Background: Pericardial effusions frequently present challenging clinical dilemmas. Whether or not to drain an effusion, and if so by what method, are two common decisions facing cardiologists. We performed a survey to evaluate pericardiocentesis practice in the United Kingdom (UK). Methods: A total of 640 questionnaires were sent to all cardiologists in the UK Directory of Cardiology in March 2003. Results: A total of 274 (43%) completed questionnaires were returned, 88% from consultants, equally distributed between tertiary referral centres and district general hospitals. More than 1500 procedures were performed, largely using a paraxiphoid approach (89%). Clinical tamponade was the commonest indication for pericardiocentesis (83%). However, the majority of respondents (69%) considered echocardiographic features alone an indication for pericardiocentesis, even in the absence of clinical tamponade. The commonest perceived indications for drainage were right ventricular diastolic collapse and right atrial collapse (69% and 33% of respondents respectively). For guidance, 82% use echocardiography, either alone or with fluoroscopy or the electrocardiogram (ECG) injury trace. 11% employ fluoroscopy alone or with the ECG injury trace. The remaining 11% stated that they would use the ECG injury trace alone or use no guidance. Using the ECG injury trace alone is said by the European Society of Cardiology (ESC) guidelines to offer an inadequate safeguard. Reported complications included ventricular puncture (n = 12, 0.8%) and hepatic damage (n = 4, 0.3%). Conclusion: Pericardiocentesis practice varies substantially in the UK. Many cardiologists would perform pericardiocentesis based on echocardiographic features alone. 11% of cardiologists use guidance that is considered inadequate by the ESC guidelines.
Introduction: The 30-day readmission rate after a heart failure (HF) hospitalization is widely used for assessing healthcare quality and system performance. However, there are different methodological approaches which may influence estimated rates, and no single accepted approach. The combined impact of these methods is unknown. Goals: We calculated 30-day HF readmission rates (RRs) of hospitalized patients using different published approaches to sampling and measurement. Methods: We included 1,849 patients discharged following unplanned hospitalization with a primary diagnosis of HF between 2016 to 2018 from the VancOuver CoastAL Acute Heart Failure (VOCAL-AHF) registry. We combined five distinct methodological factors (Table 1) to create 64 unique definitions and associated HF RRs. The readmission rates were averaged over 3-years. Multiple linear regression was used to determine the impact of different factors on estimated readmission rates. Results: The calculated 30-day RR for HF varied more than twofold depending solely on the methodological approach (6.4% to 15.0%, 8.6% absolute difference, 134% relative difference). The rates were highest when including all consecutive index admissions (11.1% to 15.0%), and lowest including only one index admission per patient per year (6.4% to 11.4%). The regression model ranked variables affecting RR as: index selection method, reference period, ICD-10 codes, 30-day survival, and index day (Table 2, p<0.001 in all). Conclusions: Our findings have important implications for policy and reporting. Transparent and consistent methods are needed to calculate 30-day RRs to ensure reproducible and comparable reporting.
Abstract Introduction The PHARM‐HF clinic is a novel, pharmacist‐led medication optimization clinic for patients with heart failure with reduced ejection fraction (HFrEF). PHARM‐HF aims to achieve maximum‐tolerated HFrEF guideline‐directed medical therapy (GDMT) as outlined by the latest Canadian Cardiovascular Society heart failure guidelines. Methods This retrospective pre‐post study evaluated consecutive patients attending PHARM‐HF (January 2021–August 2022). The primary outcome was the modified Optimal Medication Therapy (mOMT) score, an aggregate score of HFrEF quadruple therapy. The mOMT score was categorized as suboptimal (score 0–4), acceptable (score 5–7), or optimal (score 8; all four drugs at maximum tolerated dose). Secondary outcomes included change in left ventricular ejection fraction (LVEF) from baseline to 1 year, and Kansas City Cardiomyopathy Questionnaire‐12 (KCCQ; range 0 [worst] to 100 [best]) from baseline to discharge. Results Of 81 included patients, median age was 68 years, 21% were female, 61% had New York Heart Association (NYHA) class 2 functional capacity, and median LVEF was 30%. Median mOMT improved from 6 (interquartile range [IQR] 4–7) at baseline to 8 (IQR 7–8) at clinic discharge ( p < 0.001; increase from 7% to 73% categorized as optimal). LVEF improved from a median of 30% to 38% at 1 year ( p < 0.001). Among 16 patients who completed the KCCQ‐12 at both time points, the score was 62 at baseline and 77 at discharge ( p = 0.42). Conclusions Uptake of GDMT significantly increased from admission to discharge from the PHARM‐HF medication optimization clinic, during which other cardiovascular clinicians did not modify HFrEF medications. Furthermore, there was an improvement in LVEF at 1 year. A pilot randomized controlled trial is currently underway to guide the development of a multicenter trial to provide definitive evidence for the role of pharmacist‐led medication optimization in HFrEF.
Approximately one in four patients with heart failure (HF) has a clinical diagnosis of pulmonary disease, predominantly chronic obstructive pulmonary disease (COPD). A further 40–70% may have unrecognized airflow obstruction. Clinical diagnosis is challenging given the cardinal symptom of both conditions is dyspnoea. Objective documentation of airflow obstruction by pulmonary function tests is essential, performed during clinical stability to avoid obstruction associated with congestion. In patients with pulmonary disease, natriuretic peptides retain high negative predictive values for excluding heart failure. The treatment of both HF and COPD should not deviate from international guidelines. The risk of bronchoconstriction due to beta blockers, and adverse cardiovascular events attributable to bronchodilators is controversial. The balance of evidence strongly favours prescribing beta blockers irrespective of pulmonary disease, recommending caution only in very severe COPD. Similarly, bronchodilators exhibit a reassuring safety profile, particularly long-acting muscarinic antagonists. Caution is advised when commencing new bronchodilator therapy, using high-dose, short-acting compounds, or when treating patients with severe heart failure. Concurrent pulmonary disease in patients with HF further impairs symptoms, quality of life, and exercise capacity. It also increases the risk of HF hospitalization, non-cardiovascular adverse outcomes, and long-term mortality. All efforts should be made to correctly identify and treat lung disease in clinical practice.
Health inequalities are evident across the United Kingdom, exemplified by large and persistent social gradients in premature cardiovascular mortality. Four simple medical therapies improve survival in patients with coronary heart disease: antiplatelet agents including aspirin, β-blockers, statins, and angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB). But are the founding National Health Service (NHS) principles of equity and universality translating into equitable delivery of these life-saving therapies? Previous studies have been limited in size, method of classifying socioeconomic status, range of treatments examined, and trends over time.
Methods
Socioeconomic status was defined using the Index of Multiple Deprivation, a weighted composite of seven deprivation domains. Small areas (approximately 1500 individuals) were aggregated into equal quintiles by ranked deprivation score. Three patient cohorts were defined: myocardial infarction (n=111,990), secondary prevention (n=677,522), and stable angina (n=984,807). Treatments for all myocardial infarction patients in 2003 and 2007 was obtained from the Myocardial Ischaemia National Audit Project. Angina and secondary prevention treatment data in 1999 and 2007 were derived from the General Practice Research Database, the world9s largest longitudinal database of primary care records linked with morbidity and prescribing information. Treatment uptake estimates were age-standardised.
Results
The uptake of all therapies increased in all patient groups between 1999 and 2007, in both men and women. Improvements were most marked in the community, where use of β-blockers, statins, and ACEI/ARB for secondary prevention and treatment of angina essentially doubled, from around 30% to over 60%. Small age gradients persisted for some therapies, possibly reflecting ageism, appropriateness or clinical contraindications which could not assessed. No consistent gender differences were observed for ‘hard’ diagnoses (myocardial infarction, postrevascularisation), although some inequality was apparent in the treatment of younger women with angina (a less precise category). Socioeconomic gradients were likewise absent for both myocardial infarction and secondary prevention, and gradients in patients with angina apparently favoured greater treatment uptake in the most deprived.
Discussion
For a decade the National Service Framework has spearheaded efforts to reduce cardiovascular mortality. The marked improvements reported here represent a triumph for the NHS. An equally important success story lies behind these headlines. The NHS is generally delivering equitable cardiovascular treatment, independent of socioeconomic status. However, there is no room for complacency. Future strategies should aim to further increase overall treatment levels and eradicate the remaining age and gender inequalities.
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