Cardiology Unit Research Articles

Prevalence of potential DDIs in hospital cardiology unit

Prevalence of potential DDIs in hospital cardiology unit

Integrated Chinese and Western medicine for stable angina pectoris of coronary heart disease: a real-world study including 690 patients.

We aimed to evaluate the effects of integrated Chinese and Western medical therapeutic modalities on clinical prognosis in a population with stable angina pectoris (SAP) of coronary heart disease (CHD). In a prospective cohort study, 732 patients with SAP of CHD hospitalized in the Integrated Cardiology Unit of the China-Japan Friendship Hospital From October 2020 to October 2021 were included. The patients were divided into integrated treatment and conventional treatment groups according to whether they had been taking Chinese medicine for more than 6 months per year. The occurrence of composite cardiovascular events (CVEs), including cardiac death, non-fatal myocardial infarction, revascularization, stroke, all-cause death, and readmission due to angina attack, heart failure, or malignant arrhythmia, was recorded during follow-up. The effects of different treatment modalities on prognosis were evaluated using univariate and multifactorial logistic regression. Logistic regression models were evaluated using receiver operating characteristic (ROC) curves. In sensitivity analysis, the correlation between treatment modality and outcome events was corrected by rematching the two groups of patients using the propensity score matching (PSM) method. The data from 690 patients were included in the analysis, with 327 patients in the integrated treatment group and 363 patients in the conventional treatment group. CVEs occurred in 19 patients (5.8%) in the integrated treatment group and 37 patients (10.2%) in the conventional treatment group. The proportion of outcome events was significantly lower in the combination treatment group than in the conventional treatment group (P = 0.037). Covariate correction by multimodal multifactorial logistic regression revealed a lower risk of CVEs in patients receiving integrated therapy compared with conventional therapy (OR = 0.246, 95% CI = 0.097-0.622, P = 0.003). Moreover, a history of renal insufficiency (OR = 3.991, 95% CI = 1.164-13.684, P = 0.028) and a higher Gensini score (OR = 1.039, 95% CI = 1.028-1.050, P < 0.001) were risk factors for the development of CVEs. Model evaluation showed that C-statistic = 0.955 and area under the ROC curve (AUC) = 0.955. After PSM correction, the results still showed that integrated Chinese and Western medical treatment reduced the occurrence of CVEs in patients compared with Western treatment alone (OR = 0.339, 95% CI = 0.131-0.874, P = 0.025). Integrated treatment based on Chinese and Western medicine might improve the prognosis and reduce the risk of CVEs in this disease population. China Clinical Trials Registry, ChiCTR1800017891, Registered 20 August 2018, http://www.chictr.org.cn/showproj.aspx?proj = 30170.

P142 EARLY MANAGEMENT OF STEMI PATIENTS DURING COVID–19 PANDEMIC: THE ROLE OF AN EMERGENCY DEPARTMENT–BASED CARDIOLOGY UNIT IN SAN RAFFAELE SCIENTIFIC INSTITUTE

Abstract During COVID–19 pandemic, a critical issue for cardiologists was to provide early access to the standard of care for patients with time–dependent diseases such as ST–segment elevation myocardial infarction (STEMI), while making efforts to prevent their exposure to SARS CoV–2. Aims: The aim of our research project was to evaluate the role of an Emergency Department–based operative unit directly managed by the Cardiology Department in providing a prompt cardiological evaluation to STEMI patients at first medical contact, which we assumed might positively impact on the reperfusion strategy and timing and thus on the extent of myocardial salvage. Methods We retrospectively included a group of STEMI patients admitted by our ED with a definitive diagnosis of STEMI from March 2020 to November 2021 and a control group admitted from January 2019 to February 2020. The groups were compared in terms of critical time intervals, rate of PCI or initial non–invasive conservative management, pre–discharge characteristics and in–hospital clinical outcomes, including all cause mortality and complications. Results Throughout the study period, a total of 211 patients were admitted to our institution with a diagnosis of STEMI. The number of patients presenting late (at least twelve hours since symptoms onset) was significantly higher and time from symptoms onset to hospital admission was significantly longer during the first COVID–19 pandemic peak, compared with the previous year. Almost all patients in both cohorts underwent invasive coronary angiography with subsequent primary PCI. Remarkably, despite the time–consuming hygiene practices and policies necessary to prevent patients’ exposure to SARS CoV–2 virus, door–to–balloon time was comparable between the two cohorts. No statistically significant differences were found regarding the occurrence of STEMI–related complications. The in–hospital mortality was comparable between the two cohorts, as was predischarge LVEF. The high–sensitivity Troponin–T peak was significantly lower after the introduction of the ED–based cardiology unit. Total in–hospital stay was shorter after the introduction of the ED cardiology unit. Conclusions Our experience has shed light on the potential advantages of an ED–based unit directly managed by the Cardiology Department: despite the confirmation of a longer time from symptoms onset to hospital admission, no significant differences were found in terms of hard outcomes between the groups.

P190 TWIDDLER’S SYNDROME IN A 96–YEAR–OLD PATIENT TREATED BY REPOSITIONING THE VENTRICULAR LEAD

Abstract A 96–years–old woman was admitted to our cardiological intensive care unit in December 2022 with atrioventricular dissociation, with a junctional ventricular escape rhythm at a rate of 38 beats per minute, and an atrial rhythm dissociated from the ventricular rhythm, at a rate of 80 beats per minute (Figure 1). The patient had a history of third–degree atrioventricular block, effectively treated with single–chamber pacemaker implantation (Assurity MRI SR, Abbott), operation performed approximately 10 months before access, in February 2022. The patient underwent a chest X–ray, which showed "coiling" of the ventricular catheter in the pacemaker pocket area (left subclavicular), with macroscopic dislocation of the ventricular electrode, which had its distal tip in the right atrium (Figure 2). Therefore, the clinical case was typical of Twiddler‘s syndrome. The patient would therefore have undergone revision surgery. An attempt was made to reposition the original lead, with passive fixation (Isoflex 1948/58, Abbott), by inserting a "straight" stylet, a procedure which was done effectively. The ventricular lead was repositioned in the right ventricular apex. The detected parameters were optimal (sensing 7 mV, ventricular barrier threshold 0.5 mV/0.4 ms, impedance 797 Ohm). The result was considered acceptable. The remainder of the hospital stay was without complications. The patient was discharged on the fifth day in good general condition. Twiddler syndrome is defined as a dislocation of one or more catheters, resulting in the catheters "coiling" in the pocket of the device. It is usually related to the manipulation of the generator by the patient itself. It usually occurs within a year of implantation and is usually more common in females, the elderly, the obese, pediatric patients, or patients with psychiatric disorders. The identification of patients at risk for this pathology, the adequate education of the patient and family regarding the management of the device, the use of catheters with active fixation, as well as the fixation of the generator device to the pectoral muscle, through non–absorbable sutures. In the case described, the patient denied manipulation of the device, which however could not be excluded, given the age of the patient.

P426 IMPLEMENTATION OF MODULAR NURSING IN THE CARDIOLOGY CONTEXT: EXPERIENCE AND RESULTS IN THE CONEGLIANO HOSPITAL

Abstract Introduction In response to regional requirements and the ever–increasing complexity of the needs of the patients, the UOC Health Professions of the ULSS 2 Marca Trevigiana Company, in collaboration with the team of the Cardiology UOC of the Conegliano Hospital decided, in the year 2022, to start a Field Training project (FSC) oriented towards the implementation of Modular Nursing (MN) in the specific context. Methods The project involved all the staff of the Cardiology, Hemodynamics, and Intensive Care Unit, with the contribution of the Coordinator and the support of the Health Professions Unit. 4 working groups were therefore formed, relating to the User Path in the care setting, Nursing Handover, Management of care–organizational resources and Indicators of the quality of care. Furthermore, we surveyed to collect the perception of the care staff concerning Relationship Time, Clinical Risk, Safety of Professional Action, and Continuity of Care. Results During the process, each working group presented the results of the work developed, which were: the description of the admission and discharge paths, the structuring of a Handover model based on the SBAR method, the definition of standard Care Plans for care cases, the analysis of the data deriving from the collection of defined indicators and the perception of the care staff pre–post implementation of the Care Model. The first data that emerged shows a 26% decrease in phlebitides observed in patients and an average reduction of 4 minutes in the Handover process. Furthermore, the survey conducted shows how nurses, with the introduction of the NM, perceive they have more time for the relationship with patients and family members (42.6%), a reduction (65%) of interruptions in the management of drug therapy, and an improvement in the quality of information given and received during the handover (95.6%) between shifts. Discussion The data collected demonstrates how the implementation of the MN has had positive effects not only on the organizational well–being and the working methods of the assistance staff but has also contributed to better management of assistance needs. Moreover, in this first phase, the increase in the Safety of Care provided emerges, thus, the continuity of care even after discharge.

P284 POTENTIAL PROARRHYTHMIC SIDE EFFECT OF HIGH DOSE AND PROLONGED SODIUM NITROPRUSSIDE INFUSION THROUGH CALCIUM ION REDUCTION

Abstract Patient presentation. A fifty y/o male patient with a history of congenital aortic stenosis surgically corrected previously and with chronic heart failure due to severe left ventricular dysfunction presented to our emergency department complaining dyspnea. Due to acute decompensated heart failure with ongoing cardiogenic shock, he was admitted to our intensive cardiology unit. Initial work up. The blood exams showed a normal renal and liver function, normal total and free calcium, 9.4 mg/dL and 1.16 mmol/L respectively, lactates were mildly increased. The chest x–ray showed pulmonary congestion. At the echocardiography we found severe biventricular dysfunction, moderate mitral regurgitation, severe pulmonary hypertension. Since the patient was unstable, adrenaline, high–dose sodium nitroprusside (SNP), and intra–aortic balloon pump were started. The right heart catheterization revealed combined pulmonary hypertension reversible with SNP and, therefore, the patient was inserted in the heart transplant list. Diagnosis and Management. One of the side effects of SNP is the thiocyanate toxicity. A high dose of SNP was necessary for this patient (2.2 mcg/kg/min). Thus, thiocyanate levels increased up to 10 mg/100 mL (NV&amp;lt;3). Importantly, the patient was asymptomatic despite these levels. However, the free calcium ion progressively decreased up to 0.94 mmol/L, despite normal total calcium and calcium supplementation iv and orally. Since arrhythmic burden markedly increased, we started lidocaine which was not effective. Follow–up. Since we suspected a possible causative role of thiocyanate, which might bond the double positive charged free calcium ion with its two negatively charged sulfur atoms, explaining the normal total calcium level and the low calcium ion, we carefully reduced SNP dose within days. This allowed us to reduce thiocyanate to 6 mg/100 mL, without compromising patient hemodynamics. Concomitantly, the free calcium ion tended to normalize, lowering the arrhythmic burden. Conclusions We describe for the first time a proarrhythmic side effect of prolonged SNP infusion, likely related to thiocyanate accumulation and free calcium ion binding, which, despite aggressive calcium supplementation, was normalized only after SNP down titration.

P248 HOW COVID–19 PANDEMIC HAS CHANGED EPIDEMIOLOGY OF PATIENTS WITH ACUTE CORONARY SYNDROME WITHOUT ST–T ELEVATION. DATA OF SINGLE CENTER

Abstract Background In recent years, the COVID–19 pandemic has led to a profound change in the epidemiological framework and incidence of cardiovascular diseases, as described in numerous reports. This condition can be attributed to various factors including reduction of hospitalizations for ACS (acute coronary syndrome) already widely discussed and documented, reduction of programmed cardiological follow–up and last but not least, the unfavorable effects of the lock–down period on life style and current health status of cardiac patients and the general population. The aim of our study was to evaluate how the characteristics of patients referred to our Cardiology Unit affected by ACS without elevation of the ST–T segment have changed in the post–pandemic phase. We analyzed the data fo the year 2022 and in particular the average age of incidence, the difference between the two sexes and the variation in the incidence of cardiovascular risk factors compared to 2021. The results showed an important reduction in the mean age of ACS incidence of about 2 years, a confirmed prevalence in males compared to females, a statistically significant increase in newly diagnosed dyslipidemia, especially in young patients, and the uncorrected primary prevention management of other cardiovascular risk factors. These data can be explained considering important changes in the lifestyle of the general population in terms of increased sedentary, poor eating habits during the pandemic phase and poor control of cardiovascular risk factors, also due to the absence of ambulatorial follow–up. Conclusions These data direct our future measures in the careful and punctual early correction of cardiovascular risk factors starting from outpatient visits, in primary prevention and in the optimization of therapy with aggressive correction of the pathologies encountered during the hospitalization and prevention phase secondary.

P234 IT IS TIME THAT ITALIAN AMI NETWORKS ARE BASED ON DIAGNOSTIC–THERAPEUTIC PATHWAYS INCLUDING BOTH TYPES OF ACS (STEMI AND NSTEMI)

Abstract Background Nowadays AMI management represents one of the most challenging clinical scenarios. On 8 july 2022 ANMCO held a special event about the last 20 years of AMI networks in Italy. During this event it was highlighted how these networks – supported by ANMCO – led to mortality reduction in the last 20 years (till –57%). By the way, the networks are usually based on diagnostic–therapeutic (D–T) pathways that not include NSTEMI–ACS. At contrary, the prevalence of NSTEMI–ACS is increasing and it significantly contributes to whole mortality due to coronary heart disease in the world. Materials and Methods The Functional Cardiology Department of Marche Region (Italy) covers the territory of three provinces. This department provided a new diagnostic–therapeutic pathway for AMI–network on July 2022. Globally, the department provides heart diseases management to 500.000 subjects living in that area. Working group who proposed the new D–T pathway included: 1) all Cardiology Units Directors; 2) all Emergency System Directors; 3) all Emergency Rooms Directors. The diagnostic–therapeutic pathway was based on 1) latest ESC guidelines and whole medical licterature on the topic; 2) geographic area features; 3) logistic local criticisms; 4) multiple sharing meetings results. Results The D–T pathway was divided in two chapters: 1) STEMI–ACS; 2) NSTEMI–ACS. STEMI–ACS chapter included 7 steps: 1) Symptoms onset and Emergency System Alert; 2) out of hospital intervention; 3) emergency room (ER) intervention; 4) primary PCI; 5) in–hospital complications; 6) whole in–hospital management and back transfer to the spoke; 7) cardiac rehabilitation and secondary prevention programs. The novelties were represented by: 1) ECG trasmission to the ICUs; 2) detailed establishment of which HUB every town/city of the area is assigned to; 3) inclusion of cardiac rehabilitation and secondary prevention programs in the pathway; 4) inclusion of NSTEMI–ACS with the two revascularization arms cited by the ESC guidelines. Conclusions The reported D–T pathway appears very innovative in order to including both two types of ACSs (STEMI and NSTEMI). Considering the latest guidelines, it could be appropriate that new D–T pathways, promoted by AMI networks in Italy, include a specific chapter dedicated to NSTEMI–ACS, given that also this type of ACS may require a time–dependent revascularization therapy and the correct approach may affect mortality and the whole prognosis.

P333 A RARE CAUSE OF SHOCK: AORTO–PULMONARY FISTULA AS AORTIC ANEURYSM COMPLICATION

Abstract Clinical case A 69–year–old man with right shoulder discomfort, malaise for one hour and hemodynamic instability was admitted to our Emergency Department (ED). The patient had a history of arterial hypertension, diabetes, renal failure on peritoneal dialysis and ischemic cardiomyopathy with preserved ejection fraction treated by angioplasty and stent implantation on right coronary. At first medical contact out of hospital the patient appeared confused with severe hypotension (BP 70/40 mmHg). ECG transmitted to our Cardiology Unit showed sinus tachycardia with repolarization abnormalities consistent with diffuse ischemia. The patient was centralized with clinical suspicion of acute coronary syndrome complicated by cardiogenic shock. In ED, BP was 65/35 mmHg. On physical examination extremities were cold and mottled, crackles in the lower lung zones and turgid jugulars were present. Pulses were weak but present. ECG was repeated and no evolutive signs were detected. Echocardiography finding were: not dilated left ventricle with global systolic function at the lower limits, moderate aortic insufficiency, right ventricle with dimensions at the upper limits and hypocontractile, moderate tricuspid regurgitation, inferior vena cava dilated with preserved inspiratory collapse. Aortic root was non dilatated but aortic arch was 55 mm with no images of dissection flap. At blood test lactates were 4,2 with metabolic acidosis, troponin was just above the upper limit, inflammation indices were negative and electrolytes were in range. Vasopressor support with norepinephrine was started. With the high suspicion of acute aortic disease, CT angiography was performed showing a voluminous aneurysm of the aortic arch of 70x56 mm rupturing into the left pulmonary artery (Figure 1,2). Concomitant bilateral iliac artery dissection was detected. Cardiac and Vascular Surgeons were promptly alerted to plan tan emergent surgical intervention whose complexity was increased by the difficult vascular cannulation for iliac dissection. However, the patient‘s hemodynamic rapidly deteriorated requiring intubation and, after subsequent episodes of cardiac arrest in pulseless electrical activity (PEA), his death was assessed.

P133 ZEBRA HOOFBEATS: A RARE CASE OF STEMI IN GRANULOMATOUS NECROTIZING AORTITIS

Abstract We present the unusual case of an AMI STEMI, complicated by ventricular fibrillation, in a 26 years old caucasic male patient, affected by necrotizing and granulomatous aortitis, in the context of a primary immunodeficiency. Initially the patient was referred to the Cardiology Unit for worsening dyspnea and fatigue. In his medical history he has primary immunodeficiency complicated by multiple opportunistic infections. We performed an echocardiography that revealed an aneurismatic ascending aorta (58 mm) with associated significant aortic valvular regurgitation. He was later referred to heart surgery OR where Bentall–De Bono operation was performed. Two years later he developed a lateral STEMI, complicated by ventricular fibrillation. The coronary angiography, performed in foreign country, showed total occlusion of the circumflex coronary artery with diffuse aneurismatic coronary disease, granulomatosis and ulcerative lesions. A percutaneous revascularization approach was tried, but ineffective. Actually the patient, during follow up, presents dilatative post–ischemic cardiopathy with moderate ejection fraction reduction, initial aortic bioprosthesis failure. We noted at follow up echocardiograms early dilatation of the native aortic arch (35 mm), suggesting a progressive disease. In conclusion, AMI‘s etiology includes many non atherosclerotic mechanisms that should be considered alongside common causes. This case shows a rare cause of STEMI in a very young male patient, and teaches us that aortitis is a progressive and complex pathology, often involving multiple arteriosus districts, that needs close follow–up and integrated management.

P208 PREVALENCE OF TRANSTHYRETIN CARDIAC AMYLOIDOSIS IN PATIENTS HOSPITALIZED FOR HEART FAILURE

Abstract Background Bone scintigraphy with labeled diphosphonates allows for the non–invasive diagnosis of transthyretin cardiac amyloidosis, in case of high cardiac uptake of the radiotracer and concomitant absence of serum monoclonal component (Gillmore algorithm). Objective The aim of this study was to establish the prevalence of transthyretin cardiac amyloidosis in a population of patients hospitalized for heart failure. Methods In this prospective observational study, patients hospitalized for heart failure at the Cardiology Unit of Castelsangiovanni Hospital were evaluated in the period from 1 January 2021 to 31 July 2022. Twenty–five of them, who presented with echocardiographic moderate to severe left ventricular hypertrophy (i.e. maximum end–diastolic thickness of the interventricular septum ≥ 15 mm), were included in the study. All patients underwent anamnesis, physical examination, 12–lead electrocardiogram and transthoracic echocardiogram. Patients were divided into 2 groups according to the presence or absence of the following clinical, electrocardiographic and echocardiographic diagnostic red flags: history of carpal tunnel syndrome and/or rupture of the long head of the brachial biceps, low voltage QRS, granular sparkling of the ventricular myocardium, apical sparing pattern of the global longitudinal strain. Results Fifteen patients with heart failure, left ventricular hypertrophy and at least one diagnostic red flag were screened for cardiac amyloidosis by: a) search for a serum monoclonal component; b) bone scintigraphy with labeled diphosphonates. In thirteen patients, an high cardiac uptake of the radiotracer was found on bone scintigraphy. One patient with high cardiac uptake also presented a serum monoclonal component and was referred for tissue biopsy. In the remaining twelve patients (85% of the cases studied) a non–invasive diagnosis of transthyretin cardiac amyloidosis was made. In six patients affected by transthyretin cardiac amyloidosis, a salivary genetic test was also performed to search for mutations in the transthyretin gene, which resulted negative in all cases examined. Conclusions In this study of patients hospitalized for decompensated heart failure, rigorous application of Gillmore‘s algorithm in suspected cases led to non–invasive diagnosis of cardiac transthyretin amyloidosis in 85% of cases, without wasting healthcare resources.

P450 ADVANCED ATRIOVENTRICULAR BLOCK AT LOOP RECORDER MONITORING IN A YOUNG PATIENT WITH BRUGADA SYNDROME AND CONDUCTION ABNORMALITIES: CAUSE OF SYNCOPE OR INCIDENTAL FINDING?

Abstract A 32–year–old man healthy man presented to the emergency department because of remittent fever. His past medical history, physical examination and chest X–ray were unremarkable except for a body temperature of 39 Celsius degrees. Laboratory exams showed a marked elevation of transaminases, cholestasis markers and C–reactive protein, while an abdomen ultrasound revealed hepatomegaly and diffuse hyperechogenicity of the liver. He was diagnosed with acute hepatitis and admitted to the Gastroenterology Unit. Due to the persistent hyperpyrexia despite antipyretics and antibiotics, he was successfully treated with intravenous diclofenac, resulting in temporary remission of fever. First electrocardiogram during apyrexia showed sinus rhythm, first–degree atrioventricular block (PR interval 240 milliseconds), and non–specific intraventricular conduction delay. In the following days, liver and cholestasis markers improved, but he underwent two syncopal episodes without prodromes, the former while he was walking and the latter during meal. A new electrocardiogram revealed a type 1 Brugada pattern. At the time of its recording, however, his body temperature was 38.6 Celsius degrees. He was then admitted to the Cardiology Unit for monitoring and further investigations. 2D–echocardiogram and cardiac magnetic resonance imaging were unremarkable. Telemetry monitoring showed nocturnal episodes of marked sinus bradycardia (up to 35 beats per minute), but no ventricular arrhythmias were documented. He also underwent an invasive electrophysiological study with programmed ventricular stimulation, but again no ventricular arrhythmias were induced. Recording of His bundle electrogram, however, revealed the prolongation of both AH and HV interval (190 and 76 milliseconds respectively). Given the syncopal episodes, an implantable cardioverter defibrillator implantation was proposed, but the patient refused, so he underwent an implantable loop recorder implantation. After three months, at remote monitoring, a nocturnal episode of complete atrioventricular block with a pause of 15 seconds was recorded, thus he was again admitted to the Cardiology Unit. This time he was apyretic, but his electrocardiogram showed a spontaneous type 1 Brugada pattern with “high arrhythmic risk” features as first–degree atrioventricular block and a prominent S wave in lead I. He then underwent a successful implantable cardioverter defibrillator implantation with still an uneventful follow up.

Safety and efficacy of prophylactic treatment for hyperthyroidism induced by iodinated contrast media in a high-risk population.

The use of iodinated contrast media (ICM) can lead to thyrotoxicosis, especially in patients with risk factors, such as Graves' disease, multinodular goiter, older age, and iodine deficiency. Although hyperthyroidism may have clinically relevant effects, whether high-risk patients should receive prophylactic treatment before they are administered ICM is still debated. We aimed to demonstrate the safety and efficacy of prophylactic treatment with sodium perchlorate and/or methimazole to prevent ICM-induced hyperthyroidism (ICMIH) in a population of high-risk cardiac patients. We ran a cost analysis to ascertain the most cost-effective prophylactic treatment protocol. We also aimed to identify possible risk factors for the onset of ICMIH. We performed a longitudinal retrospective study on 61 patients admitted to a tertiary-level cardiology unit for diagnostic and/or therapeutic ICM-procedures. We included patients with available records of thyroid function tests performed before and after ICM were administered, who were at high risk of developing ICMIH. Patients were given one of two different prophylactic treatments (methimazole alone or both methimazole and sodium perchlorate) or no prophylactic treatment. The difference between their thyroid function at the baseline and 11-30 days after the ICM-related procedure was considered the principal endpoint. Twenty-three (38%) of the 61 patients were given a prophylactic treatment. Thyroid function deteriorated after the administration of ICM in 9/61 patients (15%). These cases were associated with higher plasma creatinine levels at admission, higher baseline TSH levels, lower baseline FT4 levels, and no use of prophylactic treatment. The type of prophylaxis provided did not influence any onset of ICMIH. A cost-benefit analysis showed that prophylactic treatment with methimazole alone was less costly per person than the combination protocol. On multivariate analysis, only the use of a prophylactic treatment was independently associated with a reduction in the risk of ICMIH. Patients not given any prophylactic treatment had a nearly five-fold higher relative risk of developing ICMIH. Prophylactic treatment can prevent the onset of ICMIH in high-risk populations administered ICM. Prophylaxis is safe and effective in this setting, especially in cardiopathic patients. Prophylaxis with methimazole alone seems to be the most cost-effective option.

Potentially Harmful Drug-Drug Interactions and Their Associated Factors Among Hospitalized Cardiac Patients: A Cross-Sectional Study.

Cardiovascular diseases are responsible for a significant proportion of mortalities worldwide. Elderly patients are the most affected by cardiovascular diseases, and because of factors such as polypharmacy, multimorbidity, and age-related changes in drug availability and metabolism, they are highly susceptible to the occurrence of drug-drug interactions. Drug-drug interactions are among the many drug-related problems leading to negative outcomes among inpatients and outpatients. Thus, it is important to investigate the prevalence, involved drugs, and factors related to potential drug-drug interactions (pDDIs) to properly optimize pharmacotherapy regimens for these patients. We aimed to determine the prevalence of pDDIs, drugs most frequently implicated, and significant predictors associated with these interactions among hospitalized patients in the Cardiology Unit at Sultan Qaboos University Hospital in Muscat, Oman. This retrospective cross-sectional study included 215 patients. Micromedex Drug-Reax® was used to identify pDDIs. Data extracted from patients' medical records were collected and analyzed. Univariable and multivariable linear regression was applied to determine the predictors associated with the observed pDDIs. A total of 2057 pDDIs were identified, with a median of nine (5-12) pDDIs per patient. Patients with at least one pDDI accounted for 97.2% of all the included patients. The majority of pDDIs were of major severity (52.6%), fair level of documentation (45.5%), and pharmacodynamic basis (55.9%). Potential drug-drug interactions between atorvastatin and clopidogrel were the most frequently observed (9%). Of all the detected pDDIs, around 79.6% of them included at least one antiplatelet drug. Having diabetes mellitus as a comorbidity (B = 2.564, p < 0.001) and the number of drugs taken during the hospitalization period (B = 0.562, p < 0.001) were factors positively associated with the frequency of pDDIs. Potential drug-drug interactions were highly prevalent among hospitalized cardiac patients at Sultan Qaboos University Hospital, Muscat, Oman. Patients having diabetes as a comorbidity and with a high number of administered drugs were at a higher risk of an increased number of pDDIs.

A Small Scale Optically Pumped Fetal Magnetocardiography System.

Fetal magnetocardiography (fMCG) is considered the best technique for diagnosis of fetal arrhythmia. It is superior to more widely used methods such as fetal, fetal electrocardiography, and cardiotocography for evaluation of fetal rhythm. The combination of fMCG and fetal echocardiography can provide a more comprehensive evaluation of fetal cardiac rhythm and function than is currently possible. In this study, we demonstrate a practical fMCG system based on optically pumped magnetometers (OPMs). Seven pregnant women with uncomplicated pregnancies underwent fMCG at 26-36 weeks' gestation. The recordings were made using an OPM-based fMCG system and a person-sized magnetic shield. The shield is much smaller than a shielded room and provides easy access with a large opening that allows the pregnant woman to lie comfortably in a prone position. The data show no significant loss of quality compared to data acquired in a shielded room. Measurements of standard cardiac time intervals yielded the following results: PR = 104 ± 6 ms, QRS = 52.6 ± 1.5 ms, and QTc = 387 ± 19 ms. These results are compatible with those from prior studies performed using superconducting quantum interference device (SQUID) fMCG systems. To our knowledge, this is the first European fMCG device with OPM technology commissioned for basic research in a pediatric cardiology unit. We demonstrated a patient-friendly, comfortable, and open fMCG system. The data yielded consistent cardiac intervals, measured from time-averaged waveforms, compatible with published SQUID and OPM data. This is an important step toward making the method widely accessible.

Initiative to increase family presence and participation in daily rounds on a paediatric acute care cardiology unit.

Family-centred rounds benefit families and clinicians and improve outcomes in general paediatrics, but are understudied in subspecialty settings. We sought to improve family presence and participation in rounds in a paediatric acute care cardiology unit. We created operational definitions for family presence, our process measure, and participation, our outcome measure, and gathered baseline data over 4 months of 2021. Our SMART aim was to increase mean family presence from 43 to 75% and mean family participation from 81 to 90% by 30 May, 2022. We tested interventions with iterative plan-do-study-act cycles between 6 January, 2022 and 20 May, 2022, including provider education, calling families not at bedside, and adjustment to rounding presentations. We visualised change over time relative to interventions with statistical control charts. We conducted a high census days subanalysis. Length of stay and time of transfer from the ICU served as balancing measures. Mean presence increased from 43 to 83%, demonstrating special cause variation twice. Mean participation increased from 81 to 96%, demonstrating special cause variation once. Mean presence and participation were lower during high census (61 and 93% at project end) but improved with special cause variation. Length of stay and time of transfer remained stable. Through our interventions, family presence and participation in rounds improved without apparent unintended consequences. Family presence and participation may improve family and staff experience and outcomes; future research is warranted to evaluate this. Development of high level of reliability interventions may further improve family presence and participation, particularly on high census days.

Profiles of patients referred to specialized palliative care from the cardiology department at a university hospital: an 11-year longitudinal retrospective study.

Although the majority of patients with cardiovascular diseases (CVD) have a significant symptom burden and progressive course towards the end of life, only a small proportion of patients currently receive palliative care. The current referral practices to palliative care from the cardiology department need to be scrutinized. The current study aimed to examine: 1) the clinical profile; 2) time between referral to palliative care and death; and 3) place of death for CVD patients who were referred to palliative care from a cardiology department. This retrospective descriptive study included all patients who were referred to the mobile palliative care team from the cardiology unit in the University Hospital of Besançon in France between January 2010 and December 2020. Information was extracted from the medical hospital files. A total of 142 patients were included, of whom 135 (95%) died. The mean age at the time of death was 76±14 years. The median time between referral to palliative care and death was 9 days. Most patients had chronic heart failure (54%). A total of 17 patients (13%) died at home. This study showed that referral of patients to palliative care from the cardiology department is suboptimal and a large proportion of patients die in the hospital setting. Further prospective studies are warranted to investigate whether these dispositions correspond to patients' wishes and end-of-life care needs, and should investigate how the integration of palliative care into the care of cardiovascular patients can be improved.

An Aza-michael Addition Product Causes Incompatibility Between Etacrynic Acid and Theophylline in a Paediatric Cardiological ICU.

In a compatibility study of parenteral drugs commonly used in paediatric cardiological intensive care units, an unknown reaction product was found in a mixture of etacrynic acid and theophylline. The conditions in terms of the concentration of etacrynic acid and theophylline as well as the materials used corresponded to the conditions in the intensive care unit. Initially, the reaction product appeared as a significant and increasing peak in the chromatograms when determining the content of etacrynic acid and theophylline via HPLC. At the same time, the concentrations of both drugs decreased. A literature search in the chemical databases Reaxys® and Scifinder ® revealed a patent from 1967 describing an aza-Michael addition between etacrynic acid and theophylline to either N-7 or N-9. Using LC-MS/MS experiments, we were able to confirm that Michael-like reaction between etacrynic acid and theophylline occurs. To elucidate the exact structure of the reaction product we performed NMR experiments (COSY, HSQC and HMBC). With the acquired data we were finally able to identify the unknown compound as the N-7 substituted adduct [2-(2,3-dichloro-4-{2-[(1,3-dimethyl-2,6-dioxo-2,3-dihydro-1H-purin-7(6H)-yl)methyl]butanoyl}phenoxy)acetic acid]. Our findings show that etacrynic acid and theophylline should not be mixed and should be administered through separate venous lines when infused.

Radial Versus Femoral Access in Percutaneous Coronary Intervention in Acute Coronary Syndrome

Background: Although it safeguards patients from hemorrhagic disorders during cardiac procedures, the radial route is technically more challenging than the femoral approach. Aim: To evaluate the hypothesis that radial approach is the preferred strategy in ACS patients, and identifying independent predictors of the choice to choose radial access. Methods: Between August 2021 and January 2022, this prospective study was conducted in the interventional cardiology unit of Hayatabad Medical Complex Peshawar. The study included all ACS (unstable angina or myocardial infarction) patients who had previously had invasive diagnostic or therapeutic cardiac procedures. Patients who opted out of the trial were excluded. Results: Those in group 1 had a lower mean GRACE score (112±31 versus 127±40; p&lt;0,001), improved renal function according to cretanine level (0.9±0.3 versus 1.1±1.0; p &lt; 0.001) and a reduced prevalence of indications of left ventricular failure (6% versus 21%, p 0.003) when compared to patients in group 2. There was no difference in the groups at the time of admission for the type of ACS heart rate (69±15 Vs 75±16), systolic arterial pressure (148±31 Vs 151±33), positive troponin 59(79.7%) Vs 51(68.9%), electrocardiographic ischemia 23(31%) Vs 19(25.7%), three-vessel disease (30, 40.5%) VS 25(33.8%) Practical implication: The variables that determined the preference for radial approach reflect the clinical status and severity of the patients, demonstrating that the convenience of the approach is more valued in extremely complex patients than its antihemorrhagic effectiveness. Conclusion: The trend for radial access to be preferred over femoral access during coronary intervention was not primarily influenced by the patient population's risk of bleeding. Keywords: Angioplasty, Coronary Artery Disease, Radial Artery, Femoral Artery.

Impact of Fetal Echocardiography on Altering Course of Action Following A Prenatal Diagnosis of Congenital Heart Disease-A Thought Analysis

Objective: To assess the impact of fetal echocardiography in altering the course of action for neonatal cardiac expertise and services available in Pakistan following an antenatal diagnosis of congenital heart defect (CHD).&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Pediatric Cardiology Unit, Armed Forces Institute of Cardiology &amp; National Institute of Heart Diseases, Rawalpindi Pakistan, from Feb 2020 to Sep 2021.&#x0D; Methodology: Fetuses aged 18 to 38 weeks of gestational age referred to the Pediatric Cardiac Unit due to risk of or suspicion of congenital heart disease underwent fetal cardiac echo. Data were collected and reviewed retrospectively to seek any impact of the antenatal diagnosis on post-natal planning.Results: The mean age of the mothers was 29.79±5.24 years (range, 17-47 years), and the mean gestational age at which the fetal echocardiography examination was performed was 27.29±4.47weeks (range: 12–38 years). Of the 609 pregnancies, fetal echocardiogram evaluation was performed, and sixty-three (10.3%) fetal echocardiograms were abnormal. Of the 63, only 06(9.5%) returned to the neonatal cardiac unit for follow-up and treatment in the first ten days of life.&#x0D; Conclusion: The real impact of fetal echocardiography is possible only with the availability of well-developed, readily accessible fetal and neonatal cardiac services. Poverty and a struggling healthcare infrastructure confound the benefits.