Pub Date : 2025-11-01DOI: 10.1016/j.cjco.2025.06.009
Nicholas Grubic MSc , Salwa Nihal MBBS, MPhil, MSc , Julia E. Herr MSc , Tomislav Jelic MD , Steven J. Montague MD, MSc , Natasha Aleksova MD, MSc , Gillian Nesbitt MD, FRCPC , Omid Kiamanesh MD, FRCPC , Daniel J. Belliveau MD , Linden Kolbenson MD , Zakhar Kanyuka MD , Sharon L. Mulvagh MD, FRCPC, FACC, FASE, FAHA , Barkha Sirwani MPH , Amer M. Johri MD, MSc, FRCPC, FASE
Background
Disparities in access to postgraduate cardiopulmonary point-of-care ultrasound (POCUS) training have limited uptake by nonspecialists in remote care centres. This multicentre pre-post study evaluated the skill improvement of learners after they participated in a longitudinal and virtual POCUS training program.
Methods
Nonexpert POCUS users were recruited at urban teaching hospitals and geographically remote hospitals/nursing stations across 4 Canadian provinces. The 3-week educational program consisted of e-learning, independent imaging practice, and point-of-care tele-ultrasound (tele-POCUS) consultations with experts during clinical encounters. Standardized assessments were used to evaluate skill improvement in image acquisition, image quality, and image interpretation for cardiac and lung/pleura POCUS (as measured on a 5-point Likert scale) after program completion and receipt of remotely delivered guidance via tele-POCUS.
Results
Among 29 learners, 17 (41% female) completed the training program, of whom 7 practiced in remote hospitals/nursing stations. For cardiac POCUS, pre- and post-training assessments revealed improvements in image acquisition (mean scores: 3.02 to 4.48, P < 0.01), quality (2.49 to 4.06, P < 0.01), and interpretation (3.03 to 4.44, P < 0.01). Improvements in image acquisition (3.27 to 4.63, P < 0.01), quality (3.25 to 4.53, P < 0.01), and interpretation (3.35 to 4.65, P < 0.01) also occurred for lung/pleura POCUS. A total of 153 tele-POCUS consultations (77 cardiac and 76 lung/pleura) were performed. Image acquisition improved after remote guidance was provided to learners using tele-POCUS (all P < 0.01). Results were similar in analyses stratified by geographic setting.
Conclusions
Cardiopulmonary POCUS can be taught successfully to learners in diverse geographic settings using a virtual training format and tele-POCUS.
{"title":"Training Nonexpert Users in Cardiopulmonary Point-of-Care Ultrasound Using a Virtual Curriculum and a Teleconsultation Model: A Multicentre Study","authors":"Nicholas Grubic MSc , Salwa Nihal MBBS, MPhil, MSc , Julia E. Herr MSc , Tomislav Jelic MD , Steven J. Montague MD, MSc , Natasha Aleksova MD, MSc , Gillian Nesbitt MD, FRCPC , Omid Kiamanesh MD, FRCPC , Daniel J. Belliveau MD , Linden Kolbenson MD , Zakhar Kanyuka MD , Sharon L. Mulvagh MD, FRCPC, FACC, FASE, FAHA , Barkha Sirwani MPH , Amer M. Johri MD, MSc, FRCPC, FASE","doi":"10.1016/j.cjco.2025.06.009","DOIUrl":"10.1016/j.cjco.2025.06.009","url":null,"abstract":"<div><h3>Background</h3><div>Disparities in access to postgraduate cardiopulmonary point-of-care ultrasound (POCUS) training have limited uptake by nonspecialists in remote care centres. This multicentre pre-post study evaluated the skill improvement of learners after they participated in a longitudinal and virtual POCUS training program.</div></div><div><h3>Methods</h3><div>Nonexpert POCUS users were recruited at urban teaching hospitals and geographically remote hospitals/nursing stations across 4 Canadian provinces. The 3-week educational program consisted of e-learning, independent imaging practice, and point-of-care tele-ultrasound (tele-POCUS) consultations with experts during clinical encounters. Standardized assessments were used to evaluate skill improvement in image acquisition, image quality, and image interpretation for cardiac and lung/pleura POCUS (as measured on a 5-point Likert scale) after program completion and receipt of remotely delivered guidance via tele-POCUS.</div></div><div><h3>Results</h3><div>Among 29 learners, 17 (41% female) completed the training program, of whom 7 practiced in remote hospitals/nursing stations. For cardiac POCUS, pre- and post-training assessments revealed improvements in image acquisition (mean scores: 3.02 to 4.48, <em>P</em> < 0.01), quality (2.49 to 4.06, <em>P</em> < 0.01), and interpretation (3.03 to 4.44, <em>P</em> < 0.01). Improvements in image acquisition (3.27 to 4.63, <em>P</em> < 0.01), quality (3.25 to 4.53, <em>P</em> < 0.01), and interpretation (3.35 to 4.65, <em>P</em> < 0.01) also occurred for lung/pleura POCUS. A total of 153 tele-POCUS consultations (77 cardiac and 76 lung/pleura) were performed. Image acquisition improved after remote guidance was provided to learners using tele-POCUS (all <em>P</em> < 0.01). Results were similar in analyses stratified by geographic setting.</div></div><div><h3>Conclusions</h3><div>Cardiopulmonary POCUS can be taught successfully to learners in diverse geographic settings using a virtual training format and tele-POCUS.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1512-1523"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555420","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1016/j.cjco.2025.07.009
Holden Lowes BSc, MSc , Ingrid Brenner BPHE, BScN, BSc, MSc, PhD , Kirsten Woodend BScN, MSc, RN, PhD , Sarah West BPHE, MSc, PhD , Manjot Sunner BSc, MD , Barinder Khehra BSc, MD , Ani Orchanian-Cheff BA, MISt , Juan Jose Rodriguez Arias PhD, MD , Farid Foroutan BSc, PhD , Chun Po S. Fan BSc, MSc, PhD , Eduard Rodenas-Alesina MSc, MD , Juan Duero Posada MSc, MD , Heather J. Ross MHSc, DSc, MD , Yasbanoo Moayedi MHSc, MD
Background
The prognostic utility of cardiopulmonary exercise testing (CPET) in heart failure (HF) is well established; however, whether optimal CPET parameter thresholds differ across HF etiologies remains unclear. This systematic review aimed to determine how CPET-derived parameters and their prognostic threshold values differ, and their association with adverse outcomes, in patients with ischemic vs nonischemic cardiomyopathy.
Methods
Eligible studies assessed adult HF patients and reported outcomes of all-cause mortality, left ventricular assist device implantation, heart transplantation, or hospitalization. CPET parameters and associated threshold values were extracted, and risk of bias was assessed using the Joanna Briggs Institute checklist for cohort studies.
Results
Four studies comprising 491 ischemic and 218 nonischemic HF patients were included. Peak oxygen consumption (pVO2) was the only CPET parameter unanimously reported. In ischemic HF, the optimal pVO2 thresholds, in mL/kg/min, were ≤ 14.10 (hazard ratio [HR] 3.3; confidence interval [CI]: 1.9-5.8), ≤ 10.0 (HR 0.76; CI: 0.59-0.98), ≤ 15.20, and ≤ 14.0 (used in one study as a guideline comparator), yielding a mean threshold of ≤ 13.33 mL/kg/min ( ± 2.28). In nonischemic HF, optimal thresholds in mL/kg/min were ≤ 14.60 (HR 4.30 [CI: 2.10-8.90]) and ≤ 14.0, yielding a mean of ≤ 14.30 mL/kg/min ( ± 0.42).
Conclusions
Significant heterogeneity was present in study design, patient populations, and CPET variables assessed. The few consistently assessed prognostic thresholds were similar across HF etiologies. Peak oxygen consumption (pVO2) remains a robust prognostic marker in both ischemic and nonischemic cardiomyopathy. Although patients with ischemic cardiomyopathy generally have worse clinical profiles, this review suggests that no meaningful differences occur in a few key CPET prognostic thresholds, namely pVO2, across etiologies. These findings support continued use of established guideline-recommended thresholds for risk stratification, irrespective of HF subtype, but require further confirmation.
{"title":"A Systematic Review of the Prognostic Value of Cardiopulmonary Exercise Testing in Patients with Ischemic and Nonischemic Cardiomyopathy","authors":"Holden Lowes BSc, MSc , Ingrid Brenner BPHE, BScN, BSc, MSc, PhD , Kirsten Woodend BScN, MSc, RN, PhD , Sarah West BPHE, MSc, PhD , Manjot Sunner BSc, MD , Barinder Khehra BSc, MD , Ani Orchanian-Cheff BA, MISt , Juan Jose Rodriguez Arias PhD, MD , Farid Foroutan BSc, PhD , Chun Po S. Fan BSc, MSc, PhD , Eduard Rodenas-Alesina MSc, MD , Juan Duero Posada MSc, MD , Heather J. Ross MHSc, DSc, MD , Yasbanoo Moayedi MHSc, MD","doi":"10.1016/j.cjco.2025.07.009","DOIUrl":"10.1016/j.cjco.2025.07.009","url":null,"abstract":"<div><h3>Background</h3><div>The prognostic utility of cardiopulmonary exercise testing (CPET) in heart failure (HF) is well established; however, whether optimal CPET parameter thresholds differ across HF etiologies remains unclear. This systematic review aimed to determine how CPET-derived parameters and their prognostic threshold values differ, and their association with adverse outcomes, in patients with ischemic vs nonischemic cardiomyopathy.</div></div><div><h3>Methods</h3><div>Eligible studies assessed adult HF patients and reported outcomes of all-cause mortality, left ventricular assist device implantation, heart transplantation, or hospitalization. CPET parameters and associated threshold values were extracted, and risk of bias was assessed using the Joanna Briggs Institute checklist for cohort studies.</div></div><div><h3>Results</h3><div>Four studies comprising 491 ischemic and 218 nonischemic HF patients were included. Peak oxygen consumption (pVO<sub>2</sub>) was the only CPET parameter unanimously reported. In ischemic HF, the optimal pVO<sub>2</sub> thresholds, in mL/kg/min, were ≤ 14.10 (hazard ratio [HR] 3.3; confidence interval [CI]: 1.9-5.8), ≤ 10.0 (HR 0.76; CI: 0.59-0.98), ≤ 15.20, and ≤ 14.0 (used in one study as a guideline comparator), yielding a mean threshold of ≤ 13.33 mL/kg/min ( ± 2.28). In nonischemic HF, optimal thresholds in mL/kg/min were ≤ 14.60 (HR 4.30 [CI: 2.10-8.90]) and ≤ 14.0, yielding a mean of ≤ 14.30 mL/kg/min ( ± 0.42).</div></div><div><h3>Conclusions</h3><div>Significant heterogeneity was present in study design, patient populations, and CPET variables assessed. The few consistently assessed prognostic thresholds were similar across HF etiologies. Peak oxygen consumption (pVO<sub>2</sub>) remains a robust prognostic marker in both ischemic and nonischemic cardiomyopathy. Although patients with ischemic cardiomyopathy generally have worse clinical profiles, this review suggests that no meaningful differences occur in a few key CPET prognostic thresholds, namely pVO<sub>2</sub>, across etiologies. These findings support continued use of established guideline-recommended thresholds for risk stratification, irrespective of HF subtype, but require further confirmation.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1441-1450"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555424","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Forty-eight-hour Holter-monitoring (HM) is recommended to identify nonsustained ventricular tachycardia (NSVT) in patients with hypertrophic cardiomyopathy (HCM). This study aims to estimate the cumulative 48-hour risk of NSVT in HCM and assess arrhythmic disease progression during follow-up evaluation.
Methods
HCM patients were retrospectively identified from 2017 to 2020 and were evaluated from patient records. Patients with a minimum of 2 available HM periods were included.
Results
We identified 97 HCM patients, with a mean age of 47 ± 16 years, and 68% of whom were male. From the first to the latest HM period, the mean follow-up duration was 4.3 ± 2.5 years. The cumulative 48-hour risk of NSVT was 31% in the first HM period, compared to 37% in the latest period. No difference occurred in number of ventricular cycles or frequency of NSVT. Cox regressions analysis showed that no significant difference occurred in event rates of NSVT between the first and the latest HM periods (hazard ratio 1.27; 95% confidence interval [CI] 0.78-2.06; P = 0.33) and that age had no effect on the risk of NSVT (hazard ratio 1.01; 95% confidence interval 0.99-1.03; P = 0.15). In the latest HM period, atrial fibrillation was identified in 6% of patients, compared to none in the first HM period (P = 0.01). Premature ventricular contractions occurred more often in the first HM period (25, interquartile range 5, 170) compared to the latest HM period (50, interquartile range 14, 360, P = 0.01).
Conclusions
This study demonstrated a modest arrhythmic disease progression in HCM patients during a 4-year follow-up period, with a significant increase in premature ventricular contractions and atrial fibrillation, and a trend toward an increase in NSVT.
{"title":"Arrhythmic Disease Progression in Hypertrophic Cardiomyopathy During 4 Years of Follow-Up Evaluation","authors":"Louise Bjerregaard MD , Christoffer Harboe Nielsen MD , Steen Hvitfeldt Poulsen MD, DMSc , Torsten Bloch Rasmussen MD, PhD , Morten Kvistholm Jensen MD, PhD","doi":"10.1016/j.cjco.2025.07.006","DOIUrl":"10.1016/j.cjco.2025.07.006","url":null,"abstract":"<div><h3>Background</h3><div>Forty-eight-hour Holter-monitoring (HM) is recommended to identify nonsustained ventricular tachycardia (NSVT) in patients with hypertrophic cardiomyopathy (HCM). This study aims to estimate the cumulative 48-hour risk of NSVT in HCM and assess arrhythmic disease progression during follow-up evaluation.</div></div><div><h3>Methods</h3><div>HCM patients were retrospectively identified from 2017 to 2020 and were evaluated from patient records. Patients with a minimum of 2 available HM periods were included.</div></div><div><h3>Results</h3><div>We identified 97 HCM patients, with a mean age of 47 ± 16 years, and 68% of whom were male. From the first to the latest HM period, the mean follow-up duration was 4.3 ± 2.5 years. The cumulative 48-hour risk of NSVT was 31% in the first HM period, compared to 37% in the latest period. No difference occurred in number of ventricular cycles or frequency of NSVT. Cox regressions analysis showed that no significant difference occurred in event rates of NSVT between the first and the latest HM periods (hazard ratio 1.27; 95% confidence interval [CI] 0.78-2.06; <em>P</em> = 0.33) and that age had no effect on the risk of NSVT (hazard ratio 1.01; 95% confidence interval 0.99-1.03; <em>P</em> = 0.15). In the latest HM period, atrial fibrillation was identified in 6% of patients, compared to none in the first HM period (<em>P</em> = 0.01). Premature ventricular contractions occurred more often in the first HM period (25, interquartile range 5, 170) compared to the latest HM period (50, interquartile range 14, 360, <em>P</em> = 0.01).</div></div><div><h3>Conclusions</h3><div>This study demonstrated a modest arrhythmic disease progression in HCM patients during a 4-year follow-up period, with a significant increase in premature ventricular contractions and atrial fibrillation, and a trend toward an increase in NSVT.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1434-1440"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555053","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1016/j.cjco.2025.06.023
Lisa M. Mielniczuk MD , Eileen O’Meara MD , Christiane Wiefels MD , Li Chen MSc , Linda Garrard RN , James White MD , Robert A. deKemp PhD , Marcelo F. Di Carli MD , Eric Larose MD , David I. Paterson MD , Justin Ezekowitz MB , Riina M. Kandolin MD , Graham Wright PhD , Roxana Campisi MD , Mika K. Laine MD , Kim Connelly MBBS, PhD , Miroslaw Rajda MD , Joao V. Vitola MD , Serge Lepage MD , Juha Hartikainen MD , Rob S.B. Beanlands MD
Background
The role of advanced (cardiac magnetic resonance [CMR] or positron emission tomography [PET]) vs single-photon emission computerized tomography (SPECT) ischemia imaging to guide management remains unclear in patients with ischemic heart failure (IHF). The primary aim was to determine the effect of imaging modality on a composite cardiovascular endpoint and cardiac death in patients with IHF who require ischemia assessment.
Methods
Patients with IHF were randomized to advanced or SPECT imaging. A parallel registry also was performed. The primary endpoint was the composite of cardiac death, infarction, arrest, and cardiac rehospitalization. The key secondary endpoint was cardiac death.
Results
Patients in the randomized population (advanced imaging [PET or CMR; n = 64] or SPECT [n = 56]) had a cumulative incidence rate (CIR) for the primary endpoint of 33.1% and 33.0%, respectively (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.49, 1.80, P = 0.853). CIRs for cardiac death were 13.8% and 25.1%, respectively (HR 0.62, 95% CI 0.25, 1.80, P = 0.296).
In the parallel registry (n = 336 advanced; n = 216 SPECT), the primary endpoint CIRs were 31.2% and 35.3%, respectively (HR 0.81, 95% CI 0.56, 1.19, P = 0.284). CIRs for cardiac death were 11.0% and 16.6%, respectively (HR 0.53, 95% CI 0.27, 1.04, P = 0.066). Patients were followed for a median (interquartile range) of 24.1 (11.6, 27.5) months.
Pooled analysis from the randomized and registry populations revealed a significant benefit of advanced imaging for reduction of cardiac death (HR 0.56, 95% CI 0.33, 0.96, P = 0.04) with minimal heterogeneity (I2 = 0%).
Conclusion
Among IHF patients assessed for ischemia, advanced imaging (PET or CMR) was not associated with reduced composite cardiac events, compared to SPECT.
Clinical Trial Registration
NCT01288560.
在缺血性心力衰竭（IHF）患者中，高级心脏磁共振（CMR）或正电子发射断层扫描（PET）与单光子发射计算机断层扫描（SPECT）缺血成像在指导治疗中的作用尚不清楚。主要目的是确定成像方式对需要缺血评估的IHF患者复合心血管终点和心源性死亡的影响。方法将IHF患者随机分为高级或SPECT组。还执行了一个并行注册表。主要终点为心源性死亡、梗死、骤停和心脏再住院。主要的次要终点是心源性死亡。结果随机分组患者（高级影像学[PET或CMR； n = 64]或SPECT [n = 56]）主要终点的累积发病率（CIR）分别为33.1%和33.0%（风险比[HR] 0.94, 95%可信区间[CI] 0.49, 1.80, P = 0.853）。心源性死亡的CIRs分别为13.8%和25.1% （HR 0.62, 95% CI 0.25, 1.80, P = 0.296）。在平行注册中（n = 336例晚期，n = 216例SPECT），主要终点CIRs分别为31.2%和35.3% （HR 0.81, 95% CI 0.56, 1.19, P = 0.284）。心源性死亡的CIRs分别为11.0%和16.6% （HR 0.53, 95% CI 0.27, 1.04, P = 0.066）。患者随访的中位数（四分位数范围）为24.1（11.6,27.5）个月。来自随机和登记人群的汇总分析显示，先进成像对降低心脏性死亡有显著益处（HR 0.56, 95% CI 0.33, 0.96, P = 0.04），异质性最小（I2 = 0%）。结论在评估为缺血的IHF患者中，与SPECT相比，晚期成像（PET或CMR）与减少复合心脏事件无关。临床试验注册编号：nct01288560。
{"title":"The Alternative Imaging Modalities in Ischemic Heart Failure (AIMI-HF) Trial—IMAGE HF Project 1A","authors":"Lisa M. Mielniczuk MD , Eileen O’Meara MD , Christiane Wiefels MD , Li Chen MSc , Linda Garrard RN , James White MD , Robert A. deKemp PhD , Marcelo F. Di Carli MD , Eric Larose MD , David I. Paterson MD , Justin Ezekowitz MB , Riina M. Kandolin MD , Graham Wright PhD , Roxana Campisi MD , Mika K. Laine MD , Kim Connelly MBBS, PhD , Miroslaw Rajda MD , Joao V. Vitola MD , Serge Lepage MD , Juha Hartikainen MD , Rob S.B. Beanlands MD","doi":"10.1016/j.cjco.2025.06.023","DOIUrl":"10.1016/j.cjco.2025.06.023","url":null,"abstract":"<div><h3>Background</h3><div>The role of advanced (cardiac magnetic resonance [CMR] or positron emission tomography [PET]) vs single-photon emission computerized tomography (SPECT) ischemia imaging to guide management remains unclear in patients with ischemic heart failure (IHF). The primary aim was to determine the effect of imaging modality on a composite cardiovascular endpoint and cardiac death in patients with IHF who require ischemia assessment.</div></div><div><h3>Methods</h3><div>Patients with IHF were randomized to advanced or SPECT imaging. A parallel registry also was performed. The primary endpoint was the composite of cardiac death, infarction, arrest, and cardiac rehospitalization. The key secondary endpoint was cardiac death.</div></div><div><h3>Results</h3><div>Patients in the randomized population (advanced imaging [PET or CMR; n = 64] or SPECT [n = 56]) had a cumulative incidence rate (CIR) for the primary endpoint of 33.1% and 33.0%, respectively (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.49, 1.80, <em>P</em> = 0.853). CIRs for cardiac death were 13.8% and 25.1%, respectively (HR 0.62, 95% CI 0.25, 1.80, <em>P</em> = 0.296).</div><div>In the parallel registry (n = 336 advanced; n = 216 SPECT), the primary endpoint CIRs were 31.2% and 35.3%, respectively (HR 0.81, 95% CI 0.56, 1.19, <em>P</em> = 0.284). CIRs for cardiac death were 11.0% and 16.6%, respectively (HR 0.53, 95% CI 0.27, 1.04, <em>P</em> = 0.066). Patients were followed for a median (interquartile range) of 24.1 (11.6, 27.5) months.</div><div>Pooled analysis from the randomized and registry populations revealed a significant benefit of advanced imaging for reduction of cardiac death (HR 0.56, 95% CI 0.33, 0.96, <em>P</em> = 0.04) with minimal heterogeneity (I<sup>2</sup> = 0%).</div></div><div><h3>Conclusion</h3><div>Among IHF patients assessed for ischemia, advanced imaging (PET or CMR) was not associated with reduced composite cardiac events, compared to SPECT.</div></div><div><h3>Clinical Trial Registration</h3><div>NCT01288560.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1423-1433"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555052","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Optimized 4-pillar guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) has significantly altered clinical practice, with a coinciding decrease in sudden cardiac death. The continued role for implantable cardioverter-defibrillators (ICDs) in primary prevention of sudden death has recently been debated in the context of residual arrhythmic risk. This survey explored contemporary attitudes toward primary prevention ICD use in ischemic and nonischemic cardiomyopathy.
Methods
An international, REDCap-based survey targeting clinicians involved in HFrEF management assessed the impact of GDMT on ICD decision-making, clinical thresholds used for implantation, and willingness to participate in randomized controlled trials.
Results
Of 210 registered responses, 140 (66.7%) could be analyzed. Most respondents were electrophysiologists (77.1%) working in academic centers (70.7%) in North America (87.1%). Fewer ICD implantations were reported after the introduction of 4-pillar GDMT, with a larger reduction in nonischemic cardiomyopathy (P = 0.003). Clinical thresholds based on left ventricular ejection fraction and New York Heart Association class were common, whereas age, renal function, and late gadolinium enhancement cut-offs were used less frequently. Willingness to randomize patients into ICD vs no-ICD trials was moderate for ischemic cardiomyopathy (38.8% for all patients, 31.8% for select patients). In nonischemic cardiomyopathy, willingness was higher, with 51.2% willing to randomize all patients and only 9.3% declining. Free-text responses emphasized individualized decision-making and the growing role of imaging and genetics.
Conclusions
In the era of optimized GDMT, practice patterns regarding primary prevention ICD implantation are increasingly heterogeneous. These findings underscore the need for nuanced shared decision-making and well-designed randomized controlled studies to guide future practice.
{"title":"Contemporary Use of Implantable Cardioverter-Defibrillators in the Era of 4-Pillar Heart Failure Therapy---an International Survey","authors":"Bert Vandenberk MD, PhD , Roopinder K. Sandhu MD, MPH , Justin Ezekowitz MBBCh, MSc , Derek S. Chew MD, MSc","doi":"10.1016/j.cjco.2025.06.016","DOIUrl":"10.1016/j.cjco.2025.06.016","url":null,"abstract":"<div><h3>Background</h3><div>Optimized 4-pillar guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) has significantly altered clinical practice, with a coinciding decrease in sudden cardiac death. The continued role for implantable cardioverter-defibrillators (ICDs) in primary prevention of sudden death has recently been debated in the context of residual arrhythmic risk. This survey explored contemporary attitudes toward primary prevention ICD use in ischemic and nonischemic cardiomyopathy.</div></div><div><h3>Methods</h3><div>An international, REDCap-based survey targeting clinicians involved in HFrEF management assessed the impact of GDMT on ICD decision-making, clinical thresholds used for implantation, and willingness to participate in randomized controlled trials.</div></div><div><h3>Results</h3><div>Of 210 registered responses, 140 (66.7%) could be analyzed. Most respondents were electrophysiologists (77.1%) working in academic centers (70.7%) in North America (87.1%). Fewer ICD implantations were reported after the introduction of 4-pillar GDMT, with a larger reduction in nonischemic cardiomyopathy (<em>P</em> = 0.003). Clinical thresholds based on left ventricular ejection fraction and New York Heart Association class were common, whereas age, renal function, and late gadolinium enhancement cut-offs were used less frequently. Willingness to randomize patients into ICD vs no-ICD trials was moderate for ischemic cardiomyopathy (38.8% for all patients, 31.8% for select patients). In nonischemic cardiomyopathy, willingness was higher, with 51.2% willing to randomize all patients and only 9.3% declining. Free-text responses emphasized individualized decision-making and the growing role of imaging and genetics.</div></div><div><h3>Conclusions</h3><div>In the era of optimized GDMT, practice patterns regarding primary prevention ICD implantation are increasingly heterogeneous. These findings underscore the need for nuanced shared decision-making and well-designed randomized controlled studies to guide future practice.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1454-1460"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555055","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1016/j.cjco.2025.07.005
Evan J. Wiens MD, MSc, FRCPC , Kristal L. Kawa MN, NP , Silvia J. Leon MD, MSc , Reid Whitlock MSc , Setor Kunutsor BSc, MD, MPhil, PhD , Navdeep Tangri MD, PhD , Ashish H. Shah MBBS, MD, MD-Research, FRCP
Background
Although delays in treatment are known to worsen outcomes in ST-elevation myocardial infarction, their effect in non-ST-elevation myocardial infarction (NSTEMI) is less clear. Care quality and timely revascularization should be comparable across presentation sites to optimize patient outcomes.
Methods
Using the Manitoba Centre for Health Policy data, we retrospectively analyzed adult NSTEMI patients who underwent cardiac catheterization and revascularization from January 2001 to March 2021. Patients were grouped by initial presentation site—rural hospital, urban noncardiac hospital, or specialized cardiac centre. We assessed in-hospital, 1-year, and long-term outcomes.
Results
Of 30,817 NSTEMI patients, 19,482 underwent catheterization, and 12,567 received revascularization. Distribution by site was as follows: 44% at cardiac centres, 28.5% at urban noncardiac hospitals, and 27.5% at rural hospitals. Urban noncardiac hospital patients experienced significantly higher cardiovascular mortality in-hospital (hazard ratio [HR] 1.64; 95% confidence interval [CI] 1.09-2.47), at 1 year (HR 1.30; 95% CI 1.11-1.53), and over an average 6.65-year follow-up period (HR 1.15; 95% CI 1.07-1.24). Rural hospital patients showed a lower mortality incidence, potentially due to selection bias if critically ill patients did not survive the transfer. Both rural and urban noncardiac cohorts had elevated rates of major adverse cardiovascular events at all follow-up intervals. Time to catheterization was notably delayed for nonspecialized sites (cardiac centre, 0.83 ± 1.90 vs urban noncardiac 3.20 ± 3.05 vs rural, 3.09 ± 2.56 days; P < 0.001).
Conclusions
NSTEMI patients presenting to rural and urban nonspecialized hospitals experience worse short- and long-term outcomes, including increased incidence of major adverse cardiovascular events and mortality. These findings highlight the need for strategies to reduce disparities in access to specialized cardiac care.
{"title":"Outcomes of Non-ST Elevation Myocardial Infarction Patients by Presentation Site: Rural, Urban Community, or Specialized Cardiac Hospital","authors":"Evan J. Wiens MD, MSc, FRCPC , Kristal L. Kawa MN, NP , Silvia J. Leon MD, MSc , Reid Whitlock MSc , Setor Kunutsor BSc, MD, MPhil, PhD , Navdeep Tangri MD, PhD , Ashish H. Shah MBBS, MD, MD-Research, FRCP","doi":"10.1016/j.cjco.2025.07.005","DOIUrl":"10.1016/j.cjco.2025.07.005","url":null,"abstract":"<div><h3>Background</h3><div>Although delays in treatment are known to worsen outcomes in ST-elevation myocardial infarction, their effect in non-ST-elevation myocardial infarction (NSTEMI) is less clear. Care quality and timely revascularization should be comparable across presentation sites to optimize patient outcomes.</div></div><div><h3>Methods</h3><div>Using the Manitoba Centre for Health Policy data, we retrospectively analyzed adult NSTEMI patients who underwent cardiac catheterization and revascularization from January 2001 to March 2021. Patients were grouped by initial presentation site—rural hospital, urban noncardiac hospital, or specialized cardiac centre. We assessed in-hospital, 1-year, and long-term outcomes.</div></div><div><h3>Results</h3><div>Of 30,817 NSTEMI patients, 19,482 underwent catheterization, and 12,567 received revascularization. Distribution by site was as follows: 44% at cardiac centres, 28.5% at urban noncardiac hospitals, and 27.5% at rural hospitals. Urban noncardiac hospital patients experienced significantly higher cardiovascular mortality in-hospital (hazard ratio [HR] 1.64; 95% confidence interval [CI] 1.09-2.47), at 1 year (HR 1.30; 95% CI 1.11-1.53), and over an average 6.65-year follow-up period (HR 1.15; 95% CI 1.07-1.24). Rural hospital patients showed a lower mortality incidence, potentially due to selection bias if critically ill patients did not survive the transfer. Both rural and urban noncardiac cohorts had elevated rates of major adverse cardiovascular events at all follow-up intervals. Time to catheterization was notably delayed for nonspecialized sites (cardiac centre, 0.83 ± 1.90 vs urban noncardiac 3.20 ± 3.05 vs rural, 3.09 ± 2.56 days; <em>P</em> < 0.001).</div></div><div><h3>Conclusions</h3><div>NSTEMI patients presenting to rural and urban nonspecialized hospitals experience worse short- and long-term outcomes, including increased incidence of major adverse cardiovascular events and mortality. These findings highlight the need for strategies to reduce disparities in access to specialized cardiac care.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1466-1473"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555415","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1016/j.cjco.2025.06.021
Alisha Labinaz BSc , Ren Jie Robert Yao MD , Farshad Hosseini MD , Ricky D. Turgeon BSc (Pharm), ACPR, PharmD , Miles Marchand MD , Liam Brunham MD, PhD, FRCPC, FACP , Nathaniel M. Hawkins MD, MBChB, MPH , Graham Wong MD, MPH, FRCPC, FACC, FCCS, FAHA , G.B. John Mancini MD, FRCPC, FACP, FACC , Christopher B. Fordyce MD, MHS, MSc, FRCPC
Following an acute coronary syndrome (ACS), patients remain at a residual increased risk of adverse cardiovascular events. As such, secondary prevention strategies, including dyslipidemia management, are key in the delivery of post-ACS care. Multiple randomized controlled trials have highlighted the benefit of lipid-lowering therapies in reducing low-density lipoprotein cholesterol levels, an independent predictor of adverse cardiovascular events post-ACS. However, registries have demonstrated that post-ACS, a significant proportion of patients are not achieving guideline-recommended low-density lipoprotein target levels, and intensification of lipid-lowering therapies continues to be underutilized. This review assesses strategies in which post-ACS lipid management can be improved, in particular by standardizing follow-up care through dedicated post-ACS clinics.
{"title":"Implementing Dyslipidemia Guidelines into Clinical Practice Following an Acute Coronary Syndrome: Challenges and Opportunities for Improvement","authors":"Alisha Labinaz BSc , Ren Jie Robert Yao MD , Farshad Hosseini MD , Ricky D. Turgeon BSc (Pharm), ACPR, PharmD , Miles Marchand MD , Liam Brunham MD, PhD, FRCPC, FACP , Nathaniel M. Hawkins MD, MBChB, MPH , Graham Wong MD, MPH, FRCPC, FACC, FCCS, FAHA , G.B. John Mancini MD, FRCPC, FACP, FACC , Christopher B. Fordyce MD, MHS, MSc, FRCPC","doi":"10.1016/j.cjco.2025.06.021","DOIUrl":"10.1016/j.cjco.2025.06.021","url":null,"abstract":"<div><div>Following an acute coronary syndrome (ACS), patients remain at a residual increased risk of adverse cardiovascular events. As such, secondary prevention strategies, including dyslipidemia management, are key in the delivery of post-ACS care. Multiple randomized controlled trials have highlighted the benefit of lipid-lowering therapies in reducing low-density lipoprotein cholesterol levels, an independent predictor of adverse cardiovascular events post-ACS. However, registries have demonstrated that post-ACS, a significant proportion of patients are not achieving guideline-recommended low-density lipoprotein target levels, and intensification of lipid-lowering therapies continues to be underutilized. This review assesses strategies in which post-ACS lipid management can be improved, in particular by standardizing follow-up care through dedicated post-ACS clinics.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1482-1494"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555417","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Populations with lower socioeconomic position (SEP) are at increased risk of developing cardiovascular disease (CVD). Movement behaviours, including physical activity, sedentary behaviour, and sleep, contribute to socioeconomic gradients in CVD risk, as low-SEP populations are less likely to meet evidence-informed recommendations for these behaviours. Adolescence represents a sensitive period for establishing lifelong health behaviours, with CVD risk beginning to accumulate before adulthood. This study will model the potential effect of adolescent movement behaviour interventions on socioeconomic inequalities in adult CVD risk. We will conduct a population-based cohort study of adolescents from the Add Health study, recruited in 1994-1995 from the US and followed into adulthood. Unhealthy movement behaviours, including a low level of moderate-to-vigorous physical activity, a high level of recreational screen time, and short sleep duration, will be operationalized based on the 24-hour Movement Guidelines and measured twice during adolescence (ages 12-24 years). Parental educational attainment and family financial hardship will be used to capture SEP in adolescence. The outcome will be the 30-year risk of CVD, assessed in adulthood (ages 33-41 years) using a validated risk score that incorporates objectively measured biomarkers, demographic information, and self-reported health indicators. We will perform causal decompositions to quantify the change of socioeconomic inequalities in adult CVD risk under 2 interventional scenarios: (i) elimination (unhealthy movement behaviours are eliminated in the whole population of adolescents); and (ii) equalization (the distributions of unhealthy movement behaviours for low-SEP adolescents are equalized to those of high-SEP adolescents). This study will provide insights into how modifying adolescent movement behaviours may contribute to reducing socioeconomic inequalities in CVD risk.
{"title":"Reducing Socioeconomic Inequalities in Adult Cardiovascular Disease Risk by Targeting Unhealthy Movement Behaviours During Adolescence: A Protocol","authors":"Nicholas Grubic MSc , Katerina Maximova PhD , Arnaud Chiolero MD, PhD , Arjumand Siddiqi ScD , Sarah Carsley PhD , Brice Batomen PhD , Kathleen Mullan Harris PhD , Cristian Carmeli PhD","doi":"10.1016/j.cjco.2025.08.002","DOIUrl":"10.1016/j.cjco.2025.08.002","url":null,"abstract":"<div><div>Populations with lower socioeconomic position (SEP) are at increased risk of developing cardiovascular disease (CVD). Movement behaviours, including physical activity, sedentary behaviour, and sleep, contribute to socioeconomic gradients in CVD risk, as low-SEP populations are less likely to meet evidence-informed recommendations for these behaviours. Adolescence represents a sensitive period for establishing lifelong health behaviours, with CVD risk beginning to accumulate before adulthood. This study will model the potential effect of adolescent movement behaviour interventions on socioeconomic inequalities in adult CVD risk. We will conduct a population-based cohort study of adolescents from the Add Health study, recruited in 1994-1995 from the US and followed into adulthood. Unhealthy movement behaviours, including a low level of moderate-to-vigorous physical activity, a high level of recreational screen time, and short sleep duration, will be operationalized based on the 24-hour Movement Guidelines and measured twice during adolescence (ages 12-24 years). Parental educational attainment and family financial hardship will be used to capture SEP in adolescence. The outcome will be the 30-year risk of CVD, assessed in adulthood (ages 33-41 years) using a validated risk score that incorporates objectively measured biomarkers, demographic information, and self-reported health indicators. We will perform causal decompositions to quantify the change of socioeconomic inequalities in adult CVD risk under 2 interventional scenarios: (i) elimination (unhealthy movement behaviours are eliminated in the whole population of adolescents); and (ii) equalization (the distributions of unhealthy movement behaviours for low-SEP adolescents are equalized to those of high-SEP adolescents). This study will provide insights into how modifying adolescent movement behaviours may contribute to reducing socioeconomic inequalities in CVD risk.</div></div>","PeriodicalId":36924,"journal":{"name":"CJC Open","volume":"7 11","pages":"Pages 1495-1506"},"PeriodicalIF":2.5,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145555418","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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