Search

Aims This report describes the findings of the 2018 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC). Methods The Italian Catheter Ablation Registry systematically collects data on the ablation procedures performed in Italy. Data collection was retrospective. A standardized questionnaire was completed by participating centres. Results We collected data on 15 714 catheter ablation procedures performed in Italy during 2018 in 94 electrophysiology centres. In most centres (75/94, 80%), a single electrophysiology laboratory was available, and a hybrid electrophysiology laboratory was available in 15% (14/94) of centres. In most (93%) centres, at least two electrophysiologists were involved in the catheter ablation procedures. In only 13 out of 94 (14%) electrophysiology laboratories, an anaesthesiologist assists every electrophysiology procedure; in most cases (74/94, 79%), an on-demand anaesthesiology service was available. On-site cardiothoracic surgery was reported in 43 out of 94 (46%) centres.Nonfluoroscopic navigation systems were available in most centres (88/94, 93%). Intracardiac echocardiography was used in 59 out of 94 (63%) electrophysiology laboratories. Atrial fibrillation (31%) was the most frequently treated ablation target, followed by atrioventricular nodal re-entrant tachycardia (20%) and cavo-tricuspid isthmus (15%). In 61.7% of all procedures, a 3D mapping system was used. In about one-third of procedures, a near-zero approach was performed. Conclusion In most Italian electrophysiology centres, a single electrophysiology laboratory was available and at least two electrophysiologists were involved in the ablation procedures. An increasing number of procedures were performed by means of a nonfluoroscopic mapping system with a near-zero approach.

Juliane Schürmann,1 Frank Noack,2,3 Steffi Bethge,4 Viktoria Heinze,4 Axel Schlitt4,5 1Department of Cardiology and Pulmonology AMEOS Clinic Bernburg, Bernburg, Germany; 2Department of Emergency Medicine, University Clinic Halle-Saale, Halle, Germany; 3Department of Medicine I, University Clinic Halle-Saale, Halle, Germany; 4Paracelsus-Harz-Clinic Bad Suderode, Quedlinburg, Germany; 5Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle, GermanyCorrespondence: Juliane SchürmannDepartment of Cardiology and Pulmonology AMEOS Clinic, Bernburg, 06406, GermanyTel +49 3471 341504Fax +49 3471 342053Email jsch.med@bernburg.ameos.deBackground: Heart failure is the third most fatal disease in Germany and generates considerable treatment costs. The multimodal program of inpatient rehabilitation can improve the symptoms and prognosis of these patients. At the present time, however, only few data are available on the effectiveness of rehabilitation for heart failure patients.Methods: After receiving study approval from the ethics committee of the Saxony–Anhalt Medical Association, 200 patients with a primary or secondary diagnosis of heart failure were prospectively included in the study at Paracelsus-Harz-Clinic Bad Suderode, Quedlinburg, Germany. Baseline parameters such as age, gender, and BMI were documented. Outcome variables included NYHA classifications, quality of life, and mortality. For follow-up, the patients were contacted again by mail or phone after three and 12 months and, data on symptoms and serious events were recorded.Results: The proportion of patients with a highly reduced ejection fraction (HFrEF) was 13.5%, with a midrange reduced ejection fraction (HFmrEF) 33%, and with preserved ejection fraction (HFpEF) 53.5%. The mean age was 64 ± 11.9 years, the proportion of women 24.1%. The effects of rehabilitation were documented by low overall mortality (no patient died during the stay, only 4% of the patients died in the 12-month follow-up) and an improvement in NYHA classification during and after the inpatient rehabilitation.Conclusion: This monocentric study showed effects both for symptoms (improvement in NYHA classifications) and prognosis (overall mortality) after rehabilitation. These data reflect the effectiveness of multimodal rehabilitation and underscore the need for rehabilitation in patients diagnosed with heart failure after an acute event and hospital stay or who present with chronic deterioration.Keywords: heart failure, cardiac rehabilitation, inpatient rehabilitation

Summary Background Heart failure management guidelines have been published, but the degree of adherence to these guidelines remains unknown. Aims To study in 2015 healthcare utilization and causes of death for people previously identified with heart failure. Methods The national health data system was used to identify adult general scheme (86% of the French population) hospitalized for heart failure between 2011 and 2014 or with only a long-term chronic disease allowance for heart failure. The frequency and median (interquartile range) of at least one healthcare use among those still alive in 2015 was calculated. Results A total of 499,296 adults (1.4% of the population) were included, and 429,853 were alive in 2015; median age 79 (68–86) years. At least one utilization was observed for a general practitioner in 95% of patients (median 8 [interquartile range 5–13] consultations), a cardiologist in 42% (2 [1–3]), a nurse in 78% (16 [4–100]), a loop diuretic in 64% (11 [8–12] dispensations), an aldosterone antagonist in 21% (8 [5–11]), a thiazide in 15% (7 [4–11]), a renin-angiotensin system inhibitor in 68% (11 [8–13]), a beta-blocker in 65% (11 [7–13]), a beta-blocker plus a renin-angiotensin system inhibitor in 57%, and a beta-blocker plus a renin-angiotensin system inhibitor plus an aldosterone antagonist in 37%. Hospitalization for heart failure was present for 8% (1 [1,2]). Higher levels of healthcare utilization were observed in the presence of hospitalization for heart failure before 2015. Among the 13.9% of people who died in 2015, heart failure accounted for 8% of causes, cardiovascular disease accounted for 39%. Conclusions General practitioners and nurses are the main actors in the regular follow-up of patients with heart failure, whereas cardiologist consultations and dispensing of first-line treatments are insufficient with respect to guidelines.

The outbreak of coronavirus disease 2019 (COVID-19) has rapidly spread worldwide. This study sought to share our experiences with in-hospital management and outcomes of acute myocardial infarction (AMI) during the COVID-19 pandemic. We retrospectively analyzed consecutive AMI patients, including those with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI), from February 1, 2020, to April 15, 2020 (during the COVID-19 pandemic), and from January 1, 2019, to December 31, 2019 (before the COVID-19 pandemic), respectively. Fifty-three AMI patients (31 STEMI, 22 NSTEMI) during the COVID-19 pandemic were matched to 53 AMI patients before the pandemic. Baseline characteristics were comparable between the matched patients. STEMI patients during the COVID-19 pandemic had a longer delay time, less primary or remedial PCI and more emergency thrombolysis than those before the pandemic. Less coronary angiography and stenting were performed in AMI patients during the COVID-19 pandemic than before the pandemic. There were no statistically significant differences in the clinical outcomes between the matched patients. However, STEMI patients during the COVID-19 pandemic had a 4-fold (12.9% vs. 3.2%) increase in all-cause mortality rate compared with those before the pandemic. AMI combined with COVID-19 infection was associated with higher rates of mortality than AMI alone. This study demonstrates that the COVID-19 pandemic results in significant reperfusion delays in STEMI patients and has a marked impact on the treatment options selection in AMI patients. The mortality rate of STEMI patients exhibits an increasing trend during the pandemic of COVID-19.

The coronavirus disease-2019 (COVID-19) pandemic has prompted a dramatic reorganization of health care systems and medical training programs across the United States. At many hospitals, cardiovascular fellows-in-training (FITs) provide front-line clinical care. The traditional cardiovascular

The COVID-19 pandemic has raised ethical questions for the cardiovascular leader and practitioner. Attention has been redirected from a system that focuses on individual patient benefit towards one that focuses on protecting society as a whole. Challenging resource allocation questions highlight the need for a clearly articulated ethics framework that integrates principled decision making into how different cardiovascular care services are prioritized. A practical application of the principles of minimizing harm, fairness, proportionality, respect, reciprocity, flexibility and procedural justice is provided, and a model for prioritization of the restoration of cardiovascular services is outlined. The prioritization model may be used to determine how and when cardiovascular services should be continued or restored. There should be a focus on an iterative and responsive approach to broader healthcare system needs, such as other disease groups and local outbreaks., for online listing: This paper provides an overview and application of relevant ethical principles in resource allocation decisions during the COVID-19 pandemic. A model for prioritization of cardiovascular services restoration is outlined. The model provides guidance on how and when cardiovascular services should be continued or restored, in an iterative and responsive fashion with the perspective of broader healthcare system needs.

Unstructured Abstract (250 words) In Ontario, on March 16th, 2020, a directive was issued to all acute care hospitals to halt non-essential procedures in anticipation for a potential surge in COVID-19 patients. This included scheduled outpatient cardiac surgical and interventional procedures that required the use of intensive care units, ventilators, and skilled critical care personnel, given that these procedures would draw from the same pool of resources required for critically ill COVID-19 patients. We adapted the COVID-19 Resource Estimator (CORE) decision analytic model by adding a cardiac component to determine the impact of various policy decisions on the incremental waitlist growth and estimated waitlist mortality for three key groups of cardiovascular disease patients; coronary artery disease, valvular heart disease, and arrhythmias. We provided predictions based on COVID-19 epidemiology available in real-time, in 3 phases. First, in the initial crisis phase, in a worst case scenario, we showed that the potential number of waitlist related cardiac deaths would be orders of magnitude less than those who would die of COVID-19 if critical cardiac care resources were diverted to the care of COVID-19 patients. Second, with better local epidemiology data, we predicted that across five regions of Ontario, there may be insufficient resources to resume all elective outpatient cardiac procedures. Finally in the recovery phase, we showed that the estimated incremental growth in waitlist for all cardiac procedures is likely substantial. These outputs informed timely, data-driven decisions during the COVID-19 pandemic regarding the provision of cardiovascular care., In Ontario, on March 16th, 2020, a directive was issued to all acute care hospitals to halt non-essential procedures in anticipation for a potential COVID-19 patient surge. This manuscript provides examples of how decision analytic models have helped informed policy decisions and to assess the impact of these policies on incremental waitlist activity for cardiac procedures during the COVID-19 pandemic.

Unattended automatic office blood pressure (BP) measurement has given new evidence regarding treatment goals. We aimed to explore any differences between unattended and conventional office BP measurements in different groups of patients visiting a European Society of Hypertension (ESH) Excellence Centre. We performed two unattended (Microlife Watch BP Home) followed by a single attended (mercury sphygmomanometer) BP measurement in 310 patients (mean age 62 ± 15 years, 151 males, 64% hypertensives and 36% normotensive individuals) visiting our ESH Centre for a scheduled follow-up. Office BP

Objective By the end of February 2020, the COVID-19 pandemic infection had spread in Northern Italy, with thousands of patients infected. In Lombardy, the most affected area, the majority of public and private hospitals were dedicated to caring for COVID-19 patients and were organized following the 'Hub-and-Spoke' model for other medical specialties, like cardiac surgery and interventional procedures for congenital cardiac disease (CHD). Here, we report how the congenital cardiac care system was modified in Lombardy and the first results of this organization. Methods We describe a modified 'Hub-and-Spoke' model - that involves 59 birthplaces and three specialized Congenital Cardiac Centers -- and how the hub center organized his activity. We also reported the data of the consecutive cases hospitalized during this period. Results From 9 March to 15 April, we performed: a total of 21 cardiac surgeries, 4 diagnostic catheterizations, 3 CT scans, and 2 CMR. In three cases with prenatal diagnosis, the birth was scheduled. The spoke centers referred to our center six congenital cardiac cases. The postop ExtraCorporeal Membrane Oxygenation support was required in two cases; one case died. None of these patients nor their parents or accompanying person was found to be COVID-19-positive; 2 pediatric intensivists were found to be COVID-19-positive, and needed hospitalization without mechanical ventilation; 13 nurses had positive COVID swabs (4 with symptoms), and were managed and isolated at home. Conclusion Our preliminary data suggest that the model adopted met the immediate needs with a good outcome without increased mortality, nor COVID-19 exposure for the patients who underwent procedures.

Background In the era of the current COVID-19 health crisis, the aim of the present study was to explore population behavior as regards the visits in the Εmergency Cardiology department (ECD) of a tertiary General Hospital that does not hospitalize SARS-CoV-2 infected patients Methods and results Daily number of visits at the EDC and admissions to Cardiology Wards and Intensive Care Unit of a tertiary General Hospital, in Athens, Greece, were retrieved from hospital’s database (January 1st–April 30th 2018, 2019 and 2020). A highly significant reduction in the visits at ECD of the hospital during March and April 2020 was observed as compared with January and February of the same year (p for linear trend

Background As a result of advances in pediatric care and diagnostic testing, there is a growing population of adults with congenital heart disease (ACHD). The purpose of this study was to better define the epidemiology and changes in the trend of hospitalizations for ACHD in Korean society. Methods We reviewed outpatient and inpatient data from 2005 to 2017 to identify patient ≥18 years of age admitted for acute care with a congenital heart disease (CHD) diagnosis in the pediatric cardiology division. We tried to analyze changes of hospitalization trend for ACHD. Results The ratio of outpatients with ACHD increased 286.5%, from 11.1% (1748/15,682) in 2005 to 31.8% (7795/24,532) in 2017. The number of ACHD hospitalizations increased 360.7%, from 8.9% (37/414) in 2005 to 32.1% (226/705) in 2017. The average patient age increased from 24.3 years in 2005 to 27.4 in 2017. The main diagnosis for admission of ACHD is heart failure, arrhythmia and Fontan-related complications. The annual ICU admission percentage was around 5% and mean length of intensive care unit (ICU) stay was 8.4 ± 14.6 days. Mean personal hospital charges by admission of ACHD increased to around two times from 2005 to 2017. (from $2578.1 to $3697.0). Total annual hospital charges by ACHD markedly increased ten times (from $95,389.7 to $831,834.2). Conclusions The number of hospital cares for ACHD dramatically increased more than five times from 2005 to 2017. We need preparations for efficient healthcare for adults with CHD such as a multi-dimensional approach, effective communication, and professional training.

Background: While major complications associated with CIED lead extractions are uncommon, they carry a significant risk of morbidity and mortality in the absence of surgical intervention. However, there is limited data on the differences in outcomes of these procedures between centers with and without on-site CS support. The present study examined outcomes of transvenous cardiac implantable electronic device (CIED) lead extractions according to admitting hospitals’ cardiac surgery (CS) facilities.\ud \ud Methods: We analyzed the National Inpatient Sample for CIED lead extraction procedures, stratified by hospitals’ CS facilities into two groups; on-site and off-site CS. Logistic regression analyses were performed to estimate the adjusted odds (aOR) of procedure-related complications in off-site CS centers. \ud \ud Results: In 221,606 procedures over an 11-year-period, CIED lead extractions were increasingly undertaken in on-site as opposed to off-site CS centers (Onsite CS 2004 vs. 2014: 78.2% vs. 90.4%, p

Replacement of an end-of-life cardiac catheterization laboratory ("cath lab") can pose a significant challenge to a hospital, particularly in single-cath-lab institutions. The disruption in patient care requires innovative approaches to minimize the inconvenience and ensure ongoing quality of care. We describe a unique approach whereby Michael Garron Hospital (MGH) "leased" a cath lab within Sunnybrook Health Sciences Centre for a 12-week period during a cath lab replacement project at MGH. The MGH cath lab and patient recovery bay remained a completely separate entity staffed by MGH nurses and physicians, with electronic connection to the home hospital. A total of 420 patients underwent cardiac catheterization with no adverse outcomes while maintaining system efficiency and high patient and staff satisfaction. Cath lab leasing involving two cooperating hospitals is an innovative and safe way to bridge a cath lab replacement.

The Asia-Pacific Society of Cardiology (APSC) high-sensitivity troponin T (hs-TnT) consensus recommendations and rapid algorithm were developed to provide guidance for healthcare professionals in the Asia-Pacific region on assessing patients with suspected acute coronary syndrome (ACS) using a hs-TnT assay. Experts from Asia-Pacific convened in 2 meetings to develop evidence-based consensus recommendations and an algorithm for appropriate use of the hs-TnT assay. The Expert Committee defined a cardiac troponin assay as a high-sensitivity assay if the total imprecision is ≤10% at the 99th percentile of the upper reference limit and measurable concentrations below the 99th percentile are attainable with an assay at a concentration value above the assay's limit of detection for at least 50% of healthy individuals. Recommendations for single-measurement rule-out/rule-in cutoff values, as well as for serial measurements, were also developed. The Expert Committee also adopted similar hs-TnT cutoff values for men and women, recommended serial hs-TnT measurements for special populations, and provided guidance on the use of point-of-care troponin T devices in individuals suspected of ACS. These recommendations should be used in conjunction with all available clinical evidence when making the diagnosis of ACS.

Background Randomized trials have shown favorable clinical outcomes for coronary CT angiography (CTA) in patients with suspected acute coronary syndrome (ACS). Our goal was to estimate the cost-effectiveness of coronary CTA as compared to alternative management strategies for ACP patients over lifetime. Methods Markov microsimulation model was developed to compare cost-effectiveness of competitive strategies for ACP patients: 1) coronary CTA, 2) standard of care (SOC), 3) AHA/ACC Guidelines, and 4) expedited emergency department (ED) discharge protocol with outpatient testing. ROMICAT-II trial was used to populate the model with low to intermediate risk of ACS patient data, whereas diagnostic test-, treatment effect-, morbidity/mortality-, quality of life- and cost data were obtained from the literature. We predicted test utilization, costs, 1-, 3-, 10-year and over lifetime cardiovascular morbidity/mortality for each strategy. We determined quality adjusted life years (QALY) and incremental cost-effectiveness ratio. Observed outcomes in ROMICAT-II were used to validate the short-term model. Results Estimated short-term outcomes accurately reflected observed outcomes in ROMICAT-II as coronary CTA was associated with higher costs ($4,490 vs. $2,513-$4,144) and revascularization rates (5.2% vs. 2.6%-3.7%) compared to alternative strategies. Over lifetime, coronary CTA dominated SOC and ACC/AHA Guidelines and was cost-effective compared to expedited ED protocol ($49,428/QALY). This was driven by lower cardiovascular mortality (coronary CTA vs. expedited discharge: 3-year: 1.04% vs. 1.10–1.17; 10-year: 5.06% vs. 5.21–5.36%; respectively). Conclusion Coronary CTA in patients with suspected ACS renders affordable long-term health benefits as compared to alternative strategies.

Background Globally the burden of heart failure is rising. Hospitalisation is one of the main contributors to the burden of heart failure and unfortunately, the majority of heart failure patients will experience multiple hospitalisations over their lifetime. Considering the high health care cost associated with heart failure, a review of economic evaluations of post-discharge heart failure services is warranted. Aim An integrated review of the economic evaluations of post-discharge nurse-led heart failure services for patients hospitalised with acute heart failure. Methods Electronic databases were searched using EBSCOHost: CINAHL complete, Medline complete, Embase, Scopus, EconLit, Global Health, and Health source (Consumer and Nursing/Academic) for published articles until 22nd June 2021. The searches focussed on papers that examined the cost-effectiveness of nurse-led clinics or telemonitoring involving nurses to follow-up patients after hospitalisation for acute heart failure. GRADE criteria and CHEERS checklist were used to determine the quality of the evidence and the quality of reporting of the economic evaluation. Results Out of 453 studies identified, eight studies were included: four in heart failure clinics and four in telemonitoring programs. Five of the articles were cost-effectiveness analyses, one a cost comparison and two studies involved economic modelling The GRADE criteria were rated as high in five studies. In which, four studies examined the cost-effectiveness of telemonitoring programs. Based on the CHEERS checklist for reporting quality of economic evaluations, the majority of economic evaluations were rated between 86 and 96%. All the studies found the intervention to be cost-effective compared to usual care with Incremental Cost Effectiveness Ratios ranging from $18 259 (Canadian dollars)/life year gained to €40,321 per Quality Adjusted Life Years gained. Conclusion Nurse-led heart failure clinics and telemonitoring programs were found to be cost-effective. Certainly, this review has shown that heart failure clinics and telemonitoring programs do represent value for money with their greatest impact and cost savings through reducing rehospitalisations.

Background: Telemedicine models play a key role in organizing the growing demand for care and healthcare accessibility, but there are no described longer-term results in health care. Our objective is to assess the longer-term results (delay time in care, accessibility, and hospital admissions) of an electronic consultation (e-consultation) outpatient care program. Methods: Epidemiological and clinical data were obtained from the 41 258 patients referred by primary care to the cardiology department from January 1, 2010, to December 31, 2019. Until 2012, all patients were attended in an in-person consultation (2010–2012). In 2013, we instituted an e-consultation program (2013-2019) for all primary care referrals to cardiologists that preceded patients’ in-person consultations when considered. We used an interrupted time series regression approach to investigate the impact of the e-consultation on (1) delay time (days) in care and (2) hospital admissions. We also analyzed (3) total number and referral rate (population-adjusted referred rate) in both periods (in-person consultation and e-consultation), and (4) the accessibility was measured as number of consultations and variation according to distance from municipality and reference hospital. Results: During the e-consultation, the demand increased (7.2±2.4% versus 10.1±4.8% per 1000 inhabitants, P P P P =0.874). Conclusions: Implementing e-consultations in the outpatient management model may improve accessibility of care for patients furthest from the referral hospital. After e-consultations were implemented, the upward trend of hospital admissions observed during the in-person consultation period was stabilized with a slight downward trend.

Background and aims Despite established guidelines on secondary prevention of cardiovascular disease, practical implementation of treatment targets is deficient even in high-income countries. This study compared long-term hospital-based treatment with follow-up at primary health care regarding new cardiovascular events and achievement of treatment targets. Methods This randomized controlled trial at Sørlandet Hospital, Norway 2007–2021 included patients hospitalized due to myocardial infarction (n = 760) or after scheduled percutaneous coronary intervention (PCI) (n = 677) or coronary artery bypass grafting (n = 103). Patients were randomized to hospital-based secondary preventive care with consultations 2 weeks, 3 months, 6 months and 1 year after the index event and annually for up to 5 years, or follow-up at primary health care. Final data was collected after 10 years and hazard ratios were calculated using Cox regression analyses. Results Composite endpoint-free survival due to a lower rate of PCI improved in patients with hospital-based follow-up (n = 788) compared to patients followed-up at primary health care (n = 752) (HR 0.80, 95% CI 0.66–0.96; p = 0.02) but all-cause mortality was not reduced (HR 0.96, 95% CI 0.59–1.56; p = 0.86). At 1 year, LDL-cholesterol (2.1 [SD 0.7] versus 2.3 [SD 0.8] mmol/l; p p Conclusions Long-term hospital-based secondary preventive follow-up improved composite endpoint-free survival, but not mortality. Substantial risk factors remained unaddressed. The beneficial effects on blood pressure and LDL-cholesterol disappeared after annual consultations ceased. Trial registration: The study is registered in ClinicalTrials.gov (NCT00679237) May 16, 2008.

Background Chest pain remains one of the most challenging serious complaints in the emergency department (ED). A prompt and accurate risk stratification tool for chest pain patients is paramount to help physcian effectively progrnosticate outcomes. HEART score is considered one of the best scores for chest pain risk stratification. However, most validation studies of HEART score were not performed in populations different from those included in the original one. Objective To validate HEART score as a prognostication tool, among Tunisian ED patients with undifferentiated chest pain. Methods Our prospective, multicenter study enrolled adult patients presenting with chest pain at chest pain units. Patients over 30 years of age with a primary complaint of chest pain were enrolled. HEART score was calculated for every patient. The primary outcome was major cardiovascular events (MACE) occurrence, including all-cause mortality, non-fatal myocardial infarction (MI), and coronary revascularisation over 30 days following the ED visit. The discriminative power of HEART score was evaluated by the area under the ROC curve. A calibration analysis of the HEART score in this population was performed using Hosmer–Lemeshow goodness of test. Results We enrolled 3880 patients (age 56.3; 59.5% males). The application of HEART score showed that most patients were in intermediate risk category (55.3%). Within 30 days of ED visit, MACE were reported in 628 (16.2%) patients, with an incidence of 1.2% in the low risk group, 10.8% in the intermediate risk group and 62.4% in the high risk group. The area under receiver operating characteristic curve was 0.87 (95% CI 0.85–0.88). HEART score was not well calibrated (χ2 statistic = 12.34; p = 0.03). Conclusion HEART score showed a good discrimination performance in predicting MACE occurrence at 30 days for Tunisian patients with undifferentiated acute chest pain. Heart score was not well calibrated in our population.

Background Timely acquisition of 12-lead Electrocardiogram (ECG) in the emergency department (ED) is crucial and recommended by current guidelines. Objectives To evaluate the association of medical history of coronary artery disease (hCAD) on door-to-ECG time in the ED. Methods In this single center, retrospective cohort study, patients admitted to ED for cardiac evaluation were grouped according to hCAD and no hCAD. The primary outcome was door-to-ECG time. A multivariate analysis adjusted for the cofounders sex, age, type of referral and shift was performed to evaluate the association of hCAD with door-to-ECG time. Results 1101 patients were included in this analysis. 362 patients (33%) had hCAD. Patients with hCAD had shorter door-to-ECG time (20 min. [Inter Quartile Range [IQR] 13–30] vs. 22 min. [IQR 14–37]; p p = 0.007; 95% confidence Interval [CI] − 5.16 to − 0.84 min]). Conclusion In this single center registry, hCAD was associated with shorter door-to-ECG time. In patients presenting in ED for cardiac evaluation, timely ECG diagnostic should be facilitated irrespective of hCAD.

BACKGROUND: Aim of our study was to assess the association between COVID-19 lockdown and cardiac pacing (CP) procedures rates in Campania Region, the third-most-populous region of Italy with about 5.8 million residents. METHODS: Data about type of CP procedures and unit admissions were obtained from 14 CP centers throughout Campania region from March 10th and May 4Th 2020 and compared with the same time frame in 2019. RESULTS: A remarkable reduction in both temporary (reduction rate: -62.5%), definitive pace maker (reduction rate: -30.2%), ICD (reduction rate: -48.3%) and CRT (reduction rate: -48.4%) implantation and in CRT replacement (reduction rate: -88.8%) procedures has been shown between the two observation periods among 951 hospitalized patients. Planned hospitalizations showed a reduction rate of 69.3%. Conversely, urgent intra-hospital admissions (increase rate +430%; P 

Background: High-sensitivity troponin assays promise earlier discrimination of myocardial infarction. Yet, the benefits and harms of this improved discriminatory performance when incorporated within rapid testing protocols, with respect to subsequent testing and clinical events, has not been evaluated in an in-practice patient-level randomized study. This multicenter study evaluated the noninferiority of a 0/1-hour high-sensitivity cardiac troponin T (hs-cTnT) protocol in comparison with a 0/3-hour masked hs-cTnT protocol in patients with suspected acute coronary syndrome presenting to the emergency department (ED). Methods: Patients were randomly assigned to either a 0/1-hour hs-cTnT protocol (reported to the limit of detection [ Results: In total, 3378 participants with an emergency presentation were randomly assigned between August 2015 and April 2019. Ninety participants were deemed ineligible or withdrew consent. The remaining participants received care guided either by the 0/1-hour hs-cTnT protocol (n=1646) or the 0/3-hour standard masked hs-cTnT protocol (n=1642) and were followed for 30 days. Median age was 59 (49–70) years, and 47% were female. Participants in the 0/1-hour arm were more likely to be discharged from the ED (0/1-hour arm: 45.1% versus standard arm: 32.3%, P P P P value=0.001, superiority P value=0.744), although an increase in myocardial injury was observed. Among patients discharged from ED, the 0/1-hour protocol had a negative predictive value of 99.6% (95% CI, 99.0–99.9%) for 30-day death or myocardial infarction. Conclusions: This in-practice evaluation of a 0/1-hour hs-cTnT protocol embedded in ED care enabled more rapid discharge of patients with suspected acute coronary syndrome. Improving short-term outcomes among patients with newly recognized troponin T elevation will require an evolution in management strategies for these patients. Clinical Trial Registration: URL: https://www.anzctr.org.au . Unique identifier: ACTRN12615001379505.

INTRODUCTION Chest pain continues to be a major burden on the healthcare system with more than eight million patients being evaluated in the emergency department (ED) setting annually at a cost of greater than 10 billion dollars. Missed chest pain diagnoses for ischemia are the leading cause of malpractice lawsuits for ED physicians. The use of cardiac computed tomography angiography (CCTA) to assess acute chest pain was adopted at the Chickasaw Nation Medical Center to attempt to accurately diagnose low to intermediate risk chest pain and potentially reduce the cost of chest pain evaluation to the system while still transferring appropriate high-risk patients. PATIENTS AND METHODS Patients presenting to the ED with low to moderate risk chest pain were evaluated with at least two negative troponin levels, an ECG, and in most instances overnight observation followed by CCTA in the morning if eligible. High-risk patients were transported to a tertiary care facility with cardiac catheterization capabilities. Medical records were checked to determine if any adverse events had occurred during follow-up. Adverse events were defined as myocardial infarction, death, and/or revascularization. Mean follow-up was 28 months. RESULTS Of the 368 patients studied, 29 patients were transferred due to findings of at least moderate obstructive disease. Of those 29 patients transferred, 11 patients underwent revascularization (10 underwent percutaneous coronary intervention and one underwent coronary artery bypass grafting). The average coronary artery calcium score for patients transferred was 96.1. The average coronary artery calcium score for patients undergoing revascularization was 174.6. Six patients had normal coronary arteries on catheterization. The remaining 12 patients had the moderate obstructive disease by catheterization that was not physiologically significant by either invasive fractional flow reserve or in two instances, negative stress perfusion testing. At 24 months, two patients had undergone revascularization and one patient had died suddenly. CONCLUSION The cost savings associated with a CCTA first strategy to evaluate chest pain were ~$1 200 244.10. For a self-insured health system such as the Chickasaw Nation, these are very important cost savings.

Background: The recent introduction of an entirely subcutaneous implantable cardioverter-defibril­lator (S-ICD) represents an important progress in the defibrillation technology towards a less invasive approach. This is a single-center observational study of S-ICD implantations in Poland. Methods: The S-ICD was implanted in 11 patients with standard indications for an ICD. Patients in whom the device was implanted were evaluated for adverse events and device function at hospital discharge. All hospitalization costs were calculated and summed up for all patients. Costs were divided into following categories: medical materials, pharmaceuticals, operating theatre staff, cardiology depart­ment staff, laboratory tests, non-laboratory tests and additional non-medical costs. Results: The mean age of patients was 51.6 ± 16.4 years, 9 were men and 2 were women. Four pa­tients had atrial fibrillation as the basal rhythm, 1 patient had atrial flutter and 6 patients had sinus rhythm. All patients had at least one condition that precluded the use of a traditional ICD system or the S-ICD was preferred due to other conditions, i.e. a history complicated transvenous ICD therapy (18%), anticipated higher risk of infection (27%), lack or difficult vascular access (18%), young age and anticipated high cumulated risk of lifetime device therapy (36%). The mean duration of the im­plantation procedure was 2 h. One patient developed a postoperative pocket hematoma. Mean total time of hospitalization was 28 (6–92) days. Average cost of hospitalization per patient was 21,014.29 EUR (minimal = 19,332.71 EUR and maximal = 24,824.14 EUR). Conclusions: S-ICD implantation appears to provide a viable alternative to transvenous ICD, espe­cially for patients without pacing requirements.

Summary Background The use of a discharge checklist may decrease heart failure readmission rate. Aims We aimed to evaluate the usefulness of a checklist in patients hospitalized for heart failure, in terms of mortality, cardiovascular mortality and readmission rates, and quality of care, including therapeutic optimization and careplan planning. Methods We prospectively used a discharge checklist in 103 patients hospitalized for heart failure between July 2015 and January 2016. Quality of care and outcomes were compared with a retrospective cohort of 137 patients with same inclusion criteria, hospitalized between June 2014 and December 2014. The primary endpoints were total and cardiovascular mortality and readmissions for heart failure at 6 months. The secondary endpoint was quality of care rendered, measured by evidence-based medications, appropriate medication uptitration and planned discharge care. Results At 6 months, there were no differences between the checklist and control cohorts in the rates of all-cause mortality (10.7% vs. 13.1%; P = 0.57), cardiovascular mortality (8.7% vs. 10.9%; P = 0.58) and readmission (29.1% vs. 32.1%; P = 0.62). Follow-up after discharge was better planned in the checklist group. The use of the checklist yielded therapeutic optimization with a higher dose of beta-blockers and renin-angiotensin-aldosterone system blockers, especially in patients with a reduced left ventricular ejection fraction ( Conclusions The use of a simple discharge checklist in patients with acute heart failure showed no benefit in terms of readmission and mortality rates; however, it yielded better quality of care, including therapeutic optimization and careplan planning.

Objectives. Two tools to categorize and present quality data, phase of care mortality analysis (POCMA) and failure to rescue (FTR) have been introduced in the cardiothoracic surgical environment, but not tested in Scandinavia. We aimed to investigate whether these tools could be used in a Norwegian patient population and to increase the understanding of why patients die after cardiac surgery. Design. A group of four, including one senior cardiothoracic surgeon and one senior anesthesiologist, scrutinized deaths within 30 days after cardiac surgery at the Clinic of Cardiothoracic Surgery, St. Olav's University Hospital, Norway between February 2012-October 2015 in line with the POCMA-methodology. We used the clinic's internal register to identify patients and utilized all available written information from each patient course. We decided whether each death was surgeon dependent, FTR or a result of a multifactorial etiology, and evaluated the strength of our decisions. Results. We identified 51 deaths out of 1983 operations in our study period, giving unadjusted mortality of 2.6%. Nine deaths were classified as surgeon dependent, 3 FTR and 39 multifactorial. Conclusions. POCMA- and FTR-analyses can be carried out in clinical data which is well documented. The operating surgeon is in many cases not responsible for operative mortality, very few die due to FTR, but most patients die due to a multifactorial etiology.

The intervention of behaviors, including physical activity (PA), has become a strategy for many hospitals dealing with patients with chronic diseases. Given the limited evidence available about PA and healthcare use with chronic diseases, this study explored the association between different levels of PA and annual hospital service use and expenditure for inpatients with coronary heart disease (CHD) in China. We analyzed PA information from the first follow-up survey (2013) of the Dongfeng-Tongji cohort study of 1460 CHD inpatients. We examined factors such as PA exercise volume and years of PA and their associations with the number of inpatient visits, number of hospital days, and inpatient costs and total medical costs. We found that the number of hospital days and the number of inpatient visits were negatively associated with intensity of PA level. Similarly, total inpatient and outpatient costs declined when the PA exercise volume levels increased. Furthermore, there were also significant associations between the number of hospital days, inpatient costs or total medical costs and levels of PA years. This study provides the first empirical evidence about the effects of the intensity and years of PA on hospital service use and expenditure of CHD in China. It suggests that the patients' PA, especially the vigorous PA, should be promoted widely to the public and patients in order to relieve the financial burden of CHD.

Predischarge cardiac testing (PDT) in low-risk patients evaluated for acute coronary syndrome in a chest pain unit (CPU) remains a challenge. It is unclear whether PDT varies by gender. We analyzed consecutive low-risk women and men evaluated in our CPU over a 2-year period and compared the utilization of PDT (exercise treadmill test, myocardial stress perfusion scintigraphy, exercise stress echocardiography, invasive coronary angiography, or no test), and incidence of major adverse cardiac events (MACE) at 30 days and 6 months. The study group comprised 619 patients (54% women). A large proportion of both genders did not undergo PDT, although this finding was more frequent in women (50% women vs 40% men, p = 0.01). At 30 days, there were no MACE in either gender. After 6 months of follow-up, MACE remained very low in both women and men (2 [1%] vs 2 [1%]), and in patients who did and did not receive PDT (2 [1%] vs 2 [1%]). Mean length of stay in the CPU was 5.4 hours in patients without PDT and 9.8 hours in those with PDT (p0.0001) without altering postdischarge MACE. When referred for PDT, women more often underwent myocardial stress perfusion scintigraphy than men (22% vs 14%, p = 0.005) and less often received exercise treadmill test (20% vs 39%, p0.0001). Yield of abnormal PDT was low in both women and men although it was lower in women (1% vs 5%, p = 0.02). In conclusion, many low-risk women and men evaluated in a CPU for acute coronary syndrome can be safely and rapidly discharged without PDT and with low risk for MACE at 30 days and at 6 months. Exclusion of PDT was associated with significantly reduced length of stay while maintaining safety in terms of postdischarge MACE.

Background Patients presenting with hypertensive urgency / emergency (HUE) often have systolic heart failure(SHF). Coronary angiography is routinely done for these patients to rule out obstructive coronary artery disease (Obs-CAD). We performed a retrospective study to investigate predictors of ObsCAD in this population. Methods Patients who underwent angiography to investigate SHF and had hospital admission(s) for HUE in the preceding 6 months were included in the study. Chart review was performed to obtain demographic, clinical and imaging / angiographic data. A risk score was formulated based on multivariable logistic regression analysis. Results 205 patients [age 58.9 ± 14.4 years; 62.4% male; 39.5% diabetic; median EF 25% (Inter Quartile Range: 11)] were included in the study. 33.1% patients (n = 68) had obs-CAD. Patients with obs-CAD were older, diabetic, more likely to have a history of stroke, echocardiographic regional wall motion abnormalities (RWMA) while African Americans were less likely to have obs-CAD. On multivariable analysis, only non-African American race (OR: 2.18; CI: 1.08–4.4) and RWMA (OR: 5.62; CI: 2.47–12.81) remained significant predictors of obs-CAD. A risk score (RANDS) from 0 to 9 was formulated which had a c-statistic of 0.75 with a sensitivity and specificity of 84% and 53% for predicting obsCAD respectively. Conclusion Our results suggest that only a minority of patients with HUE and SHF have obs-CAD. A simple risk score may be used to stratify this population and lower risk individuals may be screened with non-invasive testing instead of invasive catheterization. These results should be validated in large registry populations.

Background: The rate of cardiac device–related infective endocarditis (CDRIE) is increasing worldwide, but no detailed data are available for Poland. Aims: We aimed to evaluate clinical, diagnostic, and therapeutic data of patients hospitalized due to CDRIE in 22 Polish referential cardiology centers from May 1, 2016 to May 1, 2017. Methods: Participating cardiology departments were asked to fill in a questionnaire that included data on the number of hospitalized patients, number and types of implanted cardiac electrotherapy devices, and number of infective endocarditis cases. We also collected clinical data and data regarding the management of patients with CDRIE. Results: Overall, 99 621 hospitalizations were reported. Infective endocarditis unrelated to cardiac device was the cause of 596 admissions (0.6%), and CDRIE, of 195 (0.2%). Pacemaker was implanted in 91 patients with CDRIE (47%); cardioverter‑defibrillator, in 51 (26%); cardiac resynchronization therapy‑defibrillator, in 48 (25%); and cardiac resynchronization therapy‑pacemaker, in 5 (2.5%). The most common symptoms were malaise (62%), fever/chills (61%), cough (21%), chest pain (19.5%), and inflammation of the device pocket (5.6%). Cultures were positive in 77.5% of patients. The cardiac device was removed in 91% of patients. The percutaneous approach was most common for cardiac device removal. All patients received antibiotic therapy, and 3 patients underwent a heart valve procedure. Transesophageal echocardiography was performed in 80% of patients. The most common complication was heart failure (25% of patients). Conclusions: The clinical profile, pathogen types, and management strategies in Polish patients with CDRIE are consistent with similar data from other European countries. Transesophageal echocardiography was performed less frequently than recommended. The removal rate in the Polish population is consistent with the general rates observed for interventional treatment in patients with CDRIE.

Purpose: To determine whether using existing noise reduction strategies improves patients’ overall satisfaction level during hospitalization on an adult outpatient cardiology unit and to assess whether noise reduction strategies were effective to decrease the ambient noise for both staff and patient environments. Background: Excessive noise is a worldwide problem facing hospitals today. Noise has been proven to be detrimental to staff and patient well-being and hospital environment satisfaction levels. Intervention: Staff noise perception online surveys, a poster presentation, and education of noise reduction strategies were completed. Two 6-week phases of pre- and postimplementation noise reduction strategies were initiated including closing of the doors, verbal and visual alarm reminders for staff, posting quiet signs, and limiting equipment through the unit. Patient telephone interviews regarding the noise environment during hospitalization in both phases and a follow-up staff noise perception online survey were completed. Results: Staff surveys identified noise as an issue on the unit with staff communication (90%) being the main source. This correlated with patient surveys of five rooms closest to the desk considering the unit “noisy.” Post-implementation patient surveys noted that strategies created in helping the unit become “quiet/mostly quiet.” Closing patient doors was most effective in noise reduction, increasing patient unit satisfaction. Conclusion: The use of visual cues and staff education are effective in reducing noise levels. Decreased noise levels improved overall patient satisfaction with their hospital experience and created a less stressful work environment.

Background Despite the best efforts of pediatricians, healthcare for adult patients with congenital heart disease (ACHD) has proven challenging because of the increased numbers. This study presents the process of establishing an ACHD care system as a collaborative effort between Shinshu University Hospital and Nagano Children's Hospital. Methods and Results: Establishing an outpatient clinic for transition, a cooperation agreement for in-patient care between the 2 hospitals, and quality management of diagnostic imaging and educational meetings for adult cardiologists were the 3 major challenges. Of the 99 patients who visited the transition clinic in the children's hospital between May 2014 and December 2016, 3 returned to the pediatrician's clinic. Between June 2013 and December 2017, 273 patients visited the ACHD center in Shinshu University Hospital. Until December 2017, mortality and fatal arrhythmia were noted in 3 and 2 cases, respectively. Catheter ablation for arrhythmia was performed in 12 cases, and 4 cases of pregnancy with moderate/severe ACHD or estimated as high risk were managed with healthy livebirths. Surgical interventions for moderate/severe ACHD were performed in collaboration with the children's hospital or Sakakibara Heart Institute. Conclusions Patients were successfully transferred to adult cardiology departments. Surgical and nonsurgical interventions for ACHD were provided. Collaboration between adult and pediatric cardiologists assists in the establishment of healthcare systems for ACHD.

Chest pain is one of the most frequent chief complaints in patients admitted to the emergency department (ED). No study has evaluated this patient population in Norway. The aim of the present study was to describe the diagnoses and logistics of chest pain patients admitted to the ED at a Norwegian university hospital.Data were collected from all patients referred to the ED at St. Olav's Hospital-Trondheim University Hospital in 2015. Patients presenting at the ED with a chief complaint of chest pain based on the Rapid Emergency Triage and Treatment System were included in this study.In the study period, 22,403 patients were admitted to the ED. Chest pain was the second most common chief complaint (11%), only exceeded by acute abdominal pain (18%). Among the chest pain patients, 12% had acute coronary syndrome (ACS) and 37% were diagnosed with non-specific chest pain. Gastrointestinal, musculoskeletal, and pulmonary conditions were less common, affecting 6%, 4%, and 4% of the patients, respectively. In total, 90% of the ED chest pain patients were handled by the Clinic of Cardiology.Chest pain was the second most common chief complaint among patients admitted to the ED, and most patients were handled by the Clinic of Cardiology. More than one-third of the patients received a cardiac diagnosis, but the largest group of patients was discharged with a diagnosis of non-specific chest pain. Other conditions managed by non-cardiac medical specialties were less common.

BackgroundThe current study was to compare the management and clinical outcome between women and men with acute coronary syndrome (ACS).MethodThis was a retrospective study. Patients with ACS presented to the emergency department were enrolled. Management and clinical outcomes (including mortality and acute decompensated heart failure [ADHF]) were compared between women and men.ResultsA total of 686 patients were included and women accounted for 38.5% (n = 264). Women were less likely to receive ticagrelor at the emergency department (18.2% vs 25.1%). Duration from arrival at the emergency department to undergo electrocardiogram was longer in women (7.5 min vs 5.3 min). The duration from symptom onset to undergo percutaneous coronary intervention was longer in women (14.4 h vs 7.2 h). After adjusting for covariates, odds ratio (OR) for cardiovascular mortality was 0.42 (95% confidence interval [CI] 0.37–1.02) and ADHF was 0.63 (95% CI 0.55–1.01) for women vs men. Socioeconomic status, duration from symptom onset to arrive at the emergency department, and management at the emergency department were the important factors contributing to the sex-differences in clinical outcome.ConclusionAmong ACS patients undergoing PCI, there was no sex-difference in in-hospital clinical outcome after adjusting for covariates. Future studies are needed to evaluate whether improving management at the emergency department can improve clinical outcomes in women and men with ACS.

PURPOSE: We evaluated whether the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) pandemic was associated with changes in the pattern of acute cardiovascular admissions across European centers.METHODS: We set-up a multicenter, multinational, pan-European observational registry in 15 centers from 12 countries. All consecutive acute admissions to emergency departments and cardiology departments throughout a 1-month period during the COVID-19 outbreak were compared with an equivalent 1-month period in 2019. The acute admissions to cardiology departments were classified into 5 major categories: acute coronary syndrome, acute heart failure, arrhythmia, pulmonary embolism, and other.RESULTS: Data from 54,331 patients were collected and analyzed. Nine centers provided data on acute admissions to emergency departments comprising 50,384 patients: 20,226 in 2020 compared with 30,158 in 2019 (incidence rate ratio [IRR] with 95% confidence interval [95%CI]: 0.66 [0.58-0.76]). The risk of death at the emergency departments was higher in 2020 compared to 2019 (odds ratio [OR] with 95% CI: 4.1 [3.0-5.8], P < 0.0001). All 15 centers provided data on acute cardiology departments admissions: 3007 patients in 2020 and 4452 in 2019; IRR (95% CI): 0.68 (0.64-0.71). In 2020, there were fewer admissions with IRR (95% CI): acute coronary syndrome: 0.68 (0.63-0.73); acute heart failure: 0.65 (0.58-0.74); arrhythmia: 0.66 (0.60-0.72); and other: 0.68(0.62-0.76). We found a relatively higher percentage of pulmonary embolism admissions in 2020: odds ratio (95% CI): 1.5 (1.1-2.1), P = 0.02. Among patients with acute coronary syndrome, there were fewer admissions with unstable angina: 0.79 (0.66-0.94); non-ST segment elevation myocardial infarction: 0.56 (0.50-0.64); and ST-segment elevation myocardial infarction: 0.78 (0.68-0.89).CONCLUSION: In the European centers during the COVID-19 outbreak, there were fewer acute cardiovascular admissions. Also, fewer patients were admitted to the emergency departments with 4 times higher death risk at the emergency departments. (C) 2020 Published by Elsevier Inc.