Outpatient Cardiology Follow-up Research Articles

OUTPATIENT FOLLOW-UP OF PATIENTS WITH ATHEROSCLEROSIS OF LOWER EXTREMITIES: PROMISING WAYS TO IMPROVE RESULTS

HighlightsThe article shows the positive impact of 3-year cardiology follow-up in patients with atherosclerosis of lower extremities. Aim. To study the impact of outpatient cardiology follow-up in patients with peripheral artery disease on the prognosis and the frequency and outcomes of surgical interventions.Methods. The study included 585 patients with peripheral artery disease who underwent outpatient follow-up - by a surgeon (n = 131) and a cardiologist (n = 454). The groups were compared according to the main clinical and anamnestic data and type of drug therapy. After 3 years, the incidence of adverse outcomes (nonfatal myocardial infarction, nonfatal stroke, new amputations and deaths) and factors associated with adverse outcomes in the selected cohort were evaluated.Results. The group of patients who were followed by cardiologist received optimal drug therapy more often compared with patients followed by surgeon: β-blockers (80.4% vs. 32.8%; p < 0.001), angiotensin converting enzyme inhibitors (61.0% vs. 38.2%; p < 0.001), statins (87.0% vs. 63.4%; p < 0.001). Within three years, fatal outcome was more common in the group of patients followed by surgeon (13.0% vs. 6.8%, p = 0.023). The factors that positively affected the prognosis of patients were cardiology follow-up (OR 0.34; 95% CI 0.17–0.7; p < 0.001), taking aspirin (OR 0.12; 95% CI 0.06–0.22, p < 0.001) and statins (OR 0.11; 95% CI 0.05–0.21; p < 0.001).Conclusion. The results of this study confirm the need for more effective cardiology follow-up of patients with peripheral artery disease. This will improve the results of treatment and reduce the number of complications. Further research in this area can help determine the optimal strategies for follow-up and improve the quality of life of patients with peripheral artery disease.

Do serial troponins predict the need for cardiac evaluation in trauma patients after ground-level fall?

PurposeTroponin T levels are routinely checked in trauma patients after experiencing a ground-level fall to identify potential cardiac causes of syncope. An elevated initial troponin prompts serial testing until the...

Abstract 17489: Bupropion Poisoning: Extracorporeal Membrane Oxygenation as a Rescue Strategy

Introduction: Bupropion is a commonly prescribed antidepressant. Although generally well-tolerated, bupropion overdose can lead to severe cardiovascular and neurological toxicity. We present a case of cardiogenic shock and status epilepticus as a result of bupropion intoxication. Case Presentation: A 29-year-old female with history of depression and borderline personality disorder presented to the emergency department unresponsive after ingesting large quantities of bupropion, alprazolam and lisdexamfetamine. Vital signs were unremarkable and physical exam revealed pupil asymmetry. CT head was unremarkable. Urine toxicology was positive for amphetamines and benzodiazepines, with a blood alcohol level of 104. QTc was 522. Patient received versed for status epilepticus and was placed on mechanical ventilation. She developed sustained ventricular tachycardia and hypotension, unresponsive to bicarbonate and amiodarone. The patient was placed on venoarterial extracorporeal membrane oxygenation (VA ECMO) to provide hemodynamic support while eliminating bupropion from circulation. Following repeated episodes of VT, the patient was successfully cardioverted and started on amiodarone. TTE demonstrated left ventricular ejection fraction (LVEF) of <30%. Notably, lipid emulsion therapy was not administered as patient stabilized with ECMO support. After 48 hours of electrical stability, she was weaned off ECMO and inotropes and transitioned to guideline-directed medical therapy. Repeat TTE demonstrated LVEF of 60% on day 12. Mental status improved and patient was admitted to psychiatry with outpatient cardiology follow-up. Discussion: Bupropion overdose can cause prolonged QTc, ventricular arrhythmias, and seizures. Cardiotoxicity results from inhibition of gap junction ion channels, compromising conduction and contractility. Various approaches, including ECMO and lipid emulsion therapy, have been effectively employed in such cases. This case demonstrates that ECMO can serve as a hemodynamic bridge during the elimination of bupropion while augmenting its clearance via increased flow, underscoring the benefits of mechanical circulatory support in cases of intoxication affecting cardiac contractility and conduction.

Abstract 13011: A Rare Case of Spontaneous Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare condition; an intimal tear or bleeding of vasa vasorum leads to the creation of a false lumen filled with intramural hematoma. The hematoma causes coronary stenosis, leading to subsequent myocardial ischemia. SCAD is the cause of Acute Coronary Syndrome (ACS) in 0.1 to 4% of cases. Men account for less than 10% of cases, with a mean age of 48.6. Case Study: A 19-year-old male with prior medical history of morbid obesity and marijuana use was transferred from another hospital to our service after presenting with non-ST elevation MI. He was admitted following 30 minutes of a throbbing/pressure-like sensation in his throat, one episode of vomiting, and paresthesia in his left arm that spontaneously resolved. Initial EKG showed sinus rhythm with early repolarization changes. His troponin rose from 0.2 to 18 ng/mL. Upon admission, his high sensitivity troponin peaked at 15,000 pg/mL. Repeat EKG showed dynamic changes with T wave inversions in the inferolateral leads. The patient underwent an angiogram showing a diffuse, mid-LAD 40% de novo spontaneous dissection and a diffuse, distal-LAD 20% de novo spontaneous dissection with TIMI grade 3 and 2 flow, respectively. A repeat angiogram two days later showed improved coronary artery flow and deemed a low-risk lesion with stable patient hemodynamics; no intervention followed. The patient was treated conservatively with DAPT and discharged home with an outpatient Cardiology follow-up. A plan to have further imaging in 4 weeks to assess hematoma resolution was made. Conclusions: This case demonstrates an atypical presentation of SCAD in a very low-risk patient, given his sex, age, and clinical presentation of nonspecific chest pain. This case highlights the importance of high clinical suspicion for SCAD regardless of ACS risk profile in a patient presenting with chest pain.

Abstract 13833: Arrhythmia Patterns in Patients Managed With and Without Tyrosine Kinase Inhibitors

Introduction: Tyrosine kinase inhibitors (TKIs) are often used to treat hematologic malignancies. Ibrutinib, a Bruton’s TKI, has been associated with increased burden of treatment limiting arrhythmias. How this compares to arrhythmias in patients on non-ibrutinib TKIs or non-TKI therapy is unknown. Hypothesis: We hypothesized that ibrutinib therapy would be associated with higher atrial and ventricular arrhythmia burden than non-ibrutinib TKI or non-TKI therapies in patients with hematologic malignancies. Methods: We performed a retrospective single center chart review of consecutive patients who received 14-day cardiac event monitors while on ibrutinib, non-ibrutinib TKIs, or non-TKI therapy for a hematologic malignancy between 2014-2021. Results: A total of 176 patients were included (ibrutinib=72, non-ibrutinib TKI=36, non-TKI=68; Figure A). The ibrutinib group had higher incidence of AF (n=32, 44%) and NSVT (n=31, 43%) than the non-ibrutinib TKI (AF: n=7, 19%, p=0.02; NSVT: n=8, 22%, p=0.03) and non-TKI group (AF: n=13, 19%, p=0.003; NSVT: n=14, 21%, p=0.006; Figure B). Rates of SVT, PAC burden, and PVC burden were not significantly different. Therapy was held in 25% (n=18) of patients on ibrutinib vs 5% (n=2) on non-ibrutinib TKIs. Average duration of TKI therapy was 32 months in the ibrutinib group vs 77 months in the non-ibrutinib group (p<0.001). Of note, the non-TKI group had significantly higher outpatient cardiology follow-up versus the TKI groups (p=0.048). Conclusions: In this large retrospective comparison of cardiac event monitors in patients with hematologic malignancies on ibrutinib, non-ibrutinib TKIs, or non-TKI therapy, those receiving ibrutinib had a higher incidence of atrial and ventricular arrhythmias and higher rate of treatment interruption due to arrhythmia burden but less cardiology follow-up. Further research is needed to optimize risk stratification, surveillance, and management of TKI-related arrhythmias.

Abstract 11655: Echocardiographic Assessment of Strain and Associations With Markers of Clinical Severity in Multi-System Inflammatory Syndrome in Children (MIS-C) Associated With COVID-19

Introduction: Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 can cause cardiovascular dysfunction. We aimed to determine if strain abnormalities persist in MIS-C patients 3-10 weeks post-discharge, and whether acute markers of clinical severity are associated with lower strain at subacute follow-up. Methods: We performed a retrospective cohort study of MIS-C patients admitted at a single center from 3/2020-3/2021. Demographic and clinical variables during hospitalization were obtained. Global longitudinal strain (GLS), 4-chamber longitudinal strain (4C-LS), mid-papillary circumferential strain (CS), and left atrial strain (LAS) at 3-10 week follow-up were compared to age matched controls (n=10). Bivariate analyses were performed using Spearman rank correlation and two-sample t-test or Wilcoxon rank sum test. Results: Sixty MIS-C patients were identified (age 8.9 +/- 4 years, 35/60 male, 39% Hispanic, 29% African American). Hypotension (65%), ICU admission (57%), and inotropic support (45%) were common; 7% received mechanical ventilation. No deaths or need for ECMO were reported. Median length of stay (LOS) was 7 days. LVEF was <55% in 28% during hospitalization (median 57% [52-61]) and 6% at follow-up (median 65% [61-67]). Peak NT-proBNP (median 5321 pg/ml [IQR 1712, 17400]) and peak CRP (median 17 mg/dl [12, 22]) were significantly associated with hypotension, ICU admission, and total ICU days. Forty-five patients had available follow-up imaging for strain. CS (mean -26.0 vs -28.6; p=0.009) and LAS (mean -34.5 vs -51.2; p=0.001) were lower in MIS-C vs controls, but not GLS or 4C-LS. Lower CS (-24.2 +/- 3.1 vs -26.7 +/- 2.7; p=0.04) and lower 4C-LS (-19.1 +/- 1.9 vs -21.2 +/- 3.3; p=0.04) were associated with abnormal EF (<55%) during acute illness. CS was lower in those admitted to ICU (-25.1 +/- 2.6 vs -27.5 +/- 2.9; p=0.03). Peak CRP correlated with lower CS (r= -0.41, p=0.03) and GLS (r= -0.55, p=0.01) at follow-up. Conclusions: MIS-C patients show abnormal strain during subacute follow-up despite improvement in EF. Lower CS, GLS, and 4C-LS were associated with in-hospital markers of clinical severity. This data may allow for identification of at-risk MIS-C patients and help guide outpatient cardiology follow-up.

Impact of an electronic medical record-based appointment order on outpatient cardiology follow-up after hospital discharge

Outpatient follow-up after hospital discharge improves continuity of care and reduces readmissions, but rates of follow-up remain low. It is not known whether electronic medical record (EMR)-based tools improve follow-up. The aim of this study was to determine if an EMR-based order to secure cardiology follow-up appointments at hospital discharge would improve follow-up rates and hospital readmission rates. A pre-post interventional study was conducted and evaluated 39,209 cardiovascular medicine discharges within an academic center between 2012 and 2017. Follow-up rates and readmission rates were compared during 2 years prior to EMR-order implementation (pre-order era 2012–2013, n = 12,852) and 4 years after implementation (EMR-order era 2014–2017, n = 26,357). The primary endpoint was 90-day cardiovascular follow-up rates within our health system. In the overall cohort, the mean age of patients was 69.3 years [SD 14.7] and 60.7% (n = 23,827) were male. In the pre-order era, 90-day follow-up was 56.7 ± 0.4% (7286 of 12,852) and increased to 67.9 ± 0.3% (17,888 of 26,357, P < 0.001) in the EMR-order era. The use of the EMR follow-up order was independently associated with increased outpatient follow-up within 90 days after adjusting for patient demographics and payor status (OR 3.28, 95% CI 3.10–3.47, P < 0.001). The 30-day readmission rate in the pre-order era was 12.8% (1642 of 12,852) compared with 13.7% (3601 of 26,357, P = 0.016) in the EMR-order era. An EMR-based appointment order for follow-up appointment scheduling was associated with increased cardiovascular medicine follow-up, but was not associated with an observed reduction in 30-day readmission rates.

There is a low rate of major adverse cardiovascular events in chest pain patients with a moderate risk heart score referred from urgent care for expedited outpatient cardiology evaluation: a multi-center study

Background The HEART score is an effective method of risk stratifying emergency department (ED) patients with chest pain. The rate of major adverse cardiovascular events (MACE) in patients with moderate HEART score referred from an urgent care (UC) for an expedited outpatient cardiology evaluation for 11 months was described in 133 patients in a previous study. This is a follow-up study with 18 months of data and 206 patients.Aim. The primary outcome was to examine the rate of MACE when patients with moderate HEART score were referred for an expedited outpatient cardiology follow-up after evaluation in urgent care. The secondary outcome was to determine if there is a decrease in rate of ED transfer after this protocol was introduced.Methods. A cross-sectional study was conducted by a multispecialty group in Las Vegas, Nevada, which included 206 patients with a HEART score of 4 to 6 (i.e.: moderate risk) who presented to one of five UC centers with chest pain or an anginal equivalent. A streamlined evaluation protocol to assess each HEART score component was adopted by all UC providers to facilitate an expedited outpatient cardiology follow-up, as an alternative to referral to the emergency department. Data was collected from February 14, 2019 through August 13, 2020. The population was followed for 6 weeks with a primary endpoint of MACE determined by electronic medical record review and direct phone contact with patients. Outcomes were confirmed in 98% of patients. Chest pain transfer data was compared between 12 months prior to implementing HEART protocol and 18 months of data analysis while using the new protocol.Results. Over the course of 18 months, 206 patients with a moderate risk HEART score were referred to outpatient cardiology in an expedited manner. The average age was 65 with 53% female and 47% male patients. 150 patients (73% of the 206) were seen within 3 days, 114 (55%) underwent stress testing, 6 (3%) had coronary computed tomography angiogram, and 6 (3%) received an invasive coronary angiogram. Five patients were found to have MACE: one patient who had a non-ST-elevation myocardial infarction and subsequent coronary stent, two patients were found to have obstructive disease after coronary angiography with subsequent coronary artery bypass graft, one patient had an abnormal stress test and subsequent coronary stent, and one patient had critical mitral stenosis, multi-vessel coronary artery disease and underwent coronary artery bypass graft with mitral valve replacement with complications of renal failure and COVID-19 and expired. The emergency department referral rate declined by 21%.Conclusion. Patients with a moderate risk HEART score referred from UC for an expedited outpatient cardiology evaluation had a low rate of MACE and no deaths due to delay of care. There was also a significant decrease in the rate of ED referrals.

Recommendation for the recognition, management and follow up of cardiovascular compromise in patients with pediatric multisystemic inflammatory syndrome associated with covid-19 (Pims-ct). position statement of chilean scientific societies

Since the onset of the SARS-CoV-2 pandemic, the pediatric population has been less affected by the disease both in frequency and severity. However, since April cases of variable presentation and severity characterized by inflammatory phenomena that affect multiple organs have been reported, a condition called Multisystem Inflammatory Syndrome in Children (MIS-C). The literature has reported frequent cardiac involvement, up to 80%. This is characterized by myocardial injury with a significant increase of biomarkers such as serum troponins I and T, BNP, or NT-ProBNP coupled with varying degrees of ventricular dysfunction, pericarditis, valvulitis, and arrhythmias. Coronary compromise has also been described, which can occur in up to 23% of cases, and ranges from dila tations to aneurysms. Inpatient and outpatient cardiology follow-up has been systematized based on the clinical phenotypes such as myocardial injury (myocarditis, valvulitis, pericarditis), shock (usua lly vasoplegic), Kawasaki disease-type manifestations, and those MIS-C that do not comply with the clinic of the previous three. This last group represents the main challenge in the short-, medium- and long-term follow-up, therefore, it is necessary a multidisciplinary team for managing these patients. Considering the high frequency of cardiac compromise in MIS-C, and the importance of reaching a consensus regarding its management and follow-up, we present these recommendations according to the current state of knowledge regarding this recently described pathology.

Abstract 13645: Cardiologist Evaluation of Patients With Type 2 Myocardial Infarction

Introduction: Type 2 myocardial infarction (T2MI) is common and associated with recurrent cardiovascular events. How often T2MI patients are evaluated by a cardiologist and the association between these evaluations and diagnostic testing and treatments are unknown. Hypothesis: T2MI patients evaluated by a cardiologist are more likely to undergo cardiovascular testing and be placed on therapies for ischemic heart disease (IHD). Methods: We identified adjudicated patients with T2MI at Massachusetts General Hospital between October 2017 and May 2018. We examined baseline characteristics, diagnostic testing performed, and discharge medications, stratified by cardiologist evaluation during their admission. Results: We identified 359 patients with T2MI. During admission, 207 patients (57.7%) were evaluated by a cardiologist; 120 (33.4%) received a cardiology consultation and 87 (24.2%) were admitted to a cardiology service. Patients evaluated by a cardiologist were more likely to have hyperlipidemia (67.1% vs 52%, p=0.005), known CAD (58.9% vs. 38.8%, p&lt;0.001), prior MI (27.1% vs. 14.5%, p=0.006), and HF (56.5% vs. 44.1%, p=0.03). Patients evaluated by a cardiologist were more likely to undergo stress testing (13.5% vs 3.3%, p=0.002), transthoracic echocardiography (80.2% vs. 50.7%, p&lt;0.001), and coronary angiography (21.3% vs. 0%, p&lt;0.001) during their index admission. There was no difference in mortality among those who were or were not evaluated by a cardiologist (11.6% vs. 9.2%, p=0.58). Patients evaluated by a cardiologist were more likely to be discharged on a statin (74.5% vs 64.5%, p=0.04) and a beta blocker (72% vs. 55.9%, p=0.002). Only new prescriptions of beta blockers were more commonly prescribed among those evaluated by a cardiologist (20.3% vs. 7.9%, p=0.002). Among those with available follow-up data (N=289), 111 patients (38.4%) had an outpatient cardiology follow-up visit within 6 months of discharge. Conclusions: Fewer than 60% of patients with T2MI were evaluated by a cardiologist during their admission and those that did were more likely to undergo further cardiovascular testing and to be discharged on therapies for IHD. Most T2MI patients did not have an outpatient cardiology follow-up visit after their event.

Health literacy and caregiver understanding in the CHD population.

CHD is the most common birth defect type, with one-fourth of patients requiring intervention in the first year of life. Caregiver understanding of CHD may vary. Health literacy may be one factor contributing to this variability. The study occurred at a large, free-standing children's hospital. Recruitment occurred at a free-of-charge CHD camp and during outpatient cardiology follow-up visits. The study team revised the CHD Guided Questions Tool from an eighth- to a sixth-grade reading level. Caregivers of children with CHD completed the "Newest Vital Sign" health literacy screen and demographic surveys. Health literacy was categorised as "high" (Newest Vital Sign score 4-6) or "low" (score 0-3). Caregivers were randomised to read either the original or revised Guided Questions Tool and completed a validated survey measuring understandability and actionability of the Guided Questions Tool. Understandability and actionability data analysis used two-sample t-testing, and within demographic group differences in these parameters were assessed via one-way analysis of variance. Eighty-two caregivers participated who were largely well educated with a high income. The majority (79.3%) of participants scored "high" for health literacy. No differences in understanding (p = 0.43) or actionability (p = 0.11) of the original and revised Guided Questions Tool were noted. There were no socio-economic-based differences in understandability or actionability (p > 0.05). There was a trend towards improved understanding of the revised tool (p = 0.06). This study demonstrated that readability of the Guided Questions Tool could be improved. Future work is needed to expand the study population and further understand health literacy's impact on the CHD community.

Congenital heart disease diagnosed with echocardiogram in newborns with asymptomatic cardiac murmurs: a systematic review

BackgroundMore than 50% of newborns with congenital heart disease (CHD) are unrecognized at birth; however, the use of echocardiogram (Echo) for diagnosing CHD in newborns with asymptomatic, non-syndromic cardiac murmurs (ANCM), has not been systematically reviewed yet. We aimed to identify the incidence of CHD diagnosed with Echo and systematically review whether Echo should be recommended in this patient group.MethodsThe methodology utilized in this systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Using the MEDLINE, EMBASE, Web of Science, and Cochrane Library databases, we performed a systematic review of publications reporting CHD diagnosed with Echo in newborns with cardiac murmurs. The quality of the included studies was evaluated using the Study Quality Assessment Tools developed by the National Institutes of Health.ResultsOf the 630 studies screened, six cohort studies, four cross-sectional studies, and two case reports were included in this review. The incidence of cardiac murmurs ranged from 0.6–8.6%. Among the 1928 newborns with ANCM, 719 (37.3%) were diagnosed with Echo as having CHD, and ventricular septal defect was the most common congenital malformation. More than 50% of the newborns showed moderate CHD necessitating outpatient cardiology follow-up, and 2.5% had severe CHD requiring immediate interventions, such as cardiac catheterization and heart surgery.ConclusionsIn this systematic review, a high incidence of CHD in newborns with ANCM was detected using Echo. This indicates that the use of Echo for diagnosing CHD in healthy newborns with cardiac murmurs could be helpful in earlier detection of CHD, thereby improving clinical outcomes for newborns with severe CHD.

Smartphone and social media-based cardiac rehabilitation and secondary prevention in China (SMART-CR/SP): a parallel-group, single-blind, randomised controlled trial

Coronary heart disease is rapidly increasing in developing countries, but access to cardiac rehabilitation and secondary prevention remains low. In this study, we aimed to assess the effectiveness of a smartphone-based cardiac rehabilitation and secondary prevention programme delivered via the social media platform WeChat (SMART-CR/SP). In this parallel-group, single-blind, randomised controlled trial, we recruited patients aged 18 years or older with coronary heart disease who had received percutaneous coronary interventions from a large tertiary hospital in Shanghai, China. Participants were randomly assigned (1:1) by block randomisation to either a 2-month intensive programme followed by a 4-month step-down phase of SMART-CR/SP or to usual care. In the SMART-CR/SP group, participants received comprehensive cardiac rehabilitation and secondary prevention via WeChat. The usual care group received standard outpatient cardiology follow-up but without formal cardiac rehabilitation and secondary prevention. Assessments were done at baseline, 2 months, 6 months, and 12 months. The primary outcome was change in functional capacity from baseline, measured by 6-min walk distance, at 2 months and 6 months. Analysis was by intention to treat. Research personnel involved in assessments were blinded to group allocation. Adverse-event analysis was based on percentage of patients who discontinued the study owing to adverse events. SMART-CR/SP programme-related safety issues were also recorded. This study was registered with the Chinese Clinical Trial Registry, number ChiCTR-INR-16009598. Between Nov 17, 2016, and March 18, 2017, 312 patients (mean age 60·5 years [SD 9·2]), of whom 58 (19%) were female and 254 (81%) were male, were recruited and subsequently randomly assigned to SMART-CR/SP (n=156) or usual care (n=156). The improvement in 6-min walk distance at 2 months was significantly greater in the SMART-CR/SP group (from 489·2 m [99·4] at baseline to 539·1 m [68·0]) than in the control group (from 485·0 m [93·5] at baseline to 517·8 m [74.6]), with an adjusted mean difference of 20·64 m (95% CI 7·50-33·77; p=0·034). This improvement was maintained at 6 months (mean 6-min walk distance 543·4 m [67·5] in the SMART-CR/SP group vs 523·5 m [60·2] in the control group), with a mean between-group difference of 22·29 m (8·19-36·38; p=0·027). No adverse events or SMART-CR/SP programme-related safety issues were reported by participants during the study. SMART-CR/SP was found to be a cardiac rehabilitation and secondary prevention service model with high efficacy and accessibility and to be easy to use. These results justify the implementation of similar models of care on a broader scale. Curtin University.

Psychosocial functioning of parents of children with heart disease-describing the landscape.

The aim was to describe the psychological functioning of parents of school-age children with heart disease (HD) in a large-scale, transnational evaluation of parent dyads across the spectrum of cardiac diagnoses and a range of psychosocial domains. Parents of children with HD attending routine out-patient cardiology follow-up visits completed questionnaires assessing their mental health, coping, and family functioning. Parents (1197 mothers and 1053 fathers) of 1214 children (mean age: 12.6years; S.D. 3.0years; median time since last surgery: 8.9years) with congenital or acquired HD from three centers each in the UK and the USA participated (80% response rate). Parents of children with milder HD demonstrated few differences from healthy norms and had significantly lower scores on measures of illness-related stress and post-traumatic stress than parents of children with single ventricle conditions or cardiomyopathy. Parents in these latter two diagnostic sub-groups had significantly higher levels of anxiety and depression than healthy norms but did not differ on other measures of family functioning and coping skills. There were few differences between parents from the UK and the USA. Agreement between mothers and fathers within a dyad was highest for the measure of frequency of illness-related stressors (ICC = 0.67) and lowest for anxiety (ICC = 0.12).Conclusion: Our results suggest two different pathways for the long-term psychological well-being of parents of children with HD: on the one hand, more complex HD is associated with poorer long-term psychosocial outcomes; in contrast, there are also grounds for optimism, particularly for parents of children with less complex conditions, with better psychological outcomes noted for some groups of parents compared to previously reported early psychosocial outcomes. Future work needs to identify factors other than disease severity which might explain poorer (or better) functioning in some parents of children with more complex HD. What is Known: • Parents of children with congenital heart disease report elevated levels of anxiety, depression, and stress after cardiac surgery in infancy. • Maternal mental health problems can have an adverse impact on the psychological adjustment of the child with congenital heart disease. What is New: • Parents of children with milder forms of heart disease do not differ from healthy norms in the longer term and psychological outcomes are better than might be expected from early findings. • More complex diagnoses, particularly functional single ventricle conditions and cardiomyopathy, are associated with poorer long-term psychosocial outcomes for parents.

299 Retrospective Study of a Low-Risk Chest Pain Protocol in a Socioeconomically Disadvantaged Population

Standardized chest pain (CP) protocols are implemented in emergency departments (EDs) to safely and efficiently assess CP visits and provide the most appropriate disposition without excess resource utilization. However, whether the success of such an approach may be affected by the socioeconomic status of the target population is not known. We sought to determine the effectiveness of a standardized CP protocol in a primarily socioeconomically disadvantaged population. On November 1, 2012, a new CP protocol that utilizes the thrombolysis in myocardial infarction (TIMI) risk score, electrocardiography, and contemporary sensitivity troponin I to triage patients into low, intermediate and high-risk categories was implemented in our Detroit-based ED. Discharged low-risk patients were provided an outpatient cardiology follow-up appointment within 48 hours. We performed a retrospective analysis of patients greater than 18 years of age who presented with a chief complaint of low risk CP (TIMI score 0-1) during a 1-year period (6 months pre- and 6 months post-protocol implementation), comparing the proportion deemed low risk, ED disposition and 30-day ED recidivism rates over time using chi-square. A total of 3613 patients were included (n=1837 pre-protocol versus n=1776 post-protocol). The pre- and post-protocol populations were demographically similar with mean ages of 47.0 and 47.4, respectively. There was no statistical difference in the proportion deemed at low-risk in the pre- versus post-protocol periods (67% pre- versus 68% post-protocol; p=0.167). However, significantly more low-risk patients were discharged post-protocol implementation (55% versus 44%; p<0.001). Of the patients who were discharged, 41.9% kept their appointment with the cardiologist. ED recidivism was also significantly greater in the post-protocol versus pre-protocol (2.98% versus 1.63%; p=0.0035). Post-implementation of a CP protocol, a greater proportion of ED patients with low-risk CP were discharged, yet a higher rate of ED recidivism was seen. Such recidivism may reflect difficulty accessing outpatient follow-up in our socioeconomically disadvantaged population (Detroit has an 82.7% African-American population, and 35.7% of people live below the poverty line), but the precise cause of this important finding is unclear.Tabled 1Comparison Pre- and Post-ProtocolOutcomePre (N=1837)Post (N=1776)Low Risk1227 (67%)1213 (68%)Discharged808 (44%)970 (55%)ED Recidivism30 (1.63%)53 (2.98%) Open table in a new tab

What Is Shared Decision Making? (and What It Is Not).

Both the practice of medicine and the expectations of patients regarding their care are changing. A point of confluence is in the need for medicine to be more patient centered, and in the need for patients to be more involved in their care.1,2 This confluence is particularly pertinent when more than one reasonable approach is available to manage the patient's situation, and when those approaches differ in ways that matter to patients.3 In shared decision-making (SDM), clinicians and patients work together to understand the patient's situation and to determine how best to address it. Emergency medicine is not exempt from these trends. In this paper we seek to define SDM and its role in contemporary healthcare. Our goal is to set the stage for the active exploration of SDM in the care of patients in the emergency department. This article is protected by copyright. All rights reserved.

Children and Adults With Congenital Heart Disease Lost to Follow-Up

Many patients with congenital heart disease (CHD) require lifelong care. However, the duration of cardiology follow-up in children and adults with CHD is unknown. We sought to determine the proportion of children and young adults with CHD receiving outpatient cardiology care and to identify predictors of lack of follow-up. The study population consisted of individuals born in 1983 and alive at age 22 years who were diagnosed with CHD in Quebec, Canada, before 6 years of age (n=643). Patients and outpatient visits were identified with the use of the provincial physician's claims database. Three age groups were examined for the presence of outpatient cardiology follow-up: 6 to 12, 13 to 17, and 18 to 22 years. CHD lesions were classified as severe (n=84; 13%), simple shunts (n=390; 61%), and "other" lesions (n=169; 26%). Failure to receive cardiac follow-up after the 6th, 13th, and 18th birthday occurred in 28%, 47%, and 61%, respectively. Among those with severe lesions, only 79% were seen after the 18th birthday. However, the majority of subjects visited primary care physicians in all age groups, and 93% remained in contact with the healthcare system into early adulthood. Predictors of lack of cardiology follow-up in adulthood included male sex, a nonsevere lesion, and a history of follow-up outside a university hospital setting. Lack of cardiology follow-up begins during childhood, even among those with severe lesions. This occurs despite patients being in contact with other healthcare providers. Improved communication with primary care physicians may reduce the proportion of patients lost to cardiac follow-up.