Availability of Specialty Services for Cardiovascular Prevention Practice in the Southeastern United States.

OBJECTIVES: A comprehensive cardiovascular disease (CVD) prevention approach should address patients' medical, behavioral, and psychological issues. The aim of this study was to understand the clinician-reported availability of a pertinent CVD preventive workforce across various specialties using a survey study in the southeastern United States, an area with a disproportionate burden of CVD and commonly known as the Stroke Belt. METHODS: We surveyed physicians, advanced practice providers (APPs), and pharmacists in internal medicine, family medicine, endocrinology, and cardiology regarding available specialists in CVD preventive practice. We examined categorical variables using the χ2 test and continuous variables using the t test/analysis of variance. RESULTS: A total of 263 clinicians from 21 health systems participated (27.6% response rate, 91.5% from North Carolina). Most were women (54.5%) and physicians (72.5%) specializing in cardiology (43.6%) and working at academic centers (51.3%). Overall, most clinicians stated having adequate specialist services to manage hypertension (86.6%), diabetes mellitus (90.1%), and dyslipidemia (84%), with >50% stating having adequate specialist services for obesity, smoking cessation, diet/nutrition, and exercise counseling. Many reported working with an APP (69%) or a pharmacist (56.5%). Specialist services for exercise therapy, psychology, behavioral counseling, and preventive cardiology were less available. When examined across the four specialties, the majority reported having adequate specialist services for hypertension, diabetes mellitus, obesity, dyslipidemia, and diet/nutrition counseling. Providers from all four specialties were less likely to work with exercise therapists, psychologists, behavioral counselors, and preventive cardiologists. CONCLUSIONS: A majority of providers expressed having adequate specialists for hypertension, diabetes mellitus, dyslipidemia, obesity, smoking cessation, diet/nutrition, and exercise counseling. Most worked together with APPs and pharmacists but less frequently with exercise therapists, psychologists, behavioral counselors, and preventive cardiologists. Further research should explore approaches to use and expand less commonly available specialists for optimal CVD preventive care.

Clinicians' self-reported efficacy in cardiovascular prevention practice in the southeastern United States.

Aim: We assessed self-reported efficacy in cardiovascular prevention practice among internal medicine, family medicine, endocrinology and cardiology clinicians. Patients & methods: We emailed a 21-item questionnaire to 956 physicians, nurse practitioners, physician assistants and pharmacists. Results: 264 clinicians responded (median age: 39 years, 55% women, 47.9% specialists). Most expressed high self-efficacy in lifestyle counselling, prescribing statins, metformin, and aspirin in primary prevention, but low self-efficacy in managing specialized conditions like elevated lipoprotein(a). Compared with specialists, PCPs expressed lower self-efficacy in managing advanced lipid disorders and higher self-efficacy in prescribing sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists. Conclusion: Self-efficacy in cardiovascular prevention varied across specialties. Future research should explore relevant provider, clinic and system level factors to optimize cardiovascular prevention.

Accelerated rate of progression of bioprosthetic aortic stenosis in patients with renal disease.

BACKGROUND: Renal disease can lead to more rapid progression of aortic stenosis. However, there are limited case report data investigating the impact of renal disease on the rate of prosthetic aortic valve stenosis. We sought to quantify the rate of progression of bioprosthetic aortic stenosis in patients with renal disease. METHODS: Patients with bioprosthetic aortic valves and at least two transthoracic echocardiograms six or more months apart were included. Echocardiographic data from patients with end-stage renal disease (ESRD), chronic kidney disease (CKD) stages 3-4, and normal renal function were compared using ANOVA and Kruskal-Wallis tests. RESULTS: One hundred fifteen patients (43 ESRD, 52 CKD, and 20 controls) were included in this study. Changes in dimensionless index (DI) (units/year) for patients with normal renal function, CKD, and ESRD were .025 ± .13, -.040 ± .08, -.10 ± .13, respectively, leading to calculated changes in aortic valve area (AVA) (cm2 /year) of .04 ± .28, -.13 ± .29, -.42 ± .72, respectively. Change in peak gradient (m/sec/year) was significantly lower for patients with normal renal function compared to ESRD; -.077 ± 5.98 versus 7.18 ± 17.9. In the ESRD group, a nonsignificant trend toward greater change in DI/year was seen in TAVR compared to SAVR: -.14 ± .16 versus -.08 ± .11. CONCLUSION: Our results confirm limited available data reporting an accelerated rate of bioprosthetic stenosis in patients with CKD and ESRD. These data not only quantify this progression but may also inform clinical decision-making and valve selection in patients with renal disease.

Diagnostic accuracy of non-contrast quiescent-interval slice-selective (QISS) MRA combined with MRI-based vascular calcification visualization for the assessment of arterial stenosis in patients with lower extremity peripheral artery disease.

OBJECTIVES: The proton density-weighted, in-phase stack-of-stars (PDIP-SOS) MRI technique provides calcification visualization in peripheral artery disease (PAD). This study sought to investigate the diagnostic accuracy of a combined non-contrast quiescent-interval slice-selective (QISS) MRA and PDIP-SOS MRI protocol for the detection of PAD, in comparison with CTA and digital subtraction angiography (DSA). METHODS: Twenty-six prospectively enrolled PAD patients (70 ± 8 years) underwent lower extremity CTA and 1.5-T or 3-T PDIP-SOS/QISS MRI prior to DSA. Two readers rated image quality and graded stenosis (≥ 50%) on QISS MRA without/with calcification visualization. Sensitivity, specificity, and area under the curve (AUC) were calculated against DSA. Calcification was quantified and compared between MRI and non-contrast CT (NCCT) using paired t test, Pearson's correlation, and Bland-Altman analysis. RESULTS: Image quality ratings were significantly higher for CTA compared to those for MRA (4.0 [3.0-4.0] and 3.0 [3.0-4.0]; p = 0.0369). The sensitivity and specificity of QISS MRA, QISS MRA with PDIP-SOS, and CTA for ≥ 50% stenosis detection were 85.4%, 92.2%, and 90.2%, and 90.3%, 93.2%, and 94.2%, respectively, while AUCs were 0.879, 0.928, and 0.923, respectively. A significant increase in AUC was observed when PDIP-SOS was added to the MRA protocol (p = 0.0266). Quantification of calcification showed significant differences between PDIP-SOS and NCCT (80.6 ± 31.2 mm3 vs. 88.0 ± 29.8 mm3; p = 0.0002) with high correlation (r = 0.77, p < 0.0001) and moderate mean of differences (- 7.4 mm3). CONCLUSION: QISS MRA combined with PDIP-SOS MRI provides improved, CTA equivalent, accuracy for the detection of PAD, although its image quality remains inferior to CTA. KEY POINTS: • Agreement in stenosis detection rate using non-contrast quiescent-interval slice-selective MRA compared to DSA improved when calcification visualization was provided to the readers. • An increase was observed in both sensitivity and specificity for the detection of ≥ 50% stenosis when MRI-based calcification assessment was added to the protocol, resulting in a diagnostic accuracy more comparable to CTA. • Quantification of calcification showed statistical difference between MRI and non-contrast CT; however, a high correlation was observed between the techniques.

Diagnostic Accuracy of Noncontrast Self-navigated Free-breathing MR Angiography versus CT Angiography: A Prospective Study in Pediatric Patients with Suspected Anomalous Coronary Arteries.

RATIONALE AND OBJECTIVES: To evaluate the diagnostic accuracy of a prototype noncontrast, free-breathing, self-navigated 3D (SN3D) MR angiography (MRA) technique for the assessment of coronary artery anatomy in children with known or suspected coronary anomalies, using CT angiography (CTA) as the reference standard. MATERIALS AND METHODS: Twenty-one children (15 male, 12.3 ± 2.6 years) were prospectively enrolled between July 2014 and August 2016 in this IRB-approved, HIPAA-compliant study. Patients underwent same-day unenhanced SN3D-MRA and contrast-enhanced CTA. Two observers rated the visualization of coronary artery segments and diagnostic confidence on a 3-point scale and assessed coronary arteries for anomalous origin, as well as interarterial and intramural course. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of SN3D-MRA for the detection of coronary artery abnormalities were calculated. Interobserver agreement was assessed using Intraclass Correlation Coefficients (ICC). RESULTS: Fourteen children showed coronary artery abnormalities on CTA. The visualization of coronary segments was rated significantly higher for CTA compared to MRA (p <0.015), except for the left main coronary artery (p = 0.301), with good to excellent interobserver agreement (ICC = 0.62-0.94). Diagnostic confidence was higher for CTA (p = 0.046). Sensitivity, specificity, PPV, and NPV of MRA were 92%, 92%, 96%, and 87% for the detection of coronary artery anomalies, 85%, 85%, 74%, and 92% for high origin, 71%, 92%, 82%, and 87% for interarterial, and 41%, 96%, 87%, and 80% for intramural course. CONCLUSIONS: Noncontrast SN3D-MRA is highly accurate for the detection of coronary artery anomalies in pediatric patients while diagnostic confidence and coronary artery visualization remain superior with CTA.