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Objectives This study sought to determine whether the increased use of telehealth was associated with a difference in outcomes for outpatients with heart failure. Background The COVID-19 pandemic led to dramatic changes in the delivery of outpatient care. It is unclear whether increased use of telehealth affected outcomes for outpatients with heart failure. Methods In March 2020, a large Midwestern health care system, encompassing 16 cardiology clinics, 16 emergency departments, and 12 hospitals, initiated a telehealth-based model for outpatient care in the setting of the COVID-19 pandemic. A propensity-matched analysis was performed to compare outcomes between outpatients seen in-person in 2018 and 2019 and via telemedicine in 2020. Results Among 8,263 unique patients with heart failure with 15,421 clinic visits seen from March 15 to June 15, telehealth was employed in 88.5% of 2020 visits but in none in 2018 or 2019. Despite the pandemic, more outpatients were seen in 2020 (n = 5,224) versus 2018 and 2019 (n = 5,099 per year). Using propensity matching, 4,541 telehealth visits in 2020 were compared with 4,541 in-person visits in 2018 and 2019, and groups were well matched. Mortality was similar for telehealth and in-person visits at both 30 days (0.8% vs 0.7%) and 90 days (2.9% vs 2.4%). Likewise, there was no excess in hospital encounters or need for intensive care with telehealth visits. Conclusions A telehealth model for outpatients with heart failure allowed for distanced encounters without increases in subsequent acute care or mortality. As the pressures of the COVID-19 pandemic abate, these data suggest that telehealth outpatient visits in patients with heart failure can be safely incorporated into clinical practice., Central Illustration

Statins are recommended in heart transplant patients, but are sometimes poorly tolerated. Alternative agents are often considered including proprotein convertase subtilisin/kexin type-9 inhibitors (PCSK9i). We sought to investigate the use of PCSK9i after heart transplantation.We identified patients who received a heart transplant from 1999 to 2019 and were started on PCSK9i at our institution. Clinical, laboratory, and coronary angiography with intravascular ultrasound results were compared. Among 65 patients initiated on PCSK9i (48 for statin intolerance and 17 for refractory hyperlipidemia), the median time from transplant was 5.5 years (interquartile range [IQR], 2.8-9.9 years) with a median PCSK9 treatment duration of 1.6 years (IQR, 0.8-3.2 years) and 80% still on treatment. Evolocumab was used in 73.8%, alirocumab in 12.3%, and both in 13.8% owing to insurance coverage. All patients required prior authorization; initial denial occurred in 18.5% and 32.3% had denials in subsequent years. The median low-density lipoprotein cholesterol decreased from 130 mg/dL (IQR, 102-148 mg/dL) to 55 mg/dL (IQR, 35-74 mg/dL) after starting PCSK9i (P.001), with 72% of patients achieving a low-density lipoprotein cholesterol of70 mg/dL after treatment. There were also significant reductions of total cholesterol, non-high-density lipoprotein cholesterol, total/high-density lipoprotein cholesterol ratio, and triglycerides, with a modest increase in high-density lipoprotein cholesterol. These changes were durable at latest follow-up. In 33 patients with serial coronary angiography and intravascular ultrasound, PCSK9i were associated with stable coronary plaque thickness and lumen area.Among heart transplant recipients, PCSK9i are effective in lowering cholesterol levels and stabilizing coronary intimal hyperplasia with minimal side effects. Despite favorable effects, access and affordability remain a challenge.

Cardiogenic shock (CS) is associated with high mortality and often requires involvement of a multidisciplinary provider team to deliver timely care. Care coordination is more difficult on weekends, which may lead to a delay in care. We sought to assess the effect of weekend admissions on outcomes in patients admitted with CS. Patients admitted with CS were identified from 2005 to 2014 in the National Inpatient Sample using ICD9 code 785.51. Baseline demographics, in-hospital procedures, and outcomes were obtained and compared by day of admission. A multivariable model was used to assess the impact of weekend admission on in-hospital mortality. A total of 875,054 CS admissions were identified (age 67.4 ± 15.1 years, 40.2% female, 72.1% Caucasian), with 23% of patients being admitted on weekends. Baseline co-morbidities were similar between groups. Weekend admissions were associated with higher in-hospital mortality (40.6% vs 37.5%) and cardiac arrest (20.3% vs 18.1%, p < 0.001 for both) consistently over the study period. Use of temporary and permanent mechanical support devices and heart transplantation were slightly less common for weekend admissions. In a multivariable model adjusting for relevant confounders, weekend admission was associated with a 10% increased mortality in patients with CS. In conclusion, patients with CS admitted on weekends had higher in-hospital mortality and were slightly less likely to receive mechanical support and advanced therapies compared with those admitted on weekdays. Future studies and health system initiatives should focus on rectifying these disparities with around-the-clock multidisciplinary coordinated care for CS.

A 48-year-old woman presented with heart failure and bioprosthetic pulmonary valve regurgitation 2 years after pulmonary valve replacement. Intracardiac echocardiography demonstrated uniform thickening of a single prosthetic valve leaflet suggesting leaflet thrombosis rather than bioprosthetic valve degeneration. After 3 months of anticoagulation, valve regurgitation and symptoms improved. (Level of Difficulty: Intermediate.), Central Illustration

In contrast to most industrialized countries, maternal mortality in the USA is rising. Cardiovascular disease, both acquired heart disease (e.g. coronary disease, arrhythmias, and heart failure), as well as congenital heart disease survivors, are all potentially important factors in explaining this worrisome trend. Increase in acquired cardiac disease is likely attributable to greater rates of obesity, diabetes, hypertension, and an increase in the incidence of advanced maternal age, while congenital heart disease in pregnancy is increasing due to advances in pediatric cardiovascular surgery. Despite the growing cardiovascular risk of pregnant women, most obstetricians and cardiologists have limited experience in caring for women with heart disease. Accordingly, management is largely guided by expert opinion likely to vary greatly across centers. To address these challenges, a multidisciplinary approach to care that includes both cardiologists and obstetricians could leverage the knowledge of both specialties and support streamlined communication between the patient and her providers. Our experience highlights the necessary components and essential infrastructure for building a center of excellence in treating pregnant women with heart disease.Condensation: A guide for creating a center of excellence for prenatal care for women with cardiovascular disease.The problem: Cardiac disease is the leading cause of maternal mortality, and pregnancies affected by cardiac disease continue to rise, both congenital and acquired.The solution: Maternal fetal medicine, obstetricians, and cardiologists can join together in tertiary facilities to create Maternal Cardiac Centers of Excellence to provide multidisciplinary, structured care for these high-risk patients.

Direct acting oral anticoagulants (DOACs) are increasingly used as off-label alternatives to vitamin K antagonists for the treatment of left ventricular (LV) thrombus. However, efficacy data is limited to small case series and one meta-analysis of case reports. We aimed to determine the efficacy and safety of DOACs in treatment of LV thrombus utilizing transthoracic echocardiography (TTE) and clinical outcomes. We identified 52 patients (mean age = 64 years, 71% men) treated with a DOAC for LV thrombus (n = 26 apixaban, n = 24 rivaroxaban, and n = 2 dabigatran). Thirty-five of the 52 patients had a follow-up TTE after DOAC initiation. The primary end point was defined as resolution of LV thrombus (in patients with a subsequent TTE), or death, major bleeding requiring transfusion, intracranial hemorrhage, ischemic stroke, or peripheral embolization. An experienced echocardiographer (M.L.M.) reviewed all TTEs for presence or absence of LV thrombus without knowledge of time point or clinical data. Twenty-nine of the 35 (83%) patients who underwent follow-up TTE had resolution of LV thrombus, with a mean duration of 264 days. Of the total study population, there was 1 cardioembolic event (transient ischemic attack) 52 days after initiating DOAC, 3 gastrointestinal bleeds requiring transfusion, and 1 patient with epistaxis requiring transfusion. All patients with a hemorrhagic complication were receiving concomitant antiplatelet therapy. DOAC therapy appears promising for the treatment of LV thrombus. A larger, prospective study is warranted to confirm these results.

Introduction Anomalous aortic origin of a coronary artery (AAOCA) is a potential etiology of sudden cardiac death (SCD) in physically active individuals. Identification of coronary artery origins is an essential part of comprehensive pre-participation athletic screening. Although echocardiography is an established method for identifying AAOCA, current imaging protocols are time intensive and readers frequently have low confidence in coronary artery identification. Methods Echocardiographic images from a sample of 110 patients from a database of competitive athletes ages 13-22 years from the Kansas City metropolitan area were reviewed by six echocardiographers of varying experience. Coronary artery images were provided to the readers in the conventional single plane for all the patients; then biplane images of the same patients were presented to the readers. While reviewing the images, readers recorded perceived confidence level of identifying the coronary artery from 1 (least confident) to 5 (most confident). Ratings and differences between ratings were summarized descriptively by means and standard deviations across all readings as well as by individual reader. Results The mean confidence level of echocardiogram readers in identifying coronary artery origins increased by 0.4 points (P = .05) on a five-point confidence scale when using biplane imaging rather than single plane imaging. When assessing the variability of confidence of readers on the same patient, the between-reader variability improved from 25.9% to 10.3%. Conclusions Biplane echocardiographic imaging increases the confidence of readers in identifying coronary artery origins.

Background Gene expression profiling (GEP) and donor-derived cell-free DNA (dd-cfDNA) are useful in acute rejection (AR) surveillance in orthotopic heart transplant (OHT) patients. We report a single-center experience of combined GEP and dd-cfDNA testing for AR surveillance. Methods GEP and dd-cfDNA are tested together starting at 2 months post-OHT. After 6 months, combined testing was obtained before scheduled endomyocardial biopsy (EMB), and EMB was canceled with a negative dd-cfDNA. This approach was compared to using a GEP-only approach, where EMB was canceled with a negative GEP. We evaluated for frequency of EMB cancellation with dd-cfDNA usage. Results A total of 153 OHT patients over a 13-month period underwent 495 combined GEP/dd-cfDNA tests. 82.2% of dd-cfDNA tests were below threshold. Above threshold results identified high-risk patients who developed AR. 378 combined tests ≥6 months post-OHT resulted in cancellation of 83.9% EMBs as opposed to 71.2% with GEP surveillance alone. There were 2 acute cellular and 2 antibody-mediated rejection episodes, and no significant AR ≥6 months. Conclusion Routine dd-cfDNA testing alongside GEP testing yielded a significant reduction in EMB volume by re-classifying GEP (+) patients into a lower risk group, without reduction in AR detection. The addition of dd-cfDNA identified patients at higher risk for AR.

Background: Although several factors have been cited for risk stratification in patients with simple transposition of the great arteries (dTGA), no single predictor emerges consistently. We aimed to assess survival and determine factors associated with survival in a large cohort of dTGA adults with atrial switch. Methods and Results: We included 1,169 dTGA adults (median age 28.1 years, 38.7% female) under regular follow-up at 28 institutions between 2002 and 2019. The primary outcome was a composite of death, mechanical circulatory support (MCS) and heart transplant. During a median follow-up of 9.2 [IQR 5.5-14.2] years, 67 (5.7%) patients died, six (0.5%) patients underwent MCS and 21 (1.8%) had a heart transplant. Cumulative incidence of composite endpoint at 15 years was 12.8% [95% CI 9.8 - 15.7], see Figure). Median age at time of primary outcome was 39.5 [IQR 33.9 - 45.1] years. Leading causes of death were worsening of heart failure (34%), non-cardiac (21%) and sudden unexplained death (12%). In multivariable Cox analyses for baseline variables, age, VSD, ventricular arrhythmia and heart failure admission were each associated with increased risk of the outcome, whereas prior pacemaker (26% of patients) was not. New pacemaker implantation was performed in 107 (9.1%), ICD in 109 (9.3%), and cardiac surgery in 35 (3%) patients. Patients who died were more likely to develop arrhythmias, be admitted for heart failure or require surgery during follow-up. Conclusion: In this large contemporary cohort of dTGA adults after atrial switch, late survival was excellent and seemed to be determined by arrhythmia and heart failure-related complications. Few patients underwent advanced heart failure therapies. Figure. Cumulative incidence of the composite primary outcome (MCS, heart transplant or death) over a period of 15 years from first visit at an adult congenital heart disease clinic since 2002. Shading represents upper and lower 95% confidence limits.

Background: Occasionally patients with congenitally corrected transposition of the great arteries (ccTGA) exhibit little clinical evidence of cardiovascular limitation even to their 8th decade. We aimed to assess survival prospects in a large cohort of ccTGA adults. Methods & Results: We included 555 ccTGA adults (median age 33.0 years, 48.3% female) under regular follow-up at 28 institutions between 2002 and 2019. The primary outcome was a composite of death, mechanical circulatory support (MCS) and heart transplant. During a median follow-up of 8.1 [IQR 4.4 - 13.3] years, 56 (10.1%) patients died, 10 (1.8%) patients underwent MCS and 14 (2.5%) had a heart transplant. Median age at time of primary outcome was 51.1 [IQR 37.5 - 63.2] years and cumulative incidence at 15 years from baseline was 21.5% [95% CI 16.1 - 26.5]. Leading causes of death were worsening of heart failure (43%) and sudden death (10%). Patients who died were more likely to use heart failure (HF) medications. In multivariable Cox analyses for baseline variables, age, prior atrial arrhythmia and HF admission were each associated with an increased risk of the primary outcome. Figure shows cumulative incidence according to history of atrial arrhythmia. During follow-up, 91 (16.4%) were admitted for HF, pacemaker implantation was performed in 68 (12.3%) patients, ICD in 82 (14.7%), and major cardiac surgery (mostly for systemic AV-valve) in 89 (15.8%) patients. Conclusion: In this large cohort of ccTGA adults, survival seemed to be primarily determined by heart failure-related complications. Prior atrial arrhythmia also seems to be a harbinger for adverse outcome. Few patients underwent advanced HF therapies. Figure: Cumulative incidence of the composite primary outcome (MCS, heart transplant or death) over a period of 14 years from first visit at an adult congenital heart disease clinic since 2002 stratified according to history of atrial arrhythmia. Shading represents upper and lower 95% confidence limits.

Aortic stenosis provides a unique management challenge during pregnancy and has historically been associated with a high maternal mortality risk. We describe our experience with pregnancies in patients with aortic stenosis at a single center over a 13 year period. When managed by an experienced, multidisciplinary, cardio-obstetrics team, these pregnancies are more likely to reach term with good outcomes.

In the USA, maternal mortality has been rising since the 1980s. Cardiovascular disease is recognized as the leading cause of this worrisome trend, and a multidisciplinary approach to the care of patients with cardiovascular conditions during pregnancy is becoming increasingly important. We outline the literature supporting this multidisciplinary approach, highlight our center’s experience in building and expanding an integrated cardio-obstetrics practice, and provide guidance regarding patient selection and management within a combined practice. Antenatal management patterns and delivery planning for patients with cardiovascular disease during pregnancy vary substantially among cardiovascular and obstetric and maternal fetal medicine practices in the USA. The need for multidisciplinary care between cardiologists and obstetricians is evident and has been supported by best practice statements from the American Heart Association, the American College of Obstetrics and Gynecology, and the Cardiac Disease in Pregnancy Study (CARPREG) investigators, whose CARPREG II risk score included “late first antenatal visit” as a predictor of adverse outcomes of pregnancy. We have solid evidence supporting a multidisciplinary approach to the care of patients with cardiac conditions in pregnancy. This approach is optimal because it facilitates a consistent and clear message to the patient (and those caring for each patient) regarding management and risks associated with pregnancy, as well as subsequent risk and postpartum follow-up. We support the extension of clinical collaboration between obstetricians and cardiologists to the research realm and know that working together to investigate the outcomes of moms with heart conditions and their babies will provide clinically meaningful information to support the care of these unique patients.

Purpose To determine differences in donor transmitted atherosclerosis or rapidly progressive Cardiac Allograft Vasculopathy at 1-year post cardiac transplantation in patients with congenital heart disease. Methods This is a retrospective study of patients who underwent heart transplantation at a single center from 2009-2016 who had subsequent coronary angiography with protocol-driven IVUS assessment of the left anterior descending artery. Non-congenital cardiac transplantation patients (N=237) were compared to a cohort of patients with adult congenital heart disease (N=12). Five IVUS sections were prospectively analyzed for intimal thickness. Donor transmitted atherosclerosis was defined as maximum intimal thickness ≥0.5 mm at baseline and rapidly progressive CAV as an increase in maximum intimal thickness by ≥0.5 mm at 1-year. Results Donor transmitted atherosclerosis was present in 121 (51.1%) patients with non-congenital etiology vs. 7 (58.3%) patients with congenital etiology. Rapidly progressive CAV at 1-year post-transplantation was present in 54 (23.0%) vs. 2 (18.2%) patients, respectively. Over a median follow up of 6.1 years, 39 patients died or required re-transplantation. ACHD as an etiology of heart failure was not associated with age- and sex-adjusted outcomes. In a subsequent analysis, there were 45 patients who reached a composite outcome of coronary revascularization, epicardial CAV, or cardiovascular death. Likewise, there was no association between ACHD and this composite endpoint. Conclusion Pre-transplant adult congenital heart disease was not associated with a significant difference in donor transmitted atherosclerosis or rapidly progressive CAV in patients with heart transplantation. Long term outcomes including all-cause mortality and cardiovascular events were not different in patients with versus without ACHD.

A significant minority of cardiac transplant patients require permanent pacemaker (PPM) implant, primarily for sinus node dysfunction. The stability of pacing indices has not been determined in this unique patient population, and data regarding ongoing need for pacing are limited. Pacing indices (sensing, threshold, and impedance) as well as the percentage of time patients required pacing were recorded, from 30 cardiac transplant patients that underwent PPM implant, over 1 year of follow-up. Repeated measure ANOVA (analysis of variance) was used to compare pacing indices and the percentage of time patients required pacing in each cardiac chamber (right atrium (RA) and right ventricle (RV)) and at different time points. There was no difference in sensing among the follow-up time points (p = 0.9). Thresholds at 3 months were significantly higher compared to the day of implant (p = 0.005) and the day after implant (p = 0.03). Impedances at implant were significantly higher compared to day 1 (p

Purpose Gene expression profile (GEP) testing has a high negative predictive value for Methods dd-cfDNA was drawn beginning at 2 mos post transplant and GEP was drawn at 2 mos or 30 days post prednisone wean Results Between 2/11-10/4/19, 121 pts (54.8±12.9 yrs; 79% men) between 2 mos-3 yrs post transplant had 324 visits with both GEP/dd-cfDNA. Table shows distribution of results. Only 6% were above threshold for both. This led to an additional 12 (60%) EMBs. 20% had positive GEP with negative dd-cfDNA (which would have led to an EMB without dd-cfDNA), EMB was cancelled for 46 (70%) of these visits. 8% of visits had only dd-cfDNA elevation. 13 (52%) of these had EMBs, but 10 (40%) EMBs were cancelled in favor of repeating dd-cfDNA at the next visit. 66% had both tests negative and EMB was cancelled for 156 (73%) of these visits. With the use of dd-cfDNA, an additional 13 EMBs were performed with negative GEP but 46 EMBs were avoided due to dd-cfDNA being negative with a positive GEP. For visits starting at 6 mos, 84% of EMBs were cancelled due to combined testing. Without dd-cfDNA, only 73% EMBs would have been cancelled for negative GEP. Conclusion Adding dd-cfDNA to GEP testing helped reclassify some GEP positive only pts into a lower risk group with an additional 11% of EMBs cancelled. Further evaluation of the utility of the combined use of GEP and dd-cfDNA is warranted.

Maternal mortality in the United States is highest among all developed nations and continues to rise. The leading cause of morbidity and mortality during pregnancy and the postpartum period is cardiovascular disease. While there are large European and Canadian studies exploring the care and outcomes of moms with heart disease in pregnancy, there are no large prospective studies to guide the care of this growing group of patients in the US. We review the current approach to the management of patients with heart disease in pregnancy and the gaps in knowledge thereof. Currently, antenatal management and delivery planning are highly variable for patients with heart disease in pregnancy and maternal risk models’ application to the US patient population is limited by their derivation from an international cohort of patients and their focus on patients with congenital heart disease. As the need for interdisciplinary care between cardiologists and obstetricians becomes evident, and as broad research efforts within this space are very much needed, we propose a research collaborative called the Heart Outcomes in Pregnancy: Expectations (HOPE) for Mom and Baby Registry. The HOPE Registry aims to address key clinical questions surrounding the preconception period, antenatal care, delivery planning and outcomes, and long-term postpartum care and outcomes of these unique patients. We have made progress in recent years by recognizing the clinical need to address and standardize the management of patients with heart disease in pregnancy. We now must initiate and propel US-based cardio-obstetrics research to address key gaps in knowledge and variability in the care of patients with heart disease in pregnancy.

Orthotopic heart transplant (OHT) is the treatment of choice for end-stage heart disease. As OHT use continues and postoperative survival increases, multimodality imaging evaluation of the transplanted heart will continue to increase. Although some of the imaging is performed and interpreted by cardiologists, a substantial proportion of images are read by radiologists. Because there is little to no consensus on a systematic approach to patients after OHT, radiologists must become familiar with common normal and abnormal posttreatment imaging features. Intrinsic transplant-related complications may be categorized on the basis of time elapsed since transplant into early (0-30 days), intermediate (1-12 months), and late (>12 months) stages. Although there can be some overlap between stages, it remains helpful to consider the time elapsed since surgery, because some complications are more common at certain stages. Recognition of differing OHT surgical techniques and their respective postoperative imaging features helps to avoid image misinterpretation. Expected early postoperative findings include small pneumothoraces, pleural effusions, pneumomediastinum, pneumopericardium, postoperative atelectasis, and an enlarged cardiac silhouette. Early postoperative complications also can include sternal dehiscence and various postoperative infections. The radiologist's role in the evaluation of allograft failure and rejection, endomyocardial biopsy complications, cardiac allograft vasculopathy, and posttransplant malignancy is highlighted. Because clinical manifestations of disease may be delayed in transplant recipients, radiologists often recognize postoperative complications on the basis of imaging and may be the first to suggest a specific diagnosis and thus positively affect patient outcomes. Online supplemental material is available for this article. ©RSNA, 2019.

OBJECTIVE To describe the preparticipation examination findings among American athletes by sex, participation level, and age. DESIGN Hypothesis-generating retrospective cohort study. SETTING Saint-Luke's Athletic Heart Center, Kansas City, Missouri. PARTICIPANTS A total of 2954 student athletes. INTERVENTIONS Athletes underwent preparticipation examination, which included history and physical, electrocardiogram, and 2-D transthoracic echocardiogram. MAIN OUTCOME MEASURES Differences noted on screening preparticipation examination by sex, participation level, and age. RESULTS Female athletes reported more symptoms than male athletes (odds ratio [OR] = 1.61; 95% confidence interval [CI], 1.32-1.97; P < 0.0001) but had lower prevalence of abnormal electrocardiogram (OR 0.52; CI, 0.39-0.68; P < 0.0001). College athletes reported fewer symptoms than novice athletes (OR 0.35; CI, 0.29-0.43; P < 0.0001) with no difference in the prevalence of abnormal electrocardiography (ECG) (OR 0.96; CI, 0.73-1.26; P = 0.78). Older athletes reported fewer symptoms than younger athletes (OR 0.61; CI, 0.52-0.71; P < 0.0001) with no difference in the prevalence of abnormal ECG (OR 1.00; CI, 0.81-1.23; P = 0.89). There were 43 athletes with clinically important findings with no difference in prevalence of these findings across sex, participation level, and age. CONCLUSIONS Among this American cohort of athletes, male athletes reported fewer symptoms and had higher prevalence of abnormal ECG findings compared with female athletes. College and older athletes reported fewer symptoms and had no difference in prevalence of abnormal ECG findings compared with novice and younger athletes, respectively. Despite these differences between groups, the prevalence of clinically important findings was comparable among groups.

AimsImplantable cardioverter-defibrillators (ICDs) implantation in heart failure (HF) patients with reduced ejection fraction improves survival by reducing mortality secondary to arrhythmic events. Whether advanced HF patients treated with continuous-flow left ventricular assist devices (CF-LVADs) derive similar benefit is controversial.Methods and resultsWe searched PubMed, Cochrane Central Register of Controlled Trials, Embase, and Scopus from inception through November 2018 for studies examining the association between ICD implantation and all-cause mortality in patients with advanced HF and CF-LVADs. Analyses were performed using a random-effects model. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Heterogeneity and publication bias were formally assessed, using I2 and funnel plots, respectively. Eight observational studies with a total of 6416 patients (ICD group = 3450, no ICD group = 2966) met inclusion criteria. The majority of patients (84.6%) came from the two largest observational studies. There was no difference in mortality in the ICD and no ICD groups (HR 0.96, 95% CI 0.73–1.27, P = 0.79, I2 = 42%), and ICD implantation post-CF-LVAD was not associated with an improvement in mortality (HR 0.87, 95% CI 0.48–1.57, P = 0.64, I2 = 0%). Additionally, there was no significant difference in the likelihood of transplantation (HR 1.10, 95% CI 0.93–1.30, P = 0.28, I2 = 26%) or non-mortality adverse events between the two groups.ConclusionImplantable cardioverter-defibrillator use was not associated with improved survival in advanced HF patients with CF-LVADs. These findings underscore the need to formally study the efficacy of ICDs in this population in a dedicated randomized controlled study.

Background Type 2 diabetes mellitus (T2D) is common in post-heart transplant patients. Commonly used T2D medications, especially insulin, can promote weight gain and are not associated with cardiovascular (CV) benefits. Glucagon-like Peptide-1 receptor agonists (GLP-1 RA) and Sodium-Glucose Cotransporter-2 inhibitors (SGLT2i) are two drug classes that produce CV benefits in T2D and promote weight loss with minimal risk of hypoglycemia. Their use has not been previously evaluated in this particular group, and there have been theoretical concerns about safety in immunosuppressed patients. Methods Patients with T2D are sequentially referred by the Heart Transplant program to the Cardiometabolic Center of Excellence (CMCE) at our institution, allowing minimal selection bias. CMCE provides treatment algorithms that emphasize the use of cardioprotective T2D medications. We analyzed this initial series of transplant patients with T2D who have been on GLP-1 RA and/or SGLT-2i with at least two visits at CMCE. Results Among 15 patients, the mean age was 59.4 ± 2.6 years, 66.7% were males, 73.3% were Caucasians, 33.3% had history of ischemic cardiomyopathy and baseline eGFR was 53.5 ± 7.9 mL/min/1.73m2. The median time from transplant was 4.6 (1.6 - 10.5) years. The median follow-up time at CMCE was 5.4 (2.8 - 10.9) months. At baseline, 73% were on insulin, 40% on Metformin, 13% on Sulfonylurea, 13% on Dipeptidyl peptidase-4 inhibitors, and 7% on Thiazolidinediones. Following initiation of therapy at CMCE, 86.7% of patients were on a combination of GLP-1 RA and SGLT-2i, while the rest were taking only GLP-1 RA. Overall, the median total daily insulin requirements decreased substantially from 94 (40.5 - 124) to 34 (5 - 60) units at latest clinic visit; p = 0.003. Further, median hemoglobin A1c dropped from 7.7% (7.3 - 9.5) to 6.6% (6 - 8.5); p = 0.007. There was also a significant reduction in mean body weight (241.9 ± 35.8 at baseline vs. 217.1 ± 34.2 lbs at follow-up; p = 0.001), and mean body mass index (34.9 ± 4.5 vs. 31.1 ± 3.7; p = 0.001). Only one patient experienced side effects as one episode of severe nausea with Liraglutide that resolved when switched to Semaglutide. No infectious complications (including urinary tract or genital mycotic infections) were observed. Conclusions In this limited case series, combination therapy with GLP-1 RA and SGLT-2i was well tolerated in heart transplant patients and associated with favorable results in insulin requirement, hemoglobin A1c, and body weight.

Direct acting oral anticoagulants (DOACs) are increasingly used for thromboembolic prophylaxis in patients with atrial fibrillation (AF). However, there is limited data to evaluate the use of DOACs for the treatment of pre-existing left atrial appendage thrombus. We aimed to determine the efficacy of DOACs in treatment of left atrial appendage (LAA) thrombus utilizing transesophageal echocardiographic (TEE) and clinical outcomes. In this single-center study, we identified 33 patients that were treated for LAA thrombus with DOAC. Eighteen were treated with apixaban, 10 with dabigatran, and 5 with rivaroxaban. The primary endpoint was defined as resolution of LAA thrombus (in patients undergoing TEE), or death, major bleeding requiring transfusion, intracranial hemorrhage, ischemic stroke, or peripheral embolization. In this study, 15 of the 16 patients treated with DOACs who underwent follow-up TEE had resolution of LAA thrombus, with a mean duration of 112 days. Of the 15 patients who achieved resolution of the LAA thrombus, 14 had resolution by their first follow-up TEE. In the 17 patients without a follow-up TEE, 1 died of a retroperitoneal bleed (28 days after DOAC initiation), and 1 suffered an ischemic stroke (484 days after DOAC initiation). In general, patients without a follow-up TEE were older and had more co-morbidities. Although these results are descriptive and limited in number of patients, we believe this is ample evidence that DOACs are relatively safe and efficacious in treatment of patients with AF and concomitant LAA thrombus.

Transesophageal echocardiography (TEE) is frequently performed in patients with acute ischemic cerebrovascular events to exclude a cardioembolic source. We aimed to determine the clinical impact of TEE on management. This is a retrospective single-center study of 1,458 consecutive patients hospitalized with acute ischemic stroke or transient ischemic attack who underwent TEE for evaluation of a suspected cardioembolic cause. Significant TEE findings were determined for each patient as recorded on the TEE report. The medical record was reviewed for baseline, clinical, and demographic variables and to determine whether significant management changes occurred as a result of the TEE findings. Potential significant changes in management included initiation of anticoagulation, placement of a patent foramen ovale (PFO) closure device, initiation of antibiotic therapy for endocarditis, surgical PFO closure, other cardiac surgery, and coil embolization of a pulmonary arteriovenous malformation. A significant change in management occurred in 243 patients (16.7%); 173 (71%) underwent treatment for PFO with a percutaneous PFO closure device (n = 100), initiation of chronic systemic anticoagulation (n = 68), or surgical PFO closure (n = 5). Additional findings leading to a change in management included endocarditis (n = 20), aortic arch atheroma (n = 14), intracardiac thrombus (n = 13), pulmonary arteriovenous malformation (n = 2), aortic valve fibroelastoma (n = 2), other valve masses (n = 4), and miscellaneous causes (n = 15). In conclusion, in patients with suspected cardioembolic stroke, TEE findings led to a change in management in 16.7% of patients. Of these, most (71%) were directed at prevention of subsequent paradoxical emboli in patients with PFO.

Left atrial appendage closure with the WATCHMAN device is an alternative to chronic oral anticoagulation for thromboembolic prophylaxis in atrial fibrillation patients. Left atrial device-related thrombus (DRT) has been described in the first year after implant with an incidence of ~6%. A 79-year-old man underwent WATCHMAN device placement in 2006. Routine protocol specified follow-up transesophageal echocardiograms (TEE) at 6 weeks, 6 months, and 1 year following implant showed no evidence for DRT or peri-device flow. A decade after device implant, the patient presented with severe symptomatic aortic stenosis and underwent repeat TEE, which revealed a 21 mm × 18 mm DRT on the LA aspect of the WATCHMAN device. He was prescribed apixaban 5 mg po BID. A TEE performed 111 days later demonstrated marked diminution in the DRT (9 mm in diameter). This case demonstrates that WATCHMAN DRT may occur late following implantation.

Previous studies using 2-dimensional non-contrast echocardiography have reported a post-ST segment elevation myocardial infarction (STEMI) left ventricular (LV) thrombus incidence of 3% to 24%. However, these studies were not performed with ultrasound contrast agents (UCAs), which improve accuracy in the diagnosis of LV thrombus. We aimed to determine the early incidence and clinical correlates of LV thrombus in a large consecutive cohort of patients with STEMI. This study included consecutive patients admitted to Saint Luke's Mid America Heart Institute with STEMI who also underwent early percutaneous coronary intervention (PCI) and an echocardiogram. A total of 1,698 patients (1,205 men, mean age 61 ± 13 years) comprised the study group. Echocardiography was performed on hospital day 2, and a UCA was used in 1,292 patients (76%). LV thrombus was identified in 28 (1.6%) patients. A multivariable logistic regression model showed that left anterior descending intervention was independently associated with LV thrombus (odds ratio = 7.58, 95% confidence interval [CI] 2.20 to 26.19, p = 0.001), thrombolysis in myocardial infarction III flow was marginally associated with less LV thrombus (odds ratio = 0.41, 95% CI 0.16 to 1.04, p = 0.060), and higher LVEF was associated with less LV thrombus (odds ratio = 0.96, 95% CI 0.91 to 0.97, p 0.001). In conclusion, LV thrombus was identified in only 1.6% of patients in a large STEMI cohort, significantly lower than previous studies. A UCA was used in most echocardiograms, and it improves accuracy in the detection and exclusion of LV thrombus.

A routine of regular exercise is highly effective for prevention and treatment of many common chronic diseases and improves cardiovascular (CV) health and longevity. However, long-term excessive endurance exercise may induce pathologic structural remodeling of the heart and large arteries. Emerging data suggest that chronic training for and competing in extreme endurance events such as marathons, ultramarathons, ironman distance triathlons, and very long distance bicycle races, can cause transient acute volume overload of the atria and right ventricle, with transient reductions in right ventricular ejection fraction and elevations of cardiac biomarkers, all of which return to normal within 1 week. Over months to years of repetitive injury, this process, in some individuals, may lead to patchy myocardial fibrosis, particularly in the atria, interventricular septum, and right ventricle, creating a substrate for atrial and ventricular arrhythmias. Additionally, long-term excessive sustained exercise may be associated with coronary artery calcification, diastolic dysfunction, and large-artery wall stiffening. However, this concept is still hypothetical and there is some inconsistency in the reported findings. Furthermore, lifelong vigorous exercisers generally have low mortality rates and excellent functional capacity. Notwithstanding, the hypothesis that long-term excessive endurance exercise may induce adverse CV remodeling warrants further investigation to identify at-risk individuals and formulate physical fitness regimens for conferring optimal CV health and longevity.

Current guidelines for preparticipation screening of competitive athletes in the US include a comprehensive history and physical examination. The objective of this study was to determine the incremental value of electrocardiography and echocardiography added to a screening program consisting of history and physical examination in college athletes.Competitive collegiate athletes at a single university underwent prospective collection of medical history, physical examination, 12-lead electrocardiography, and 2-dimensional echocardiography. Electrocardiograms (ECGs) were classified as normal, mildly abnormal, or distinctly abnormal according to previously published criteria. Eligibility for competition was determined using criteria from the 36(th) Bethesda Conference on Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities.In 964 consecutive athletes, ECGs were classified as abnormal in 334 (35%), of which 95 (10%) were distinctly abnormal. Distinct ECG abnormalities were more common in men than women (15% vs 6%, P.001) as well as black compared with white athletes (18% vs 8%, P.001). Echocardiographic and electrocardiographic findings initially resulted in exclusion of 9 athletes from competition, including 1 for long QT syndrome and 1 for aortic root dilatation; 7 athletes with Wolff-Parkinson-White patterns were ultimately cleared for participation. (Four received further evaluation and treatment, and 3 were determined to not need treatment.) After multivariable adjustment, black race was a statistically significant predictor of distinctly abnormal ECGs (relative risk 1.82, 95% confidence interval, 1.22-2.73; P=.01).Distinctly abnormal ECGs were found in 10% of athletes and were most common in black men. Noninvasive screening using both electrocardiography and echocardiography resulted in identification of 9 athletes with important cardiovascular conditions, 2 of whom were excluded from competition. These findings offer a framework for performing preparticipation screening for competitive collegiate athletes.

Aims To compare haemodynamic responses during the 6-min walk test (6MWT) and daily living activities in heart failure (HF) patients. Methods and results Eighteen HF patients received an implantable haemodynamic monitor, which continuously measured heart rate (HR), estimated pulmonary artery diastolic pressure (ePAD), and several right ventricular (RV) pressure parameters. During the 6MWT, haemodynamics were assessed at rest and peak exercise. Ambulatory values were measured as the daily minimum, maximum, and median, averaged over the 14-day period surrounding each 6MWT. During the 6MWT, HR increased from 71 ± 17 to 101 ± 20 b.p.m. and ePAD from 20 ± 5 to 34 ± 8 mmHg. Daily minimum values were significantly lower and daily maximum values higher compared with rest and peak exercise. Patients with a walked distance above the median (402 m) had lower resting HR (64 ± 10 vs. 77 ± 20, P = 0.001) and ePAD (18 ± 4 vs. 21 ± 7, P = 0.022) compared to patients with walked distances below the median; values at peak exercise were similar. This pattern was also observed during the ambulatory periods. Conclusion Ranges of HR and RV pressures are significantly larger during daily living activities compared with 6MWT in HF patients. Haemodynamic characteristics of patients with greater exercise capacity include lower resting HR and RV pressures and are similar during the 6MWT and daily life.

Objective: Evaluate the utility of a combined risk stratification scheme including diastolic dysfunction and “no-reflow,” to identify high-risk patients following acute myocardial infarction (AMI). Background: Recent studies have demonstrated that the “no-reflow” phenomenon (defined by myocardial contrast echocardiography) and severe diastolic dysfunction (identified by Doppler echocardiography) identify patients at high risk for mortality following AMI. Methods: We evaluated 111 patients with recent anterior acute myocardial infarction from July 2000 to June 2004. Diastolic function and myocardial perfusion was evaluated by echocardiography. Patients were placed into 1 of 3 groups based on diastolic function and myocardial perfusion: Group 1 (normal perfusion and normal diastolic function), Group 2 (abnormal perfusion or abnormal diastolic function), and Group 3 (abnormal perfusion and abnormal diastolic function). We compared the long term all-cause mortality within these groups. Results: Patients in each group were similar with respect to myocardial infarction size as defined by biomarkers, extent and severity of coronary artery disease, and medical and interventional therapy. Mortality was much higher in Group 3 (26.9%) compared to Group 1 (0%) and Group 2 (15.2%) (p = 0.048). Conclusion: Combined assessment of diastolic function and myocardial perfusion enhances risk stratification post myocardial infarction.

ObjectivesThe purpose of this study was to establish an electrocardiographic (ECG) profile in a biracial population of highly-trained American football players.BackgroundIntense physical training can induce cardiac structural and functional changes (“athlete's heart”), including 12-lead ECG alterations. That race might play a role in determining ECG patterns has been suggested, although not studied in a large athletic population comparing black and white athletes.MethodsElectrocardiographic analysis of 1,959 elite male athletes attending the National Football League Invitational Camp from 2000 to 2005 was performed. Subjects were classified by race and player position and judged free of structural heart disease.ResultsAbnormal ECG patterns were present in 480 (25%) athletes and were significantly more common among black players (n = 396; 30%) compared with white players (n = 78; 13%) or other races (n = 6; 15%) (p < 0.0001). Distinctly abnormal ECG patterns, suggestive of cardiac disease, were also more common in blacks (n = 76; 6%) than whites (n = 11; 2%) (p = 0.0005). In multivariable analysis, black race was an independent predictor of abnormal ECGs (risk ratio [RR] 2.03, 95% confidence interval [CI] 1.56 to 2.64, p < 0.0001), including patterns judged distinctly abnormal (RR 2.59, 95% CI 1.18 to 5.67, p = 0.02). Abnormal ECGs were also related to player position: most frequent in wide receivers (n = 91; 35%) and least common in quarterbacks (n = 16; 14%) and place kickers (n = 8; 11%). Echocardiograms, obtained in 203 athletes (10%), did not show structural cardiac abnormalities.ConclusionsElectrocardiographic abnormalities were 2-fold more common in black than in white highly-trained male American football players, with race an independent determinant of ECG pattern. These findings have important implications for pre-participation cardiovascular screening of athletes with ECGs.

Objectives The purpose of this study was to determine whether a heart failure (HF) management strategy using continuous intracardiac pressure monitoring could decrease HF morbidity. Background Patients with HF may experience frequent decompensations that require hospitalization despite intensive treatment and follow-up. Methods The COMPASS-HF (Chronicle Offers Management to Patients with Advanced Signs and Symptoms of Heart Failure) study was a prospective, multicenter, randomized, single-blind, parallel-controlled trial of 274 New York Heart Association functional class III or IV HF patients who received an implantable continuous hemodynamic monitor. Patients were randomized to a Chronicle (Medtronic Inc., Minneapolis, Minnesota) (n = 134) or control (n = 140) group. All patients received optimal medical therapy, but the hemodynamic information from the monitor was used to guide patient management only in the Chronicle group. Primary end points included freedom from system-related complications, freedom from pressure-sensor failure, and reduction in the rate of HF-related events (hospitalizations and emergency or urgent care visits requiring intravenous therapy). Results The 2 safety end points were met with no pressure-sensor failures and system-related complications in only 8% of the 277 patients who underwent implantation (all but 4 complications were successfully resolved). The primary efficacy end point was not met because the Chronicle group had a nonsignificant 21% lower rate of all HF-related events compared with the control group (p = 0.33). A retrospective analysis of the time to first HF hospitalization showed a 36% reduction (p = 0.03) in the relative risk of a HF-related hospitalization in the Chronicle group. Conclusions The implantable continuous hemodynamic monitor-guided care did not significantly reduce total HF-related events compared with optimal medical management. Additional trials will be necessary to establish the clinical benefit of implantable continuous hemodynamic monitor-guided care in patients with advanced HF.

Echocardiographic contrast agents improve endocardial border delineation in patients with technically difficult baseline studies. With medical and device therapy for heart failure increasingly based on left ventricular (LV) ejection fraction (EF) partition values, the accurate and reproducible assessment of LV function is necessary. It was hypothesized that routine contrast enhancement would significantly reduce interobserver variability in the determination of LVEFs in a cohort of patients with LV dysfunction and good baseline endocardial delineation. All patients underwent baseline noncontrast studies followed by contrast-enhanced imaging using Definity. Two experienced echocardiographers, blinded to the clinical data, determined LVEFs using 4 different techniques: noncontrast estimated (NCE), noncontrast calculated (NCC), contrast estimated (CE), and contrast calculated (CC). Using a mixed-model procedure that allows for fixed and random events, the variance due to error and that due to the patient was obtained (interclass correlation). The proportion of variation due to the reader was calculated as 1--interclass correlation. Mean standardized percentage differences ([reader 1 EF--reader 2 EF]/mean EF) were also calculated for each method. The proportion of variation due to the reader was smallest in the CC group and largest in the NCC group (NCE = 0.21, NCC = 0.33, CE = 0.25, CC = 0.11). The results were similar when only patients with NCE EFsor=20% andor=50% were analyzed (NCE = 0.29, NCC = 0.47, CE = 0.33, CC = 0.15). The mean standardized percentage difference between readers was smallest in the CC group for all patients and for those with NCE EFsor=20% andor=50%. In conclusion, contrast administration reduces interobserver variability in LVEF assessment, even in patients with good baseline endocardial border delineation, and should be used routinely regardless of the perceived adequacy of baseline images, especially if the LVEF isor=20% andor=50%.

Balloon occlusion and release during elective percutaneous coronary intervention (PCI) provides a unique opportunity to study dynamic temporal alterations in myocardial perfusion in a controlled setting. These changes in flow and volume mimic those that occur during presentation with, and successful therapy of, ST-segment elevation acute myocardial infarction (AMI). Eleven patients underwent myocardial contrast echocardiography (MCE) using a continuous infusion of Definity at baseline, during coronary occlusion, and during reactive hyperemia immediately after balloon deflation. Fifty separate flow state sequences were acquired, and off-line analysis was performed to determine myocardial contrast intensity within a region of interest in the distribution of the left anterior descending artery (LAD). A reader blinded to flow state also performed qualitative evaluation (perfusion or lack of perfusion). Quantitative analysis demonstrated significant differences in myocardial contrast intensity by flow state (p = 0.0001 for occlusion vs reperfusion). Qualitative assessment demonstrated a high rate of correct classification (92%). Real-time myocardial perfusion assessment using MCE accurately differentiates coronary occlusion and reactive hyperemia in humans by qualitative and quantitative assessment. This technique may be clinically useful in assessing the efficacy of thrombolytic therapy in ST-segment elevation AMI and in clinical trial assessment of new drugs and devices aimed at limitation of infarct size.

Objectives This study examined the characteristics of continuously measured right ventricular (RV) hemodynamic information derived from an implantable hemodynamic monitor (IHM) in heart failure patients. Background Hemodynamic monitoring might improve the day-to-day management of patients with chronic heart failure (CHF). Little is known about the characteristics of long-term hemodynamic information in patients with CHF or how such information relates to meaningful clinical events. Methods Thirty-two patients with CHF received a permanent RV IHM system similar to a single-lead pacemaker. Right ventricular systolic and diastolic pressures, heart rate, and pressure derivatives were continuously measured for nine months without using the data for clinical decision-making or management of patients. Data were then made available to clinical providers, and the patients were followed up for 17 months. Pressure characteristics during optimal volume, clinically determined volume-overload exacerbations, and volume depletion events were examined. The effect of IHM on hospitalizations was examined using the patients’ historical controls. Results Long-term RV pressure measurements had either marked variability or minimal time-related changes. During 36 volume-overload events, RV systolic pressures increased by 25 ± 4% (p Conclusions Long-term ambulatory pressure measurements from an IHM may be helpful in guiding day-to-day clinical management, with a potentially favorable impact on CHF hospitalizations.

Die Diagnose der chronischen Herzinsuffizienz nimmt mit steigendem Lebensalter uberproportional zu. Da fur diese Patienten haufig nur noch eine medikamentose Therapie in Frage kommt, ware es wunschenswert, uber in vivo Messdaten des rechtsventrikularen Druckes sowie des diastolischen pulmonalarteriellen Druckes zu verfugen, um den Erfolg der medikamentosen Therapie zu verifizieren und zu optimieren. Wir prasentieren unsere Erfahrungen mit einem einfach zu implantierenden hamodynamischen Monitorsystem (Chronicle®-IHM), das den systolischen und diastolischen RV-Druck misst und den diastolischen pulmonalarteriellen Druck (ePAD) bestimmt. Weiterhin bestimmt es den RV dP/dt max. und dP/dt min, das systolische Zeitintervall, Aktivitat und Herzfrequenz. Wir berichten uber den Beobachtungszeitraum der ersten sechs Monate. Der Chronicle®-IHM wurde bei 20 Mannern und 12 Frauen, die an chronischer Herzinsuffizienz in Folge von Kardiomyopathie (n=22), koronarer Herzerkrankung (n=19), pulmonalem (n=10) und arteriellem Hypertonus (n=12), Diabetes mellitus (n=12), litten und von denen 16 bereits katheterinvasiv oder operativ behandelt worden waren, im Rahmen einer Multicenterstudie implantiert. Das Durchschnittsalter betrug 58 Jahre (36–77 Jahre), die durchschnittliche Ejektionsfraktion lag bei 29% (14–62%). Das System wurde wie ein Schrittmacher links pektoral implantiert. Die Druckmesssonde wurde im rechten Ventrikel platziert. Die uber den Chronicle®-IHM erhobenen Daten wurden uber eine simultane Swan-Ganz-Katheteruntersuchung am Op-Tag, 3 und 6 Monate postoperativ in Ruhe und unter Belastung verglichen. Die Werte von Chronicle®-IHM und Swan-Ganz-Katheter zeigten eine gute Ubereinstimmung fur den systolischen und diastolischen RV-Druck sowie fur den pulmonalarteriellen diastolischen Druck. Diese ersten Ergebnisse zeigen, das der Chronicle®-IHM akkurat und prazise misst und leicht zu implantieren ist. Das System eignet sich fur die Evaluierung und Fuhrung von Patienten mit chronischer Herzinsuffizienz und pulmonalem Hypertonus.

ObjectivesWe sought to determine the relative accuracy of myocardial contrast echocardiography (MCE) and low-dose dobutamine echocardiography (LDDE) in predicting recovery of left ventricular (LV) function in patients with a recent anterior wall myocardial infarction (MI).BackgroundLeft ventricular dysfunction after acute MI may be secondary to myocardial stunning or necrosis. Myocardial contrast echocardiography allows real-time echocardiographic perfusion assessment from a venous injection of a fluorocarbon-based contrast agent. Although this technique is promising, it has not been compared with LDDE.MethodsForty-six patients underwent baseline wall motion assessment, MCE, and LDDE two days after admission, as well as follow-up echocardiography after a mean period of 53 days.ResultsPerfusion by MCE predicted recovery of segmental function with a sensitivity of 69%, specificity of 85%, positive predictive value of 74%, negative predictive value of 81%, and overall accuracy of 78%. Contractile reserve by LDDE predicted recovery of segmental function with a sensitivity of 50%, specificity of 88%, positive predictive value of 72%, negative predictive value of 73%, and overall accuracy of 73%. Concordant test results occurred in 74% of segments and further increased the overall accuracy to 85%. The mean wall motion score at follow-up was significantly better in perfused versus nonperfused segments (1.9 vs. 2.6, p < 0.0001) and in segments with contractile reserve, compared with segments lacking contractile reserve (1.9 vs. 2.5, p < 0.0001).ConclusionsMyocardial contrast echocardiography compares favorably with LDDE in predicting recovery of regional LV dysfunction after acute anterior wall MI. Concordant contractile reserve and myocardial perfusion results further enhance the diagnostic accuracy.

Background We evaluated the prevalence of isolated T-wave inversions (TWI) in American athletes using contemporary ECG criteria. Ethnic and gender disparities including the association of isolated TWI with underlying abnormal cardiac structure are evaluated. Methods From 2004 to 2014, 1755 collegiate athletes at a single American university underwent prospective collection of medical history, physical examination, 12-lead ECG, and 2-dimensional echocardiography. ECG analysis was performed to evaluate for isolated TWI as per contemporary ECG criteria. Results The overall prevalence of isolated TWI is 1.3%. Ethnic and gender disparities are not observed in American athletes (black vs. white: 1.7% vs. 1.1%; p=0.41) (women vs. men: 1.5% vs. 1.1; p=0.52). No association was found with underlying cardiomyopathy. Conclusion A lower prevalence of isolated TWI in American athletes than previously reported. Isolated TWI was not associated with an abnormal echocardiogram. No ethnic or gender disparity is seen in American college athletes.

Objectives: A clinical pathway standardizing management for patients with an admission diagnosis of pneumonia was initiated after a previous study found delayed time to initial antibiotic administration, a longer length of stay, and higher mortality rate for the authors patients as compared with those in a “benchmark” hospital. The current study was undertaken to determine whether implementation of the clinical pathway resulted in statistically significant decreases for these measures, both in the initial year following pathway implementation and two years later. Methods: A retrospective chart review was completed for three cohorts of pneumonia patients admitted via the ED: 1) three months immediately prior to pathway implementation, 2) 10-12 months after implementation of the pathway, and 3) 34-36 months after implementation of the pathway. Four standard antibiotic regimens were used following pathway implementation: community-acquired, community-acquired penicillin-allergic, nursing home-acquired, and nursing home-acquired penicillin-allergic. Demographics, medical history, presentation signs and symptoms, process of care, and outcome data were abstracted from each patient's medical record. Results: The mean time to antibiotic administration decreased from 315 minutes prepathway to approximately 175 minutes during the first postpathway period and 171 minutes at three years (ANOVA, p < 0.0001). The percentage of patients who received antibiotics in the ED increased from 58% prepathway to 94% during the first postpathway period and 97% at three years (chi square, p < 0.0001). Length of stay decreased from 9.7 prepathway to 8.9 days during the first postpathway period and 6.4 days at three years (ANOVA, p < 0.0001). There was no significant change of in-hospital mortality (9.6% prepathway to 5.2% and 4.9%) in the two respective periods. Conclusions: This study demonstrates that implementation of a pneumonia clinical pathway for the management of hospitalized patients admitted via the ED decreases the time to initial antibiotic treatment and increases the proportion of patients initially treated with antibiotics in the ED. These effects were evident in the first year following pathway implementation and sustained at the three-year study interval.