpatient cardiology visit with one month of exertional dyspnea and near-syncopal episodes with a new diastolic murmur. Notable history included aortic regurgitation due to bicuspid aortic valve resulting in subcoronary implantation of a 27 mm Medtronic Freestyle stentless porcine bioprosthesis 20 years prior to presentation. Following the development of severe bioprosthetic regurgitation, a valve-in-valve TAVR with a 26 mm Edwards SAPIEN 3 Ultra was implanted 3 years prior to presentation with no evidence of stenosis or regurgitation on transthoracic echocardiograms completed 1 month and 1 year after implantation. Transesophageal echocardiogram now demonstrated migration of the TAVR valve into the left ventricular outflow tract 2 cm proximal to the surgical bioprosthesis. Severe eccentric transvalvular regurgitant flow through the surgical bioprosthesis and severe paravalvular regurgitation around the TAVR valve was seen with an unstable “rocking appearance”. No evidence of abscess or endocarditis was appreciated and blood cultures showed no growth. Following a short hospitalization, the patient underwent TAVR explantation and implantation of a 25 mm Edwards Inspiris Resilia stented bovine bioprosthesis with subsequent resolution of his symptoms. Discussion: Recognizing atypical presentations of TAVR complications such as delayed valve migration is facilitated by understanding key risk factors. This case highlights notable risk factors for TAVR migration including a valve-in-valve TAVR over a degenerative regurgitant bioprosthesis, decreased aortic annulus calcification resulting in suboptimal anchoring, the patient’s younger age, and the lack of a radiopaque marker on the stentless bioprosthesis which increases the potential for malpositioning.

Cardiovascular sequelae in symptomatic SARS-CoV-2 infection survivors.

SARS-CoV-2 infection may lead to myocardial and endothelial damage. The present study sought to characterize the cardiovascular sequel in a large group of consecutive patients admitted for out-patient cardiovascular follow-up after a symptomatic COVID-19 infection. The aims of this study were as follows: to evaluate the presence of post-covid cardiovascular symptoms in an unselected population of outpatients referred to a post-COVID outpatient cardiology clinic and to characterize the long-term abnormalities associated with a more severe COVID-19 infection clinical course. A total of 914 patients were included in this single-center, observational, cross-sectional study, of which 163 were hospitalized and 149 required mechanical ventilation for COVID-19 pneumonia. Patients were analyzed at follow-up according to the care setting during the initial presentation. The median time to follow-up was 126 days. At that time, only 3.5% of patients reported no persistent dyspnea, chest pain, or fatigue on exertion. In a follow-up echocardiographic assessment, patients who required hospitalization showed slight alterations in the pulmonary acceleration time and the tricuspid regurgitation pressure gradient, as well as reduced exercise tolerance during treadmill exercise testing when compared to patients with a benign clinical course. 24-hour Holter EKG monitoring or 24-hour blood pressure monitoring did not identify significant differences between the analyzed subgroups. The current study reports on an association between COVID-19 severity and the presence of cardiovascular alterations at follow-up. A simple diagnostic protocol, comprising an exercise treadmill test and transthoracic echocardiography is useful in identifying patients who may benefit from regular, structured cardiovascular medical care.

Vicious cycle of vitamin B1 insufficiency and heart failure in cardiology outpatients.

Heart failure is a major manifestation of vitamin B1 deficiency; beriberi. We have previously reported that even vitamin B1 insufficiency, milder than deficiency, is a risk for heart failure in the institutionalized elderly. Then in this cross-sectional study, sixty-eight cardiology outpatients were evaluated for their whole blood vitamin B1 and plasma brain natriuretic peptide (BNP) concentrations, a sensitive marker of heart failure, as well as their dietary intake. Whole blood vitamin B1 concentration was significantly correlated with plasma BNP level in vitamin B1-deficient/insufficient patients (whole blood vitamin B1<28 ‍ng/ml) but not in sufficient patients. Whole blood vitamin B1 concentration was significantly lower in loop diuretics users than non-users. Multiple regression analysis has identified whole blood vitamin B1 concentration and eGFR as the significant contributors to log-transformed plasm BNP level, and loop diuretics use, serum albumin level, and eGFR as the contributors to whole blood vitamin B1 concentration. ROC analysis has shown the significant predictability of whole blood vitamin B1 for plasma BNP ≥100 pg/ml with the cut-off value of 23.5 ‍ng/ml. Vitamin B1 insufficiency is a risk of heart failure in the cardiology outpatients, and the therapeutic use of loop diuretics aggravates heart failure and possibly forms a vicious cycle.

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

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

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 (&amp;gt;440 &amp;lt;2000ng/L) and those with grossly raised levels (&amp;gt;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.

Initial experience with a 5G cellular network and robotic arm-based remote echocardiographic system in an all-comers setting

Abstract Background Echocardiography is the test-of-choice for the initial evaluation of many cardiac diseases and requires expertise that is often limited in rural area. Robotic arm-assisted remote echocardigram has been attampted for teleconsultation but was limited to heart failure patients(ref), primarily due to the network delay in telecommunication and the subsequent incoordination in robotic arm control. Purpose We aim to assess the feasibility and diagnostic accuracy of a 5G cellular network and robotic arm-based remote echocardiographic system in an all-comers setting. Methods 51 pts were enrolled from the outpatient cardiology clinic of our institute. All pts underwent standard comprehensive echocardiography on a 5G cellular network and robotic arm-based remote echocardiographic system (the robotic part was deployed at our hospital and the control part was located at another campus 20 kilometers away) (Figure 1)and a conventional echocardiographic platform (at our hospital) successively. The order in which patients were examined on the remote and conventional instruments was randomly determined. There was no interval between the two examinations, and examinations of the same patient were performed by experienced but different cardiologists, who were blinded to each other’s diagnosis. The doctor who used the remote system was also randomly allocated and had not been previously specifically trained. The exams were real-time and diagnoses were made right after the exams. Results Of the 51 pts, the image quality was sufficient for diagnosis in 50 patients (48% female, 40±18 years). 1 pt was excluded because some key views could not be obtained using the remote system (98% of exams successful). 17 pts had positive findings, including 10 with a primary diagnosis of valvulopathy (1 Barlow's syndrome, 1 bicuspid aortic valve and 8 less-than-moderate regurgitation), 2 cardiac surgery follow-ups (1 case of aortic valve replacement and septal myectomy, and 1 case of mitral valve replacement and tricuspid annuloplasty), and 2 hypertrophic cardiomyopathy (including 1 case of obstruction at papillary muscle level), 2 with abnormal left ventricular wall motion(including 1 case of apical mural thrombus) (Figure 2), and 1 with congenital heart disease (secumdum atrial septal defect). The main diagnosis was consistent in 98% of cases (papillary muscle level obstruction was missed in one case), using conventional echocardiographic findings as the standard. Time for image acquision using remote echocardiography was significantly longer than conventional one (24 minutes 36 seconds ± 4 minutes 52 seconds vs. 16 minutes 15 seconds ± 1 minute 54 seconds, p&amp;lt;0.0001, paired t-test). Conclusions Comprehensive echocardiographic exam with a 5G cellular network and robotic arm-based remote system is feasible with relatively good diagnostic accuracy.Figure 1Figure 2

Assessment of experimental circulating biomarkers in volume and pressure overload: insights from a cohort study

Abstract Introduction Experimental biomarkers including Angiopoietin-2 (ANG2), bone morphogenetic protein 10 (BMP10), fibroblast growth factor 23 (FGF23), and insulin-like growth factor-binding protein 7 (IGFBP7) are hypothesized to reflect cardiac pathophysiological processes that are potentially present in adverse cardiac remodeling in volume or pressure overload. This study aims to elucidate the relationship between these circulating biomarkers and the presence of hemodynamically significant pressure or volume overload and adverse outcomes and compare it to N-terminal pro B-type natriuretic peptide (NT-proBNP). Methods We studied the association between the four experimental circulating biomarkers in patients with pressure or volume overload with reference to none/mild valvular disease in N=1302 of an observational outpatient cardiology cohort. The median age was 63.0 (25th/75th quartile 51.5, 71.4) years, 445 (34.2%) were women. Circulating biomarkers were quantified using a novel antibody-based method. Logistic regression models with cox regression plots were employed to assess the association of each biomarker with the severity of valve disease concerning volume or pressure overload, adjusted for age and sex. Results In the overall population, elevated levels of ANG2, BMP10, FGF23 and IGFB7 were positively associated with the presence of significant volume overload (ANG2: Odds ratio (OR) 1.26 (95% confidence interval (CI) 1.17-1.35), p&amp;lt;0.001; BMP10: OR 2.57 (CI 1.89-3.48), p&amp;lt;0.001; FGF23: OR 1.51 (CI 1.14-1.20), p=0.004; IGFBP7: OR 1.39 (CI 1.14-1.69), p=0.001, NT-proBNP: OR 1.69 (CI 1.47-1.95), p&amp;lt;0.001). No statistically significant association between circulating biomarkers and pressure overload was observed. Over a median follow-up of 4 years, 31 (20.1%) participants died in the group of volume overload and 9 (40.9%) individuals in the group of pressure overload. After multivariable-adjustment, elevated levels of BMP 10 showed a borderline association with an increased risk of all-cause mortality in individuals with volume overload compared to none/mild valvular disease: hazard ratio (HR) 1.51 (CI 0.96- 2.38), p=0.075. Higher concentrations of all biomarkers were predictive of all-cause mortality for both individuals with volume overload and those with none/mild valvular disease (ANG2: HR 3.72 (CI 1.67-8.33), p=0.001; BMP10: HR 1.65 (CI 1.20-2.26), p=0.002; FGF23: HR 2.08 (CI 1.65-2.62), p&amp;lt;0.001; IGFBP7: HR 1.55 (CI 1.25-1.91), p&amp;lt;0.001; NT-proBNP: HR 1.72 (CI 1.47-2.00), p&amp;lt;0.001). Conclusions This study demonstrates that circulating biomarkers involved in distinct pathophysiological pathways of inflammation, fibrosis and calcification are elevated in patients with hemodynamically significant volume overload. Since they are also related to mortality, their clinical role needs to be explored further, also in context with the routine biomarker NT-proBNP.

Value-based versus usual care for heart failure patients leads to reduction in cost, hospital admissions and improved survival

Abstract Background OptumCare (OC) in our city, Nevada established a heart failure (HF) program comprised of a team of outpatient cardiologists including two who are board certified in advanced heart failure. Referred patients are enrolled in the HF program once HF is diagnosed by a cardiologist. Patients are managed by an interdisciplinary team of cardiologists, advanced practice clinicians (APC), registered nurse case managers (RNCM), and a social worker. Patients at higher risk for HF admissions are enrolled in remote patient telemonitoring. In contrast, OC in Arizona utilizes a "usual" care approach of fee-for-service contracted cardiology groups to manage HF patients in outpatient and in-patient settings. Purpose A head-to-head comparison was performed between the cohort of patients enrolled in HF program in OC Nevada (treatment group) and patients with HF diagnosis in OC Arizona (control group). The groups were compared on the following measures: medical cost, hospital admissions, and survival rates. Methods In this retrospective study, a 1:1 iterative propensity score (PS) matching was performed to closely approximate patient demographics and comorbidities, which resulted in 818 matched pairs (total n=1,636) of the patients with program enrollment or 1st HF diagnosis between March 1, 2019 and June 30, 2022. For Difference-in-Difference Analysis (Diff-in-Diff), generalized linear models were used on PS matched data to test the difference in difference in medical cost and utilizations changes between control and treatment group over a six month period. Log-Binomial regression was used to estimate the relative risk of post period 30-day readmission and hospice enrollment. Kaplan Meier Estimator was used to test the difference in survival rates over time. Results Average age of patients was 77.6 years old, and 49% were female. The treatment group resulted in significantly lower overall medical costs per member per month (PMPM), significantly less emergency room (ER) visits, less acute hospital and skilled nursing facility (SNF) admissions, and shorter overall hospital length of stays. The control group was twice as likely to be readmitted to the hospital. Lastly, the treatment group had a significantly better survival rate than the control group. 19% of the patients in the control group expired within 12 months of enrollment vs. 10% of the patients in the treatment group expired during the same time period. Average survival was 142 days in the control group vs. 200 days in the treatment group. Conclusions A value-based care approach involving a multidisciplinary team in an outpatient-based cardiology HF program resulted in statistically significant improvement in medical costs, acute care visits/admissions, and survival rates compared to "usual" care approach for HF patients.

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

Evaluation of Lipid Profile Management in Coronary Artery Disease Patients on Statin Therapy: A Single-Centre, Retrospective, Observational Study.

Lipid control is crucial in managing coronary artery disease (CAD) to reduce cardiovascular risk. This study aimed to evaluate the effectiveness of lipid-lowering therapy, particularly statins, in achieving target lipid levels in patients with CAD. This single-center, retrospective, observational study was conducted at the Cardiology Outpatient Department of Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharastra, India. A sample size of 72 patients was included in this study. Adult patients receiving treatment for acute coronary syndrome (ACS), chronic stable angina (CSA), or unstable angina (UA) were included. Exclusion criteria were comorbidities affecting clinical decisions, HIV-positive status, pregnancy, or breastfeeding. Data on lipid profiles, including low-density lipoprotein (LDL) cholesterol (LDL-C), were collected, with LDL-C calculated using the Friedewald equation or measured directly. The primary outcome was the proportion of patients achieving LDL-C targets as per the 2019European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines. Statistical analysis was performed using chi-square tests, with significance set at p < 0.05. Of the enrolled patients, a substantial proportion did not achieve target LDL-C levels, with LDL-C remaining above the recommended thresholds in a significant number of patients. Despite ongoing statin therapy, lipid control was suboptimal in many cases, particularly among those with elevated LDL-C levels. A detailed analysis of lipid profiles and the achievement of target levels was done, highlighting areas where current treatment strategies may fall short. The study reveals that a significant number of patients with CAD on statin therapy do not achieve optimal lipid control, particularly in LDL-C management. This underscores the need for more aggressive or tailored lipid-lowering strategies to reduce residual cardiovascular risk in this high-risk population. Further studies are needed to explore the factors contributing to suboptimal lipid control and to develop interventions that can enhance the effectiveness of current therapies.

Premature ventricular contraction patterns associated with nonsustained ventricular tachycardia

BackgroundOccurrence of nonsustained ventricular tachycardia (NSVT) is associated with negative outcomes. It is not clear whether specific electrocardiographic characteristics of premature ventricular contractions (PVCs) are associated with the occurrence of NSVT. The aim of this study was to identify electrocardiographic patterns associated with the presence of NSVT during 24-h electrocardiographic monitoring in patients with >10 PVCs per hour. MethodsThis was a retrospective, observational, cross-sectional study. We reviewed consecutive patients who received 24-h ECG monitoring performed at a single outpatient cardiology center. Patients who received 24-h electrocardiographic monitoring, with a PVC burden ≥10 PVCs/h were included. Occurrence of NSVT during 24-h electrocardiographic monitoring was the main outcome. ResultsA total of 343 patients were analyzed (mean [SD] age, 69.7 [12.5] years; 177 men [51.6 %]). NSVT occurred in 72 patients who were compared with 271 patients without NSVT. The novel term “premature beat ratio”, which aims to correlate the coupling interval and compensatory pause, was introduced; a value >0.5 was independently associated with NSVT according to the multivariate model (OR = 3.73, 95 % CI = 1.57–8.82; P = 0.002). PVC burden (OR = 1.09, 95 % CI = 1.02–1.17; P = 0.006), and triplets (OR = 18.19, 95 % CI = 7.32–45.18 P = 0.0) were also associated with NSVT in the multivariate model. ConclusionThese findings suggest that patients with a high PVC burden, triplets, and a premature beat ratio greater than 0.5 have an increased probability of presenting with NSVT and may benefit from more rigorous follow-up.

Implementation and analysis of clinic administered behavioural health screen in an outpatient paediatric cardiology clinic.

Previous studies investigating behavioural health screening processes have focused on selected diagnoses within paediatric cardiology and focused on a smaller number of potential concerns. We developed and administered a brief survey in our paediatric heart centre to assess the presence of a wider variety of behavioural health concerns and to connect patients with resources. A cohort of 305 patients aged 2-29 years (M = 11.97 years; SD = 6.00 years; 50.49% female), representing a variety of indications for a cardiology clinic visit, or a parent, completed a survey of 14 common behavioural health concerns. Behavioural health concerns were included based on practice patterns within paediatric psychology. Respondents indicated if they were currently receiving behavioural health services and if they were interested in behavioural health follow-up. Surveys were administered during check in and collected by clinic staff. A behavioural health provider attempted to reach all those who indicated interest by phone. Approximately 45% of the sample endorsed one or more behavioural health concerns and 30.16% of the sample endorsed at least one concern but were not already connected to services. Only 27.17% of this group requested follow-up. Most commonly endorsed concerns were anxiety, sleep problems, depressed/irritable mood, and somatic complaints. Survey results converge with existing literature to indicate that behavioural health concerns are common among youth seen in a paediatric cardiology clinic but most patients are not connected to appropriate services. Screening programmes can help meet this need but challenges remain. Clinical implications and future directions are discussed.

Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility in athletes with heart disease: update 2024.

Nearly 35 years after its initial publication in 1989, the Italian Society of Sports Cardiology and the Italian Federation of Sports Medicine (FMSI), in collaboration with other leading Italian Cardiological Scientific Associations (ANCE - National Association of Outpatient Cardiology, ANMCO - National Association of Inpatient Cardiology, SIC - Italian Society of Cardiology), proudly present the 2023 version of the Cardiological Guidelines for Competitive Sports Eligibility. This publication is an update of the previous guidelines, offering a comprehensive and detailed guide for the participation of athletes with heart disease in sports. This edition incorporates the latest advances in cardiology and sports medicine, providing current information and recommendations. It addresses various topics, including the details of the pre-participation screening in Italy and recommendations for sports eligibility and disqualification in competitive athletes with various heart conditions. This revised version of the Cardiological Guidelines for Competitive Sports Eligibility, recorded in the Italian Guidelines Registry of the Italian Minister of Health, stands as a crucial resource for sports medicine professionals, cardiologists, and healthcare providers, marked by its completeness, reliability, and scientific thoroughness. It is an indispensable tool for those involved in the care, management and eligibility process of competitive athletes with heart conditions.

Prevalence of hyperlipoproteinemia(a) in individuals of European ancestry treated at outpatient cardiology clinics: results from a cross-sectional STAR-Lp(a) study.

Elevated levels of lipoprotein(a) [Lp(a)] are independently associated with an increased risk of cardiovascular disease (CVD). We aimed to evaluate the levels of Lp(a) among patients of European ancestry referred to outpatient cardiology clinics. We analyzed 2475 consecutive patients referred to 2 outpatient cardiology clinics between March 2022 and January 2024. Individuals with atherosclerotic CVD, heart failure, significant valve disease, and aortic aneurysm were excluded. A majority of the study population were women (n = 1724 [69.7%]). The median (interquartile range) age of the participants was 66 (53-73) years. An Lp(a) level greater than or equal to 30 mg/dl (≥75 nmol/l) was recorded in 21.5% and a level greater than or equal to 50 mg/dl (≥125 nmol/l) was recorded in 13.5% of the patients. In univariable analysis, the Lp(a) level was significantly associated with hypertension, sleep apnea, migraine, polycystic ovary syndrome, physical activity level, as well as fasting blood glucose, glycated hemoglobin A1c (HbA1c), low‑density lipoprotein cholesterol (LDL‑C), and non-high‑density lipoprotein cholesterol concentrations. Female sex (β [SE] = 0.06 [0.02]), atrial fibrillation (β [SE] = 0.05 [0.02]), and the levels of HbA1c (β [SE] = 0.14 [0.02]) and LDL‑C (β [SE] = 0.09 [0.02]) were independently related to the level of Lp(a). Atrial fibrillation (odds ratio [OR], 1.8; 95% CI, 1.01-3.19), migraine (OR, 0.51; 95% CI, 0.32-0.83), and hyperlipidemia (OR, 1.56; 95% CI, 1.22-1.99) were related to the Lp(a) level of 30 mg/dl or above (≥75 nmol/l), while female sex (OR, 1.46; 95% CI, 1.10-1.92), hyperlipidemia (OR, 1.49; 95% CI, 1.12-1.97), hypertension (OR, 1.42; 95% CI, 1.1-1.84) and HbA1c concentration (OR, 0.84; 95% CI, 0.72-0.96) were significantly associated with the Lp(a) level greater than or equal to 50 mg/dl (≥125 nmol/l). The observed prevalence of increased Lp(a) concentration among patients of European ancestry treated at outpatient cardiology clinics was 21.5%. Female sex, hypertension, atrial fibrillation, migraine, and concentrations of LDL‑C and HbA1c were independently related to the level of Lp(a) in this population.

Prediction model for recommending coronary artery calcium score screening (CAC-prob) in cardiology outpatient units: A development study.

Despite the well-established significance of the CAC score as a cardiovascular risk marker, the timing of using CAC score in routine clinical practice remains unclear. We aim to develop a prediction model for patients visiting outpatient cardiology units, which can recommend whether CAC score screening is necessary. A prediction model using retrospective cross-sectional design was conducted. Patients who underwent CAC score screening were included. Eight candidate predictors were preselected, including age, gender, DM or primary hypertension, angina chest pain, LDL-C (≥130 mg/dl), presence of low HDL-C, triglyceride (≥150 mg/dl), and eGFR. The outcome of interest was the level of CAC score (CAC score 0, CAC score 1-99, CAC score ≥100). The model was developed using ordinal logistic regression, and model performance was evaluated in terms of discriminative ability and calibration. A total of 360 patients were recruited for analysis, comprising 136 with CAC score 0, 133 with CAC score 1-99, and 111 with CAC score ≥100. The final predictors identified were age, male gender, presence of hypertension or DM, and low HDL-C. The model demonstrated excellent discriminative ability (Ordinal C-statistics of 0.81) with visually good agreement on calibration plots. The implementation of this model (CAC-prob) has the potential to enhance precision in recommending CAC screening. However, external validation is necessary to assess its robustness in new patient cohorts.

Medication management and electrocardiogram screening in children with attention deficit hyperactivity disorder.

To quantify the proportion of referrals sent to Crumlin Cardiology Department for cardiac screening prior to commencement or modifying attention deficit hyperactivity disorder medication and assess the number detected with a clinically significant abnormality. A prospective audit was performed over a 6-month period, from November 2021 to April 2022 inclusive. Referrals sent via outpatient department triage letters, electrocardiogram dept. email, and walk-in electrocardiogram service were screened for those pertaining to commencing or modifying medication for children with attention deficit hyperactivity disorder. Each referral was coded against National Institute for Health and Care Excellence guidelines to determine the degree of clinical details given. Reported abnormalities, recommended management, and correspondence were recorded. Ninety-one referrals were received during the 6-month audit period. More than half lacked a clinical indication for referral (53/91, 58.2%), with fewer than one third (26/91, 28.5%) meeting National Institute for Health and Care Excellence criteria for referral for cardiology. Eighty (80/91) referrals had clinical outcomes available for review (missing outpatient department information and age outside of service range accounted for eleven referrals with unavailable clinical outcomes). Of the eighty clinically reviewed referrals, seventy-two (72/80, 90%) were reported as normal with no cardiology follow up required. Eight referrals (8/80, 10%) were reviewed in the Cardiology Outpatient Department prior to commencement or modifying attention deficit hyperactivity disorder medication. Of these, only one (1/80 1%) had a clinically significant abnormality which was a potential contraindication to attention deficit hyperactivity disorder medication use, and this referral was appropriate as per National Institute for Health and Care Excellence guidelines. Routine screening prior to attention deficit hyperactivity disorder medication prescription in the absence of clinical indications (as per National Institute for Health and Care Excellence) contributed to delays in medication initiation among young people with attention deficit hyperactivity disorder. Unnecessary referrals have resource implications for cardiology clinical team. Improved adherence to National Institute for Health and Care Excellence guidelines would provide benefits for patients and clinicians.