Critical Pathways in Cardiology最新文献

Background: Patients with hypertrophic cardiomyopathy (HCM) usually have abnormal electrocardiograms consistent with left ventricular hypertrophy (LVH). The goal of this study was to evaluate the prevalence of abnormal ECG findings (LVH, T wave inversion, left bundle branch block, and left atrial enlargement) in participants with suspected HCM detected during screening echocardiography.

Method: The Anthony Bates Foundation has been performing screening echocardiography across the United States for the prevention of sudden death since 2001. A total of 682 subjects between the ages of 8 and 71 underwent echocardiographic screening together with ECG documentation. We evaluated the prevalence of abnormal ECG in participants with suspected HCM defined as any left ventricular wall thickness ≥15 mm.

Results: The prevalence of LVH and T wave inversion were higher in HCM subjects as expected [HCM occurred in 23.5% (4/17) vs. 5.6% (37/665), P = 0.002, T wave inversion occurred in 17.6% (3/17) vs. 4.1% (27/664), P = 0.007]. However, despite adding these 2 common ECG abnormalities in this population, the presence of detected abnormal ECG remained less than 25% (23.5% of HCM subjects had LVH or T wave inversion on ECG vs. 8.7% of control, P = 0.036). Left bundle branch block or abnormal left atrium on ECG were not found in any participants with suspected HCM.

Conclusions: The prevalence of abnormal ECG in the participants with suspected HCM detected during screening echocardiography is less than 25%. This suggests that ECG alone is not a sensitive marker for the detection of HCM.

Background: Evidence continues to accumulate that select patients with acute low-risk pulmonary embolism (PE) can be safely discharged from the emergency department. Despite this, outpatient management continues to be uncommon. We report changes in emergency providers' stated preferences on low-risk acute PE management before and after the development and implementation of an institutional clinical pathway and decision tool.

Methods: We performed an observational analysis of attending emergency physicians' stated preferences towards the management of low-risk acute PE using survey results before and after the development and implementation of an electronic health record-embedded institutional low-risk acute PE pathway.

Results: Attending emergency medicine providers reported feeling more comfortable using PE risk stratification scores to identify dischargeable low-risk PE patients and also reported that they would be more likely to discharge a hypothetical patient with low-risk acute PE.

Conclusion: Our results suggest that the implementation of an institutional clinical pathway with integration into the electronic health record was associated with a change in emergency physicians' stated preferences for managing patients with acute low-risk PE in the emergency department. Implementation of an evidence-based standard pathway was associated with increased comfort and familiarity with PE risk stratification, and an increased comfort with and preference for early outpatient management of low-risk PE.

The systemic amyloidoses are a broad spectrum of diseases that result from misfolding of proteins that aggregate into amyloid fibrils. In cardiac amyloidosis, amyloid fibrils accumulate in the interstitial space between cardiac myocytes causing cellular injury and impairing compliance. Current data suggest that cardiac amyloidosis is more common than previously thought. Advances in cardiac imaging, diagnostic strategies, and therapies have improved the recognition and treatment of cardiac amyloidosis. A position statement for the diagnosis and treatment of cardiac amyloidosis has been published in 2021 by the European Society of Cardiology and an expert consensus decision pathway was published in 2023 by the American College of Cardiology. These are excellent documents but quite lengthy and complex. For this reason, our team developed a novel and simple pathway to help health care providers diagnose and treat patients with cardiac amyloidosis. Our pathway starts with a section titled "suspicion" in which we provide simple clues or "red flags" that are associated with the cardiac amyloidosis phenotype. It is followed by a section titled "diagnosis," where we present in a simplified 2 × 2 format the laboratory and imaging tests that must be performed for an accurate diagnosis. In the section titled "treatment," we describe the 4 pillars in the management of patients with cardiac amyloidosis, which includes the following: heart failure treatments, management of arrhythmias, treatment of significant aortic stenosis, and appropriate selection of disease modifying therapies. Our algorithm ends with our simplified recommendation for follow-up.

Background: Left ventricular (LV) ejection fraction (LVEF) is not a sensitive marker of LV systolic function in a subset of patients with preserved EF. The relation between LV pump function and global longitudinal strain (GLS) has not been elucidated well in patients with objectively preserved EF and no apparent heart failure (HF). We aimed to detect whether LV GLS can discover impaired LV pump function [presented as low stroke volume index (SVI) and low cardiac output (COP)] in patients with objectively preserved EF and no apparent clinical HF and its practice utility.

Methods: In total, 100 participants with LVEF of ≥50% were studied for demographic and echocardiographic data, including LVEF, stroke volume, SVI, COP, LV longitudinal strain assessments, apical 4-, 3-, and 2-chamber views averaged for GLS, and were classified into 2 groups: group 1: normal GLS (more negative than -18%) and group 2: low GLS (less negative than -18%).

Results: Reduced LV GLS was associated with lower SVI (35.6 ± 13.6 vs. 43.8 ± 12.7 mL/m 2 ; P = 0.01), lesser COP (5.4 ± 1.9 vs. 6.5 ± 2.1 l/min; P = 0.02), GLS had strong positive correlations with SVI ( r = 0.75; P < 0.001), and COP ( r = 0.66; P < 0.001). LV GLS at a cutoff value less negative than -15% is a strong predictor of SVI ≤35 mL/m 2 (76% sensitivity and 79% specificity) and at a cutoff value less negative than -13.5% it is a strong predictor of COP ≤4 L/min (76% sensitivity and 73% specificity). LV GLS was the best independent predictor of low SVI (<35 mL/m 2 ) and low COP (<4 L/min).

Conclusion: Impaired LV strain is associated with lower LV pump function, presented as lower COP and lower SVI in patients with preserved EF even in the absence of clinical HF. It is of great importance to incorporate GLS in the routine evaluation of LV function hand-by-hand with the noninvasive assessment of LV stroke volume and COP that can replace GLS on evaluation of LV pump function in old machines with no GLS modalities, for early pick-up of patients with impaired LV pump function before apparent HF.

Objectives: The aim of this study was to assess adherence to the European Society of Cardiology 2020 non-ST elevation acute coronary syndrome (NST-ACS) guidelines, identify factors affecting this compliance, and explore the link between adherence and adverse cardiac outcomes.

Methods: This prospective cohort study was conducted in a tertiary-level academic hospital between January 2022 and January 2023. Patients diagnosed with NST-ACS in the emergency department (ED) were included. The primary outcome measured was the rate of adherence to the guidelines, and secondary outcomes were factors affecting this adherence in the ED and its association with 28-day adverse cardiac outcomes.

Results: Of the 298 patients included, guideline adherence was achieved in 32.2% in the ED. The highest compliance was observed in performing a 12-lead electrocardiogram (ECG) within 10 minutes (99.7%), while the lowest was found for obtaining additional right and posterior ECG leads when ongoing ischemia was suspected (42.3%). Factors associated with better adherence included the experience level of the treating physician, the presence of cardiac-quality chest pain, initial ischemic ECG findings, higher initial troponin levels, and advanced history, electrocardiogram, age, risk factors, and troponin score and Charlson comorbidity index. Complete guideline adherence over 28 days was achieved in 19.1% of patients and was found to be significantly associated with lower rates of adverse cardiac outcomes.

Conclusions: Adherence to NST-ACS guidelines was generally low but was associated with improved patient outcomes. This study highlighted the importance of various factors associated with guideline adherence. Future research should explore further barriers to guideline adherence and develop targeted interventions.

Background: Hypercholesterolemia (HCL) affects nearly half of Emergency Department (ED) patients who present with possible acute coronary syndrome (ACS). However, it is unknown whether US ED providers obtain lipid panels, calculate 10-year atherosclerotic cardiovascular disease (ASCVD) risk, and prescribe cholesterol-lowering medications for these patients.

Methods: We conducted a nationwide cross-sectional ED survey from April 18, 2023, to May 12, 2023. An electronic survey assessing current preventive HCL care practices for patients being evaluated for ACS. A convenience sample was obtained by sharing the survey with ED medical directors, chairs, and senior leaders using emergency medicine professional organization listservs and snowball sampling. Responding EDs were categorized as being associated with an academic medical center (AMC) or not (non-AMC).

Results: During the 4-week study period, 110 EDs (50 AMC and 60 non-AMC EDs) across 39 states responded. Just 1.8% (2/110) stated that their providers obtain a lipid panel on at least half of patients with possible ACS and only one ED (0.9%) responded that its providers calculate 10-year ASCVD risk and prescribe cholesterol medication for the majority of eligible patients. Most reported never obtaining lipid panels (60.9%, 67/110), calculating 10-year ASCVD risk (55.5%, 61/110), or prescribing cholesterol-lowering medications (52.7%, 58/110).

Conclusions: The vast majority of US ED providers do not provide preventive cardiovascular care for patients presenting with possible ACS. Most ED providers do not evaluate for HCL, calculate ASCVD risk, or prescribe cholesterol-lowering medications for these patients.

Objective: Hypertension (HTN) is a major risk factor for cardiovascular disease. Obesity has been found to be associated with HTN. However, there are not many studies available to evaluate any association between overweight alone and HTN.

Methods: A database from the Anthony Bates Foundation that performs preventive cardiovascular examinations including measurement of body mass index (BMI) and blood pressure across the United States was used for our study. Using recorded measurements, we evaluated any association between being overweight defined as a BMI of 25 to 30 and the occurrence of systolic and diastolic HTN in adults over the age of 18 years.

Results: A total of 1558 participants with documented BMI and blood pressure over the age of 18 years were studied. Among them, 758 participants had a normal BMI, and 800 had a BMI in overweight category. The prevalence of systolic and diastolic HTN was significantly higher in participants in the overweight versus normal weight cohort. Systolic HTN was present in 36% of participants in the overweight versus 14% of the normal weight group ( P < 0.00.1). Diastolic HTN was present in 43% of participants with overweight versus 21% of normal weight cohort ( P < 0.001). After adjusting for age and gender, high systolic blood pressure (SBP) and diastolic blood pressure (DBP) remained independently associated with overweight (SBP prevalence OR, 2.8; CI, 2.1-3.6; P < 0.001; DBP prevalence OR, 2.1; CI, 1.7-2.7; P < 0.001).

Conclusions: Our study found that increased BMI in the overweight category alone is independently associated with SBP and DBP in adults undergoing screening warranting further investigation.

Left heart catheterizations, coronary angiography, and coronary interventions are important common cardiac procedures. Performing a successful cardiac catheterization and intervention and proper catheterization and device delivery is not always without difficulties, especially in the context of calcification or vessel tortuosity. Although there are some techniques to overcome these issues, performing respiratory maneuvers (inspiration or expiration) can be simply tried as the first step to increase successful procedures which is underreported and underutilized. The goal of this article is to review current literature regarding useful respiratory maneuvers that can aid left heart cardiac catheterization, coronary angiography, and intervention for a successful procedure.

Clinical pathways are useful tools for conveying and reinforcing best practices to standardize care and optimize patient outcomes across myriad conditions. The NewYork-Presbyterian Healthcare System has utilized a clinical chest pain pathway for more than 20 years to facilitate the timely recognition and management of patients presenting with chest pain syndromes and acute coronary syndromes. This chest pain pathway is regularly updated by an expanding group of key stakeholders, which has extended from the Columbia University Irving Medical Center to encompass the entire regional healthcare system, which includes 8 hospitals. In this 2023 update of the NewYork-Presbyterian clinical chest pain pathway, we present the key changes to the healthcare system-wide clinical chest pain pathway.