Objective: To ascertain the use of secondary prevention medications and cardiac rehabilitation after an acute coronary syndrome (ACS) and the impact on 2-year outcomes.
Methods: CONCORDANCE (Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events) is a prospective, observational registry of 41 Australian hospitals. A representative sample of 6859 patients with an ACS and 6 months' follow-up on 31 May 2016 were included. The main outcome measure was use of ≥75% of indicated medications (≥4/5 (or ≥3/4 if contraindicated) of angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker, beta-blocker, lipid-lowering therapy, aspirin and other antiplatelet). Major adverse cardiovascular events (MACE) included myocardial infarction, stroke or cardiovascular death.
Results: The mean age was 65±13 years, 29% were women, and the mean Global Registry of Acute Coronary Events (GRACE) score was 106±30. At discharge, 92% were on aspirin, 93% lipid-lowering therapy, 78% beta-blocker, 74% ACE/angiotensin receptor blocker and 73% a second antiplatelet; 89% were taking ≥75% of medications at discharge, 78% at 6 months and 66% at 2 years. At 6 months, 38% attended cardiac rehabilitation, 58% received dietary advice and 32% of smokers reported quitting. Among 1896 patients followed to 2 years, death/MACE was less frequent among patients on ≥75% vs <75% of medications (8.3% vs 13.9%; adjusted OR 0.75, 95 % CI 0.56 to 0.99), and was less frequent in patients who attended versus who did not attend cardiac rehabilitation (4.6% vs 13.4%; adjusted OR 0.44, 95% CI 0.31 to 0.62).
Conclusions: Use of secondary prevention therapies diminishes over time following an ACS. Patients receiving secondary prevention had decreased rates of death and MACE at 2 years.
Background: The aim of this study was to assess the status of cardiovascular health among a semi-urban population of Nepal, and determine factors associated with ideal cardiovascular health.
Methods: A population-based, cross-sectional study using a systematic random sample was conducted among 2310 adults aged ≥ 25 years in a semi-urban area of the Pokhara Metropolitan City previously named Lekthnath in Nepal. The ideal, intermediate and poor cardiovascular health were defined as the presence of 6-7, 4-5 or 1-3 health metrics, among a list of 7 health behaviours and healthfactors, namely smoking, body mass index, physical activity, fruits and vegetables intakes, harmful alcohol consumption, blood pressure, and fasting blood glucose. We used univariate and multivariate Poisson regression models adjusting for sex, age groups, ethnicity, educational level and socioeconomic status, and calculated the prevalence ratios with 95% CIs.
Results: Only 14.3 % of the participants had ideal cardiovascular health, whereas 67.0% and 18.7% of the participants had intermediate and poor cardiovascular health, respectively. Age groups 45-54 years (prevalence ratio 0.88, 95% CI: 0.83 to 0.94, p<0.001) and 55-64 years (prevalence ratio 0.84, 95% CI: 0.79 to 0.90, p<0.001) were significantly associated with low prevalence of ideal cardiovascular health compared with the age group 35-44 years. Ethnic groups, including Janajati (prevalence ratio 0.89, 95% CI: 0.85 to 0.93, p<0.001) and Dalit (prevalence ratio 0.9, 95% CI: 0.84 to 0.95, p=0.001), were significantly associated with low prevalence of ideal cardiovascular health.
Conclusions: Prevalence of ideal cardiovascular health is low in the semi-urban population in Nepal. Concerted efforts are needed to develop a population-based intervention to improve cardiovascular health in Nepal.
Background: The importance of registries for collaborative quality improvement has been overlooked in low/middle-income countries (LMIC). Aga Khan University Hospital (AKUH) in Pakistan joined the Congenital Cardiac Catheterization Project on Outcomes-Quality Improvement (C3PO-QI) in March 2017 with the goal of leveraging international collaboration to improve patient care and institutional standards.
Methods: The C3PO-QI key driver-based approach was used, with certain modifications, for process re-engineering in AKUH's congenital cardiac catheterisation laboratory (CCL) to reduce radiation exposure during cardiac catheterisation procedures (the primary outcome of C3PO- QI). Educating staff and standardising procedural documentation were the principal goals of the process re-engineering. Data survey was used to assess staff knowledge, attitude and practice before and after the initiative. Additionally, case demographics and outcomes were compared between AKUH and C3PO-QI centres.
Results: There was an increase in appropriate recording of radiation surrogates (0%-100%, p=0.00) and in the percentage of cases that met the established benchmark of 'Ideal documentation' (35% vs 95%, p=0.001). There was also an increase in self-reported staff interest during the case (25% vs 75%, p=0.001). AKUH versus C3PO-QI data showed similar demographic characteristics. There was a slight over-representation of diagnostic cases (42% vs 32%) as compared with interventional (58% vs 68%) at AKUH. Furthermore, interventional procedures were predominately PDA and ASD device closures (n=19 and 15, respectively). The frequency of adverse events were the same between AKUH and collaborative sites.
Conclusion: Collaborative efforts between developed and LMIC CCL are significant in advancing system-level processes.
Objective: Exposure of implantable electrical devices may increase morbidity and mortality significantly. Usually superficial infections are conservatively managed whereas invasive infections necessitate complete capsulectomy, sub-pectoral placement or implant exchange. Most commonly inadequate soft tissue coverage, soft tissue thinning and scar dehiscence over the edge of the pacemaker are the primary predisposing event. Multiple local surgical options have been described, however, with all these designs, the final scar still remains over the edge of the pacemaker and continue to have a tendency of thinning out with time. We have described a local skin flap which can be de-epithelialized and partially buried under the skin to increase the thickness over the pacemaker edge, thereby preventing further recurrence.
Methods: Three patients admitted in the Cardiology Department presented with impending exposure (n=2)and exposed implant (n=1) over the edge of pacemaker with superficial infection. Local modified rotation skin flap which was de-epithelialized and partially buried under the skin to increase the thickness over the pacemaker edge was performed under local anaesthesia in all the cases.
Results: Flaps settled well in all patients with no evidence of infection, scar dehiscence and recurrence over a follow-up period of 2 years.
Conclusions: This flap technique is recommended for cases of impending pacemaker exposure resulting due to scar dehiscence over the edge and helps by addressing the predisposing factors at an initial stage. In our experience, this technique also helped to salvage exposed pacemaker with superficial infection. To our bestof knowledge this technique has not been described before in the literature.
Objective: Different definitions have been used for screening for rheumatic heart disease (RHD). This led to the development of the 2012 evidence-based World Heart Federation (WHF) echocardiographic criteria. The objective of this study is to determine the intra-rater and inter-rater reliability and agreement in differentiating no RHD from mild RHD using the WHF echocardiographic criteria.
Methods: A standard set of 200 echocardiograms was collated from prior population-based surveys and uploaded for blinded web-based reporting. Fifteen international cardiologists reported on and categorised each echocardiogram as no RHD, borderline or definite RHD. Intra-rater and inter-rater reliability was calculated using Cohen's and Fleiss' free-marginal multirater kappa (κ) statistics, respectively. Agreement assessment was expressed as percentages. Subanalyses assessed reproducibility and agreement parameters in detecting individual components of WHF criteria.
Results: Sample size from a statistical standpoint was 3000, based on repeated reporting of the 200 studies. The inter-rater and intra-rater reliability of diagnosing definite RHD was substantial with a kappa of 0.65 and 0.69, respectively. The diagnosis of pathological mitral and aortic regurgitation was reliable and almost perfect, kappa of 0.79 and 0.86, respectively. Agreement for morphological changes of RHD was variable ranging from 0.54 to 0.93 κ.
Conclusions: The WHF echocardiographic criteria enable reproducible categorisation of echocardiograms as definite RHD versus no or borderline RHD and hence it would be a suitable tool for screening and monitoring disease progression. The study highlights the strengths and limitations of the WHF echo criteria and provides a platform for future revisions.
Objective: The South Asian population has a lower burden of arrhythmia compared with Caucasians despite a higher prevalence of traditional cardiovascular risk factors. We aimed to determine whether this was due to differences in the electrophysiological properties of the South Asian heart.
Methods: We performed a retrospective cohort study of South Asian and Caucasian patients who underwent an electrophysiology study for supraventricular tachycardia between 2005 and 2017. Surface ECG, intracardiac ECG and intracardiac conduction intervals were measured and a comparison between the two ethnic cohorts was performed.
Results: A total of 5908 patients underwent an electrophysiology study at the Yorkshire Heart Centre, UK, during the study period. Of these 262 were South Asian and 113 met the eligibility criteria. South Asians had a significantly higher resting heart rate (p=0.024), shorter QRS duration (p=0.012) and a shorter atrioventricular (AV; p=0.001)) and ventriculoatrial (VA; p=0.013) effective refractory period (ERP). There was no difference in atrial or ventricular ERP. On linear regression analysis, South Asian ethnicity was independently predictive of a higher resting heart rate, narrower QRS and shorter AV-ERP and VA-ERP.
Conclusions: South Asians have significant differences in their resting heart rate, QRS duration and AV nodal function compared with Caucasians. These differences may reflect variations in autonomic function and may also be influenced by genetic factors. Electrophysiological differences such as these may help to explain why South Asians have a lower burden of arrhythmia.
Objective: We studied the optimal duration of ambulatory event monitors for symptomatic patients and the predictors of detected events.
Methods: Patients with palpitations or dizziness received a patient-activated handheld event monitor which records 30 s single-lead ECG strips. Patients were monitored in an ambulatory setting for a range of 1-4 weeks and ECG strips interpreted by five independent electrophysiologists. Event pick-up rates and clinical covariates were analysed.
Results: Of 335 consecutive adults (age 50±16 years, 58% female) with palpitations (94%) and dizziness (25%) monitored, 286 patients (85%) reported events, and clinically significant events were detected in 86 (26%) patients. Of these 86 patients, 26% had ≥2 significant events, and 73% had events detected in the first 3 days. No significant events were detected after 12 days. The most common ECG abnormalities detected were premature ventricular ectopy (38%), premature atrial ectopy (37%) and atrial fibrillation (AF)/atrial flutter (34%). A history of AF (adjusted OR (AOR) 4.2, 95% CI 1.1 to 15.8), previous arrhythmia (AOR 2.8, 95% CI 2.3 to 5.9) and previous abnormal ambulatory monitoring (AOR 3.4, 95% CI 1.0 to 9.4) were associated with detection of clinically significant events. Patients older than 50 years were 82% more likely to have a clinically significant event (OR 1.8, 95% CI 1.3 to 3.6).
Conclusion: Patient-activated ambulatory event monitoring for 7 days may be sufficient in the diagnosis of symptomatic patients as significant events first detected beyond 10 days were rare. Patients with a history of AF, arrhythmia or previous abnormal ambulatory monitoring may require even shorter monitoring periods.
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