A Multi-Specialty Delphi Consensus on Assessing and Managing Cardiopulmonary Risk in Patients with COPD.

Background: In Canada, COPD represents a significant burden to the patient and health system, as it is often under or misdiagnosed and sub-optimally treated. Cardiovascular disease (CVD) is a common co-morbidity in COPD and there is significant interplay between these two chronic conditions. Across all stages of COPD disease severity, deaths can be attributed not only to respiratory causes but also to cardiovascular-related factors. The established links between COPD and CVD suggest the need for a greater degree of collaboration between respirologists and cardiologists. This modified Delphi consensus was initiated to consider how optimal COPD care can be delivered within Canada, with specific consideration of reducing cardiopulmonary risk and outcomes in COPD patients. Methods: A steering group with interest in the management of COPD and CVD from primary care, cardiology, and respirology identified 40 statements formed from four key themes. A 4-point Likert scale questionnaire was sent to healthcare professionals working in COPD across Canada by an independent third party to assess agreement (consensus) with these statements. Consensus was defined as high if ≥75% and very high if ≥90% of respondents agreed with a statement. Results: A total of 100 responses were received from respirologists (n=30), cardiologists (n=30), and primary care physicians (n=40). Consensus was very strong (≥90%) in 28 (70%) statements, strong (≥75 and <90%) in 7 (17.5%) statements and was not achieved (<75%) in 5 (12.5%) of statements. Conclusion: Based on the consensus scores, 9 key recommendations were proposed by the steering group. These focus on the need to comprehensively risk stratify and manage COPD patients to help prevent exacerbations. Consensus within this study provides a call to action for the expeditious implementation of the latest COPD guidelines from the Canadian Thoracic Society.

Exploring the impact of cardiologists expertise on publication metrics.

BACKGROUND: In the field of academic cardiology, the assessment of an author's scholarly impact and professional progression heavily relies on publications and citations. This study investigates whether specific cardiology expertise correlates with accelerated professional growth. METHODS: Using data from the 2023 European Society of Cardiology congress, 948 faculty attendees with an h-index of 30 or higher were analyzed. Expertises were categorized into six groups, and their association with publications and citations peaks was explored. RESULTS: Interventional cardiologists exhibited the highest annual publication peak, followed by imaging and electrophysiology experts. However, no significant differences were observed in citation peaks among expertise groups. While imaging experts initially appeared to reach citation peaks faster, this effect diminished after statistical adjustments. Additionally, holding multiple expertise areas prolonged the time to reach publication and citation peaks by approximately six years. CONCLUSION: This study underscores the influence of expertise in interventional cardiology on publication peaks but suggests that citation peaks and career progression velocity remain unaffected by expertise type. Furthermore, it highlights that holding multiple areas of expertise slowers the attainment of career peak for scholarly authors.

Sharing the multidisciplinary clinical approach to peri- and postmenopausal women: A Delphi consensus among Italian gynecologists, endocrinologists, and cardiologists for an integrated and optimal approach to clinical practice.

OBJECTIVE: The critical phase of perimenopausal period is marked by a reduction in estrogen levels, leading to various clinical issues (vasomotor and neurodegenerative symptoms, increased osteoporosis risk and cardiovascular risk). These complex clinical scenarios pose challenges to clinicians in providing the right support for diagnosis and treatment. A group of Italian cardiologists, endocrinologists, and gynecologists conducted a survey among expert colleagues to assess consensus on controversial issues and best practices for screening and treating peri- and postmenopausal women. METHODS: The Delphi methodology was used to analyze responses from a qualitative expert panel comprising 25 cardiologists, 25 endocrinologists, and 25 gynecologists, selected nationwide. Two consecutive questionnaires were proposed between February and May 2023. Agreement among experts was assessed following the Delphi method as developed by the RAND Corporation. RESULTS: The results of this Delphi Consensus have been shared by the leading scientific societies: Italian Society of Cardiology, Italian Society of Endocrinology, Italian Society of Gynecology and Obstetrics, and Italian Hospital Obstetricians Gynecologists Association. CONCLUSIONS: The experts highlighted comorbidities and hormone deprivation as crucial clinical problems to be evaluated in perimenopausal women, requiring investigation from cardiovascular and endocrinologic perspectives to assess cardiovascular risk, involving the use of BMI, standard blood samples, endocrine-metabolic tests, and lifestyle assessment, particularly in women with higher cardiovascular and metabolic risks candidates for hormone replacement therapy (HRT). The experts also agreed on the benefits of HRT in improving lipid metabolism and reducing insulin resistance, thereby mitigating the metabolic risks associated with menopause. However, this therapy should be tailored considering individual women's comorbidities and thrombotic risk.

Competency based curriculum for cardiovascular magnetic resonance: A position statement of the Society for Cardiovascular Magnetic Resonance.

This position statement guides cardiovascular magnetic resonance (CMR) imaging program directors and learners on the key competencies required for Level II and III CMR practitioners, whether trainees come from a radiology or cardiology background. This document is built upon existing curricula and was created and vetted by an international panel of cardiologists and radiologists on behalf of the Society for Cardiovascular Magnetic Resonance (SCMR).

AI and the cardiologist: when mind, heart and machine unite.

Artificial intelligence (AI) and deep learning has made much headway in the consumer and advertising sector, not only affecting how and what people purchase these days, but also affecting behaviour and cultural attitudes. It is poised to influence nearly every aspect of our being, and the field of cardiology is not an exception. This paper aims to brief the clinician on the advances in AI and machine learning in the field of cardiology, its applications, while also recognising the potential for future development in these two mammoth fields. With the advent of big data, new opportunities are emerging to build AI tools, with better accuracy, that will directly aid not only the clinician but also allow nations to provide better healthcare to its citizens.

Extreme Heat and Cardiovascular Health: What a Cardiovascular Health Professional Should Know.

As global temperatures continue to rise, extreme heat events are becoming more frequent and intense. Extreme heat affects cardiovascular health as it is associated with a greater risk of adverse cardiovascular events, especially for adults with preexisting cardiovascular diseases. Nonetheless, the pathophysiology underlying the association between extreme heat and cardiovascular risk remains understudied. Furthermore, specific recommendations to mitigate the effects of extreme heat on cardiovascular health remain limited to guide clinical practice within the context of a warming climate. The overall objective of this review article is to raise awareness that extreme heat poses a risk for cardiovascular health. Specifically, the review discusses why cardiovascular healthcare professionals should care about extreme heat, how extreme heat affects cardiovascular health, and recommendations to minimise the cardiovascular consequences of extreme heat. Future research directions are also provided to further our understating of the cardiovascular health consequences of extreme heat. A better awareness and understanding of the cardiovascular consequences of extreme heat will help cardiovascular health professionals assess the risk and optimise the care of their patients exposed to an increasingly warm climate.

Effects of the COVID-19 pandemic on the formation of fellows in training in cardiology.

CoronaVIrus Disease-19 (COVID-19) had a huge impact on human health and economy. However, to this date, the effects of the pandemic on the training of young cardiologists are only partially known. To assess the consequences of the pandemic on the education of the cardiologists in training, we performed a 23-item national survey that has been delivered to 1443 Italian cardiologists in training, registered in the database of the Italian Society of Cardiology (SIC). Six hundred and thirty-three cardiologists in training participated in the survey. Ninety-five percent of the respondents affirmed that the training programme has been somewhat stopped or greatly jeopardized by the pandemic. For 61% of the fellows in training (FITs), the pandemic had a negative effect on their education. Moreover, 59% of the respondents believe that they would not be able to fill the gap gained during that period over the rest of their training. A negative impact on the psycho-physical well being has been reported by 86% of the FITs. The COVID-19 pandemic had an unparalleled impact on the education, formation and mental state of the cardiologists in training. Regulatory agencies, universities and politicians should make a great effort in the organization and reorganization of the teaching programs of the cardiologists of tomorrow.

Treating heart failure in patients with diabetes: The view of the cardiologist.

Diabetes is a very important comorbidity in patients with heart failure. When both diseases coexist cardiovascular morbidity and mortality is greatly increased. Therefore, it is of clinical importance to treat both diseases as early as possible with an optimal therapy. Hitherto, heart failure therapy did not differ if a patient had concomitant diabetes. However, with SGLT-2 inhibitors having demonstrated to reduce hospitalization of heart failure independent of diabetes state and expected to be included into the ESC heart failure treatment guidelines in 2021 coexisting diabetes potentially will make a difference when to start therapy. In this article we provide an overview of current recommendations and also provide clinical considerations for the therapy of heart failure with concomitant diabetes.

Interventional cardiologists' perceptions of percutaneous coronary intervention quality measurement and feedback.

BACKGROUND: Interventional cardiologists receive feedback on their clinical care from a variety of sources including registry-based quality measures, case conferences, and informal peer interactions. However, the impact of this feedback on clinical care is unclear. METHODS: We interviewed interventional cardiologists regarding the use of feedback to improve their care of percutaneous coronary intervention (PCI) patients. Interviews were assessed with template analysis using deductive and inductive techniques. RESULTS: Among 20 interventional cardiologists from private, academic, and Department of Veterans Affairs practice, 85% were male, 75% performed at least 100 PCIs annually, and 55% were in practice for 5 years or more. All reported receiving feedback on their practice, including formal quality measures and peer learning activities. Many respondents were critical of quality measure reporting, citing lack of trust in outcomes measures and poor applicability to clinical care. Some respondents reported the use of process measures such as contrast volume and fluoroscopy time for benchmarking their performance. Case conferences and informal peer feedback were perceived as timelier and more impactful on clinical care. Respondents identified facilitators of successful feedback interventions including transparent processes, respectful and reciprocal peer relationships, and integration of feedback into collective goals. Hierarchy and competitive environments inhibited useful feedback. CONCLUSIONS: Despite substantial resources dedicated to performance measurement and feedback for PCI, interventional cardiologists perceive existing quality measures to be of only modest value for improving clinical care. Catherization laboratories should seek to integrate quality measures into a holistic quality program that emphasizes peer learning, collective goals and mutual respect.

Nonimmune hydrops fetalis management from the perspective of fetal cardiologists: A single tertiary center experience from Egypt.

BACKGROUND: Despite advances in managing nonimmune hydrops fetalis (NIHF), perinatal mortality is still significant. Fetal cardiac failure eventually occurs regardless of etiology. However, no previous study has addressed NIHF from fetal cardiologists' perspective. Therefore, we evaluated etiology and management of a NIHF cohort requiring fetal cardiologist consultation in a developing country. METHODS: A single-center retrospective cohort study of 70 cases with NIHF that were referred to a fetal cardiology unit over four years was performed. Demographics, etiologic diagnosis, and outcomes of the cases were assessed. Antenatal management was evaluated using cardiovascular profile score (CVPS). RESULTS: The most frequent diagnosis was Idiopathic hydrops 42(62.6%), followed by hydrops due to cardiac diseases 19(28.4%), and 3 dead fetuses were detected at the first fetal echocardiography. Treatment of fetal tachyarrhythmia (n = 7) had 100% success rate in terms of antenatal hydrops resolution. Digoxin was used in cases of structural heart diseases, twin- twin transfusion syndrome, and dilated cardiomyopathy with perinatal mortality occurring in all cases (n = 9). In cases of idiopathic hydrops, 14 fetuses received digoxin with intrauterine hydrops resolution in 2/14 (14%) while non-treated cases had intrauterine or early neonatal death. CONCLUSION: Nonimmune hydrops is the worst complication of diverse etiologies. Limitations in resources for advanced investigations in developing countries increase the possibility of categorizing NIHF as idiopathic. Tachyarrhythmia induced hydrops can be entirely reversed with antenatal therapy while non-tachyarrhythmia fetal cardiac disease outcomes are unfavorable regardless of therapy. On the other hand, idiopathic hydrops shows a limited potential response to digoxin in utero.

Computer versus cardiologist: Is a machine learning algorithm able to outperform an expert in diagnosing a phospholamban p.Arg14del mutation on the electrocardiogram?

BACKGROUND: Phospholamban (PLN) p.Arg14del mutation carriers are known to develop dilated and/or arrhythmogenic cardiomyopathy, and typical electrocardiographic (ECG) features have been identified for diagnosis. Machine learning is a powerful tool used in ECG analysis and has shown to outperform cardiologists. OBJECTIVES: We aimed to develop machine learning and deep learning models to diagnose PLN p.Arg14del cardiomyopathy using ECGs and evaluate their accuracy compared to an expert cardiologist. METHODS: We included 155 adult PLN mutation carriers and 155 age- and sex-matched control subjects. Twenty-one PLN mutation carriers (13.4%) were classified as symptomatic (symptoms of heart failure or malignant ventricular arrhythmias). The data set was split into training and testing sets using 4-fold cross-validation. Multiple models were developed to discriminate between PLN mutation carriers and control subjects. For comparison, expert cardiologists classified the same data set. The best performing models were validated using an external PLN p.Arg14del mutation carrier data set from Murcia, Spain (n = 50). We applied occlusion maps to visualize the most contributing ECG regions. RESULTS: In terms of specificity, expert cardiologists (0.99) outperformed all models (range 0.53-0.81). In terms of accuracy and sensitivity, experts (0.28 and 0.64) were outperformed by all models (sensitivity range 0.65-0.81). T-wave morphology was most important for classification of PLN p.Arg14del carriers. External validation showed comparable results, with the best model outperforming experts. CONCLUSION: This study shows that machine learning can outperform experienced cardiologists in the diagnosis of PLN p.Arg14del cardiomyopathy and suggests that the shape of the T wave is of added importance to this diagnosis.

2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography: A Statement from the Society of Cardiovascular Computed Tomography.

Cardiovascular computed tomography (CCT) is a well-validated non-invasive imaging tool with an ever-expanding array of applications beyond the assessment of coronary artery disease. These include the evaluation of structural heart diseases, congenital heart diseases, peri-procedural electrophysiology applications, and the functional evaluation of ischemia. This breadth requires a robust and diverse training curriculum to ensure graduates of CCT training programs meet minimum competency standards for independent CCT interpretation. This statement from the Society of Cardiovascular Computed Tomography aims to supplement existing societal training guidelines by providing a curriculum and competency framework to inform the development of a comprehensive, integrated training experience for cardiology and radiology trainees in CCT.

Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety.

OBJECTIVE: To understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload. METHODS: Single centre prospective observational evaluation of 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. A proforma including frequency, nature, magnitude and level of procedural risk at the time of each distraction/interruption was completed for each case. The primary operator completed a National Aeronautical and Space Administration (NASA) task load questionnaire rating mental/physical effort, level of frustration, time-urgency, and overall effort and performance. RESULTS: 264 distractions occurred in 106 (55%) out of 194 procedures observed; 80% were not relevant to the case being undertaken; 14% were urgent including discussions of potential ST-elevation myocardial infarction requiring emergency angioplasty. In procedures where distractions were observed, frequency per case ranged from 1 to 16 (mean 2.5, SD ±2.2); 43 were documented during high-risk stages of the procedure. Operator rating of NASA task load parameters demonstrated higher levels of mental and physical workload and effort during cases in which distractions occurred. CONCLUSIONS: In this first description of HF in adult cardiac catheter laboratories, we found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. We propose the introduction of a 'sterile cockpit' environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.

Diagnosis, treatment, and follow-up of heart failure patients by general practitioners: A Delphi consensus statement.

AIMS: Creation of an algorithm that includes the most important parameters (history, clinical parameters, and anamnesis) that can be linked to heart failure, helping general practitioners in recognizing heart failure in an early stage and in a better follow-up of the patients. METHODS AND RESULTS: The algorithm was created using a consensus-based Delphi panel technique with fifteen general practitioners and seven cardiologists from Belgium. The method comprises three iterations with general statements on diagnosis, referral and treatment, and follow-up. Consensus was obtained for the majority of statements related to diagnosis, referral, and follow-up, whereas a lack of consensus was seen for treatment statements. Based on the statements with good and perfect consensus, an algorithm for general practitioners was assembled, helping them in diagnoses and follow-up of heart failure patients. The diagnosis should be based on three essential pillars, i.e. medical history, anamnesis and clinical examination. In case of suspected heart failure, blood analysis, including the measurement of NT-proBNP levels, can already be performed by the general practitioner followed by referral to the cardiologist who is then responsible for proper diagnosis and initiation of treatment. Afterwards, a multidisciplinary health care process between the cardiologist and the general practitioner is crucial with an important role for the general practitioner who has a key role in the up-titration of heart failure medication, down-titration of the dose of diuretics and to assure drug compliance. CONCLUSIONS: Based on the consensus levels of statements in a Delphi panel setting, an algorithm is created to help general practitioners in the diagnosis and follow-up of heart failure patients.

Maintenance of Competence in Cardiovascular Training and Practices: Worth the Effort?

Americans expect their doctors to have the competence to deliver high-quality care and expect safeguards to be in place that assure their doctors are competent. However, competence requires knowledge, and people have trouble assessing their own knowledge and level of competence. Because external assessment is required, several organizations have taken on the roles of defining and assuring medical competence. For example, professional organizations such as the American College of Cardiology (ACC) have developed consensus documents that define core competencies for cardiologists. External organizations such as the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine (ABIM) have defined training requirements for cardiologists, and the ABIM has developed a process to certify that physicians maintain their competence, although the process has generated considerable criticism from the profession. Recently, the ACC and ABIM have worked together to make the certification process less onerous and more meaningful. This paper provides a brief summary of the history and ongoing efforts to assure the competence of cardiologists.