Frailty, health literacy and self-care in patients admitted with acute heart failure. / Skrøpelighet, helsekompetanse og egenomsorg hos pasienter som innlegges med akutt hjertesvikt.

BACKGROUND: There is limited knowledge from Norway on clinical characteristics, self-care and health literacy in patients admitted to hospital with acute heart failure. Our aim was to identify these factors in this group. MATERIAL AND METHOD: We included patients admitted with acute heart failure over a period of six months (2022/2023) at Drammen Hospital and Vestfold Hospital Trust. Cardiac nurses collected information from the patients, including self-assessed knowledge on an ordinal scale from 0 (little knowledge) to 10 (good knowledge). Clinical frailty scores were calculated and data from the hospital records were recorded. RESULTS: Of 136 patients with acute heart failure, 81 were included. Median age was 79 (range 35-95) years, 35 (43 %) were women. A total of 35 (43 %) had been admitted with heart failure exacerbation in the past year. The patients had a median of 5 (1-10) diagnoses, and the median score on the clinical frailty scale was 4 (1-7), corresponding to 'vulnerable'. A total of 63 (78 %) had been diagnosed with heart failure before admission to hospital. Of these, 13 (21 %) were unaware of the diagnosis, and their self-assessed knowledge was median 3 (25th and 75th percentile, 0-5) for management of heart failure, 2 (25th and 75th percentile, 0-5) for lifestyle interventions and 0 (25th and 75th percentile, 0-2) for heart medications. Altogether 42 out of 63 (67 %) weighed themselves weekly, 13 (21 %) measured their blood pressure, while 3 (5 %) had a self-care plan. Of 50 patients with left ventricle ejection fraction ≤ 40 %, 32 (64 %) were discharged with betablockers and angiotensin II receptor blockers or a combination drug with a neprilysin inhibitor, whereas 11 (22 %) were also prescribed SGLT2 inhibitors and mineralocorticoid receptor antagonists. INTERPRETATION: The included patients were multimorbid and had a low level of self-care and health literacy. There is potential to optimise well-documented medicinal treatment.

Brief group training of medical students in focused cardiac ultrasound may improve diagnostic accuracy of physical examination.

BACKGROUND: Physical examination and auscultation can be challenging for medical students. The aim of this study was to investigate whether a brief session of group training in focused cardiac ultrasound (FCU) with a pocket-sized device would allow medical students to improve their ability to detect clinically relevant cardiac lesions at the bedside. METHODS: Twenty-one medical students in their clinical curriculum completed 4 hours of FCU training in groups. The students examined patients referred for echocardiography with emphasis on auscultation, followed by FCU. Findings from physical examination and FCU were compared with those from standard echocardiography performed and analyzed by cardiologists. RESULTS: In total, 72 patients were included in the study, and 110 examinations were performed. With a stethoscope, sensitivity to detect clinically relevant (moderate or greater) valvular disease was 29% for mitral regurgitation, 33% for aortic regurgitation, and 67% for aortic stenosis. FCU improved sensitivity to detect mitral regurgitation (69%, P < .001). However, sensitivity to detect aortic regurgitation (43%) and aortic stenosis (70%) did not improve significantly. Specificity was ≥89% for all valvular diagnoses by both methods. For nonvalvular diagnoses, FCU's sensitivity to detect moderate or greater left ventricular dysfunction (90%) was excellent, detection of right ventricular dysfunction (79%) was good, while detection of dilated left atrium (53%), dilated right atrium (49%), pericardial effusion (40%), and dilated aortic root (25%) was less accurate. Specificity varied from 57% to 94%. CONCLUSIONS: After brief group training in FCU, medical students could detect mitral regurgitation significantly better compared with physical examination, whereas detection of aortic regurgitation and aortic stenosis did not improve. Left ventricular dysfunction was detected with high sensitivity. More extensive training is advised.

The diagnostic accuracy of pocket-size cardiac ultrasound performed by unselected residents with minimal training.

Pocket-size imaging devices may represent a tool for fast initial cardiac screening in the emergency setting. Pocket-size cardiac ultrasound (PCU) examinations performed by experienced echocardiographers yield acceptable diagnostic accuracy compared to standard echocardiogram (SE). However, the success of this method when used by unselected non-cardiologists remains unexplored. The current study studies the diagnostic accuracy of PCU when used by unselected internal medicine residents with minimal training. All residents were given a 2-hour introductory course in PCU (Vscan) and reported PCU results for up to 15 predefined cardiac landmarks. These were arbitrarily divided into 3 priority groups, such that left ventricle (LV) and pericardium were of first priority. Diagnostic accuracy [sensitivity/specificity and negative/positive predictive values (PPV/NPV)] and agreement were evaluated using a subsequent SE as reference. During a 9.2 months period a total of 303 patients were included in the study, the majority on the basis of presenting with chest pain or suspected heart failure. In the pooled LV and pericardial (1st priority) data, sensitivity/specificity/PPV/NPV were 61/92/70/89% respectively. Similar specificities and NPVs were observed for the 11 remaining indices, as were lower sensitivities and PPVs. The best PCU sensitivity (76%) was attained for the assessment of LV wall motion abnormalities. Overall agreement was k = 0.50. PCU examination performed by internal medicine residents with minimal training could provide a suitable means of ruling out cardiac pathology, as reflected in the high specificities and NPVs. It is not, however, a satisfactory tool for identifying patients with various cardiac disorders.

The anesthesia in abdominal aortic surgery (ABSENT) study: a prospective, randomized, controlled trial comparing troponin T release with fentanyl-sevoflurane and propofol-remifentanil anesthesia in major vascular surgery.

BACKGROUND: On the basis of data indicating that volatile anesthetics induce cardioprotection in cardiac surgery, current guidelines recommend volatile anesthetics for maintenance of general anesthesia during noncardiac surgery in hemodynamic stable patients at risk for perioperative myocardial ischemia. The aim of the current study was to compare increased troponin T (TnT) values in patients receiving sevoflurane-based anesthesia or total intravenous anesthesia in elective abdominal aortic surgery. METHODS: A prospective, randomized, open, parallel-group trial comparing sevoflurane-based anesthesia (group S) and total intravenous anesthesia (group T) with regard to cardioprotection in 193 patients scheduled for elective abdominal aortic surgery. Increased TnT level on the first postoperative day was the primary endpoint. Secondary endpoints were postoperative complications, nonfatal coronary events and mortality. RESULTS: On the first postoperative day increased TnT values (>13 ng/l) were found in 43 (44%) patients in group S versus 41 (43%) in group T (P = 0.999), with no significant differences in TnT levels between the groups at any time point. Although underpowered, the authors found no differences in postoperative complications, nonfatal coronary events or mortality between the groups. CONCLUSIONS: In elective abdominal aortic surgery sevoflurane-based anesthesia did not reduce myocardial injury, evaluated by TnT release, compared with total intravenous anesthesia. These data indicate that potential cardioprotective effects of volatile anesthetics found in cardiac surgery are less obvious in major vascular surgery.

Is 3D echocardiography superior to 2D echocardiography in general practice? A systematic review of studies published between 2007 and 2012.

BACKGROUND: Recent developments in 3-dimensional echocardiography (3DE) have resulted in smaller probes, faster data acquisition and wider applicability. In spite of this, there is still an ongoing debate as to its ability to provide additional information to 2DE in general hospital clinical practice. METHODS: A systematic literature search in EMBASE and MEDLINE was performed in order to identify original articles comparing the two techniques. Studies with a blinded comparison between 2DE and 3DE against a "gold standard" were included; these studies comprised patients with well defined inclusion and exclusion criteria. The number of patients, selection criteria, echo manufacturer, cardiac disorder, and types of comparisons, along with "gold standard" and principal results were compared. RESULTS: A total of 836 original articles were identified, of which 35 were screened for eligibility. 20 studies from 18 publications were included for analysis. The results for LV assessment and reproducibility were clearly in favour of 3DE. In valvular heart disease the superiority of 3DE was also apparent, but was less convincing due to patient selection, methodological problems and the application of questionable "gold standards". CONCLUSIONS: In patients with a regular heart rhythm and for whom it was possible to obtain good quality images the introduction of 3DE has improved the accuracy and reproducibility of LV volume and EF measurements. The results for valvular heart disease are still controversial. It does not seem justifiable to introduce 3DE into common cardiac practice. Further studies are needed in order to support such an implementation.

Proinflammatory cytokines and complement activation in salvaged blood from abdominal aortic aneurism surgery and total hip replacement surgery.

BACKGROUND: Levels of proinflammatory mediators in unwashed salvaged blood from abdominal aortic aneurism (AAA) surgery are unknown. We hypothesized that there are higher levels of these mediators in unwashed blood salvaged in AAA surgery compared to hip replacement surgery. STUDY DESIGN AND METHODS: Ten patients scheduled for AAA surgery (Group A) and 10 patients for total hip replacement surgery (Group H) were included. Blood samples from the autotransfusion set were obtained during surgery and arterial samples before, during, and 6 hours after surgery. Determination of interleukin (IL)-1ß, IL-6, IL-8, tumor necrosis factor-α, activated complement 3 (C3a), and high-sensitivity C-reactive protein (CRP) were performed. Salvaged blood was not retransfused. RESULTS: Levels (median [range]) of IL-8 in blood in the salvage system were higher in Group A versus Group H (215.3 [22.5-697.2] vs. 35.3 [16.7-66.6] pg/mL; p = 0.002). Higher levels of IL-6 were also seen in Group A versus Group H (60.0 [52.6-62.2] vs. 42.34 [19.4-62.2] pg/mL; p = 0.049). Levels of IL-6 in blood sampled during surgery were approximately fivefold higher in Group A versus Group H (p = 0.023), whereas approximately 70% higher levels of C3a were observed in Group H versus Group A (p = 0.021). Postoperative concentrations of IL-1ß (p = 0.002), IL-6 (p = 0.001), and IL-8 (0.005) were higher in Group A versus Group H. CONCLUSION: Salvaged blood in AAA surgery contains substantially higher levels of proinflammatory mediators compared to blood in total hip replacement surgery.

The "smoker's paradox" in patients with acute coronary syndrome: a systematic review.

BACKGROUND: Smokers have been shown to have lower mortality after acute coronary syndrome than non-smokers. This has been attributed to the younger age, lower co-morbidity, more aggressive treatment and lower risk profile of the smoker. Some studies, however, have used multivariate analyses to show a residual survival benefit for smokers; that is, the "smoker's paradox". The aim of this study was, therefore, to perform a systematic review of the literature and evidence surrounding the existence of the "smoker's paradox". METHODS: Relevant studies published by September 2010 were identified through literature searches using EMBASE (from 1980), MEDLINE (from 1963) and the Cochrane Central Register of Controlled Trials, with a combination of text words and subject headings used. English-language original articles were included if they presented data on hospitalised patients with defined acute coronary syndrome, reported at least in-hospital mortality, had a clear definition of smoking status (including ex-smokers), presented crude and adjusted mortality data with effect estimates, and had a study sample of > 100 smokers and > 100 non-smokers. Two investigators independently reviewed all titles and abstracts in order to identify potentially relevant articles, with any discrepancies resolved by repeated review and discussion. RESULTS: A total of 978 citations were identified, with 18 citations from 17 studies included thereafter. Six studies (one observational study, three registries and two randomised controlled trials on thrombolytic treatment) observed a "smoker's paradox". Between the 1980s and 1990s these studies enrolled patients with acute myocardial infarction (AMI) according to criteria similar to the World Health Organisation criteria from 1979. Among the remaining 11 studies not supporting the existence of the paradox, five studies represented patients undergoing contemporary management. CONCLUSION: The "smoker's paradox" was observed in some studies of AMI patients in the pre-thrombolytic and thrombolytic era, whereas no studies of a contemporary population with acute coronary syndrome have found evidence for such a paradox.

The effect of tobacco smoking and treatment strategy on the one-year mortality of patients with acute non-ST-segment elevation myocardial infarction.

BACKGROUND: The aim of the present study was to investigate whether a previously shown survival benefit resulting from routine early invasive management of unselected patients with acute non-ST-segment elevation myocardial infarction (NSTEMI) may differ according to smoking status and age. METHODS: Post-hoc analysis of a prospective observational cohort study of consecutive patients admitted for NSTEMI in 2003 (conservative strategy cohort [CS]; n = 185) and 2006 (invasive strategy cohort [IS]; n = 200). A strategy for transfer to a high-volume invasive center and routine early invasive management was implemented in 2005. Patients were subdivided into current smokers and non-smokers (including ex-smokers) on admission. RESULTS: The one-year mortality rate of smokers was reduced from 37% in the CS to 6% in the IS (p < 0.001), and from 30% to 23% for non-smokers (p = 0.18). Non-smokers were considerably older than smokers (median age 80 vs. 63 years, p < 0.001). The percentage of smokers who underwent revascularization (angioplasty or coronary artery bypass grafting) within 7 days increased from 9% in the CS to 53% in the IS (p < 0.001). The corresponding numbers for non-smokers were 5% and 27% (p < 0.001). There was no interaction between strategy and age (p = 0.25), as opposed to a significant interaction between strategy and smoking status (p = 0.024). Current smoking was an independent predictor of one-year mortality (hazard ratio 2.61, 95% confidence interval 1.43-4.79, p = 0.002). CONCLUSIONS: The treatment effect of an early invasive strategy in unselected patients with NSTEMI was more pronounced among smokers than non-smokers. The benefit for smokers was not entirely explained by differences in baseline confounders, such as their younger age.

Effect of implementing routine early invasive strategy on one-year mortality in patients with acute myocardial infarction.

The aim of the present study was to investigate whether the implementation of an early invasive strategy for unselected patients with acute myocardial infarction (AMI) would be associated with reduced long-term mortality compared to a conservative approach. In this prospective observational cohort study of consecutive patients admitted for AMI in 2003 (conservative cohort, n = 311) and 2006 (invasive cohort [IC], n = 307), an 11% absolute and 41% relative reduction in 1-year mortality was found for patients with AMI in the IC compared to the conservative cohort (p = 0.001). These findings were consistent after adjustment for age, gender, previous AMI, previous stroke, diabetes, smoking status, previous left ventricular systolic dysfunction, and serum creatinine at admission (hazard ratio 0.54, 95% confidence interval 0.38 to 0.78) and Global Registry of Acute Coronary Events risk score (hazard ratio 0.67, 95% confidence interval 0.46 to 0.97). More patients with ST-segment elevation myocardial infarction received primary percutaneous coronary intervention in the IC (57% vs 3%, p <0.001), and a sixfold (25% vs 4%, p <0.001) increase in early percutaneous coronary intervention (<72 hours) for patients with non-ST-segment elevation myocardial infarction was observed. A greater proportion of patients in the IC received clopidogrel, aspirin, and statins during follow-up; otherwise, the secondary prevention measures were similar in the 2 cohorts. In conclusion, the introduction of a strategy for routine transfer to a high-volume percutaneous coronary intervention center for early invasive therapy was accompanied by a substantial reduction in mortality among unselected patients with AMI. Differences in unmeasured confounders might have accounted for a part of the difference in outcome.

Reference values for left ventricular volumes with real-time 3-dimensional echocardiography.

OBJECTIVES: Obtain normal reference ranges for left ventricular (LV) volume indexes (VI) and ejection fraction (EF) with fast real-time 3-dimensional echocardiography (RT3DE) with online analysis. DESIGN: After a screening visit 166 healthy participants, 79 males and 87 females aged 29-80 years were examined with RT3DE and Doppler. RESULTS: Upper normal values (mean + 2 standard deviations [SD]) for LV end-diastolic volume index (LVEDVI) and LV end-systolic volume index (LVESVI) were 82 ml/m(2) and 38 ml/m(2), respectively. The lower limit (mean - 2 SD) for LVEF was 49%. LVVI were significantly larger among males (p < 0.001). LV stroke volume (SD) was 87 (22) ml with Doppler vs. 69 (14) ml with RT3DE (p < 0.001). In males there was a positive correlation between age and LVEF (r = 0.34, p = 0.003). In a reproducibility study of RT3DE and 2-dimensional echocardiography (2DE) the coefficients of variability for repeated recordings were 5.7% for LVEDV, 7.7% for LVESV and 6.7% for LVEF with RT3DE, and 8.6%, 8.6% and 6.4% with 2DE, respectively. CONCLUSIONS: These reference values presented from a large group of normal subjects over a wide age range with RT3DE may represent a valuable tool to evaluate if LV systolic dysfunction is present or not.

The limited usefulness of real-time 3-dimensional echocardiography in obtaining normal reference ranges for right ventricular volumes.

BACKGROUND: To obtain normal reference ranges and intraobserver variability for right ventricular (RV) volume indexes (VI) and ejection fraction (EF) from apical recordings with real-time 3-dimensional echocardiography (RT3DE), and similarly for RV area indexes (AI) and area fraction (AF) with 2-dimensional echocardiography (2DE). METHODS: 166 participants; 79 males and 87 females aged between 29-79 years and considered free from clinical and subclinical cardiovascular disease. Normal ranges are defined as 95% reference values and reproducibility as coefficients of variation (CV) for repeated measurements. RESULTS: None of the apical recordings with RT3DE and 2DE included the RV outflow tract. Upper reference values were 62 ml/m2 for RV end-diastolic (ED) VI and 24 ml/m2 for RV end-systolic (ES) VI. Lower normal reference value for RVEF was 41%. The respective reference ranges were 17 cm2/m2 for RVEDAI, 11 cm2/m2 for RVESAI and 27% for RVAF. Males had higher upper normal values for RVEDVI, RVESVI and RVEDAI, and a lower limit than females for RVEF and RVAF. Weak but significant negative correlations between age and RV dimensions were found with RT3DE, but not with 2DE. CVs for repeated measurements ranged between 10% and 14% with RT3DE and from 5% to 14% with 2DE. CONCLUSION: Although the normal ranges for RVVIs and RVAIs presented in this study reflect RV inflow tract dimensions only, the data presented may still be regarded as a useful tool in clinical practice, especially for RVEF and RVAF.

Normal reference ranges for left and right atrial volume indexes and ejection fractions obtained with real-time three-dimensional echocardiography.

AIMS: The aim of this study was to obtain normal reference ranges and intra-observer reproducibility for left (L) and right (R) atrial (A) volume indexes (VI, corrected for body surface area) and ejection fractions (EF) with real-time three-dimensional echocardiography. METHODS AND RESULTS: One hundred and sixty-six participants, 79 males and 87 females, aged 29-79 years considered free from clinical and subclinical cardiovascular disease, were included. Normal ranges are defined as 95% reference values for atrial dimensions and reproducibility as coefficients of variations (CVs) for repeated measurements. Upper normal reference values were 41 mL/m(2) for maximum (max) LAVI and 19 mL/m(2) for minimum (min) LAVI. The lower normal reference value was 45% for LAEF. The respective values for RA were 47 mL/m(2), 20 mL/m(2), and 46%. The only relevant gender difference was a higher upper normal max RAVI among males vs. females. The CVs for repeated measurements were 9% for max LAVI, 8% for max RAVI, 13% for LAEF, and 14% for RAEF. CONCLUSION: The present study provides normal ranges for atrial dimensions and contractility with a new, fast, and reproducible technique that can be used bedside without offline analysis.

High mortality rates in conservatively managed patients with acute coronary syndrome.

OBJECTIVES: The revised diagnostic criteria for the acute coronary syndrome (ACS) have created the need for accurate and representative data on treatment and outcome for the three categories of ACS. DESIGN: Consecutive patients admitted with a suspected ACS (n = 755) from February 1, 2003 to January 31, 2004 was registered and categorised into five diagnostic groups: 1) ST-elevation myocardial infarction (STEMI) (n = 126), 2) Non-ST-elevation myocardial infarction (NSTEMI) (n = 185), 3) Unstable angina pectoris (UAP) (n = 55), 4) Coronary heart disease (CHD) without ACS (n = 164) and 5) Non-coronary chest pain (n = 225). RESULTS: All-cause one-year mortality rates were 20%, 32%, 7%, 10% and 3%, in patients with STEMI, NSTEMI, UAP, CHD without ACS and non-coronary chest pain, respectively. In patients with STEMI, 61% received immediate reperfusion therapy (ratio thrombolysis: primary PCI = 18:1). Only 3% of those with NSTEMI had PCI within two days. CONCLUSION: In this conservatively managed population of consecutive patients with ACS, the one-year mortality rate is significantly higher than seen in most registries and clinical trials.

[Referral to elective and emergency coronary investigation from a medium-size central hospital]. / Henvisning til elektiv og akutt koronarutredning fra et middels stort sentralsykehus.

BACKGROUND: Little is known about regional differences in the incidence of acute and elective invasive coronary procedures in Norway. Such information is important in the planning of new invasive centres. MATERIALS AND METHODS: In this prospective study all patients referred to coronary angiography at the Rikshospitalet University Hospital in Oslo (100 km remote) from the county of Vestfold (218,000 inhabitants) from 1 December 2002 to 30 November 2003 were included. Referrals were categorised as acute or elective. Based upon the discharge summaries from Oslo, all coronary angiographies, percutaneous interventions and coronary artery bypass grafts were registered. RESULTS: A total of 760 patients were referred, of whom 746 (98 %) underwent coronary angiography (19 % acutely). They were treated as follows: percutaneous coronary intervention, n = 295 (31 % acutely); coronary artery bypass grafting, n = 123 and conservative treatment, n = 342. INTERPRETATION: Based upon these results, the incidence figures for 100,000 inhabitants per year in 2003 were similar to the nation-wide average for percutaneous interventions per year in Norway in 2001 and approximately 30 % below that average for 2003. Therefore, in the planning of an optimal peripheral catheterisation laboratory, the population basis has to be calculated from the local incidence of procedures, since there are obviously significant regional differences in the use of such procedures.

[Prehospital diagnosis and treatment of acute myocardial infarction in Vestfold]. / Prehospital diagnostikk og behandling av akutt hjerteinfarkt i Vestfold.

BACKGROUND: Pre-hospital thrombolysis is a relatively new treatment modality in Norway. The present study is a county-based evaluation of the first phase of this procedure after its introduction in 2002. MATERIALS AND METHODS: This is a retrospective cohort study of all patients who, over a nine-month period, had a pre-hospital ECG taken by paramedics and transmitted to the county's two coronary care units. The medical records of all patients who received pre-hospital thrombolysis were analysed and compared with those who received in-hospital thrombolysis over the same period. MATERIAL AND METHODS: A pre-hospital ECG was successfully taken and transmitted in 840 patients. Pre-hospital thrombolytic therapy was given to 45 (5.4%) patients, of whom 38 (84%) developed ST-elevation myocardial infarction (STEMI). Over the same period, 32 patients received in-hospital thrombolysis, of whom 28 (87%) developed STEMI. Among the 738 hospitalised patients who did not receive pre-hospital thrombolytic therapy, 218 (28%) had a diagnosis of acute coronary syndrome, 258 (35%) had established coronary heart disease but no evidence of coronary ischaemia, while 262 (36%) had no evidence of coronary heart disease at all. Median call-to-thrombolysis time was 42 minutes (range 21-75). INTERPRETATION: The findings indicate good paramedical pre-hospital routines with short call-to-thrombolysis-time, but the routines for pre-hospital ECG and thrombolytic therapy need reassessment.