Dearth of electrophysiology fellows: perspectives from cardiology fellows-in-training.

BACKGROUND: Over the last 6 years, there has been a high percentage of unfilled cardiac electrophysiology (EP) training spots each year. The authors aimed to investigate potential explanations for the unfilled positions based on a survey from the current Fellows-In-Training (FITs). METHODS: An attempt was made to reach the current cardiology FITs across all programs of the U.S. via email. An anonymous questionnaire was created consisting of 14 questions. Questions posed were regarding factors affecting each participant's interest in or lack of pursuing an EP fellowship. Descriptive statistics of the responses were performed. RESULTS: A total of 26% (35/134) respondents expressed their interest in applying to an EP fellowship. The most common reasons to apply to EP were: Interest in EP, procedural specialty, and work-life balance. Of the 99 respondents that were not applying to EP, the most common reasons not to apply were: Less interest in EP, two-year training duration, and complexity of the specialty. The top reasons for the fellows to believe there is a dearth of EP FITs were: two-year training duration, lack of interest in EP, and the complexity of the specialty. The changes that would encourage EP fellowship interest were: More exposure to EP training during general cardiology fellowship, shortening the EP training duration, and having more information available regarding employment opportunities. CONCLUSION: The study was able to identify factors responsible for vacancies in EP fellowship positions from the view of current cardiology FITs. Stakeholders at the national level involved in framing policies related to fellowship education would be able to utilize this information to address the shortage of EP FITs and increase recruitment to EP fellowships.

An Incidental Case of a Rare Ventricular Septal Defect (VSD): Does Infective Endocarditis Ger-Bode Well?

The Gerbode defect is a rare ventricular septal defect (VSD) between the left ventricle (LV) and right atrium (RA). We describe a challenging case of a rare acquired Gerbode defect from infective endocarditis. A 73-year-old male presented for left lower extremity edema and shortness of breath with exertion. He was discharged from the hospital one week prior after being diagnosed with right hip septic arthritis. A transthoracic echocardiogram (TTE) did not demonstrate an abscess or vegetation, but was significant for severely elevated tricuspid regurgitation velocity and pulmonary artery (PA) systolic pressure of 70 mm Hg without structural changes to the right ventricle or RA. A transesophageal echocardiogram (TEE) was performed due to these abnormal values and demonstrated a VSD between the LV and RA. This type of defect is known as a Gerbode defect, which is suggestive of an aortic root abscess. The patient ultimately was transferred to a tertiary care center, and the Gerbode defect with aortic root abscess was confirmed by direct visualization. This case reports a unique case of an acquired Gerbode defect secondary to infective endocarditis. Our patient's defect was noted to be above the tricuspid valve, which essentially confirmed the etiology as a VSD. Although the TEE did not demonstrate a clear aortic root abscess, direct visualization during the surgical intervention confirmed this suspicion. Prompt diagnosis of the Gerbode defect allowed the patient to receive urgent surgical intervention. Gerbode defects are rare but clinically important complications of infective endocarditis. This case highlights the importance of maintaining a high level of suspicion, especially if the values obtained during TTE do not fully explain a patient's clinical presentation. A high level of suspicion leading to a timely diagnosis of this condition is essential in preventing further valvular destruction and allowing prompt surgical intervention.

Unmasking a Silent Threat: Office-Based Diagnosis of an Ascending Aortic Dissection With Transthoracic Echocardiography.

Type A aortic dissection (TAAD) is a potentially life-threatening diagnosis that can present with elusive symptomatology. A high degree of clinical suspicion is necessary for prompt diagnosis and management. We describe a case of a transthoracic echo (TTE) in a non-suspicious clinic patient diagnosed with TAAD. A 66-year-old Caucasian male presented for a routine clinic visit with one episode of acute severe chest pain. An echocardiogram was ordered for further workup of hypertension and chest discomfort. The echocardiogram demonstrated an ejection fraction of 60% without significant valvular abnormalities. There was suspicion of aortic pathology, which required multiple attending to review the images. The final interpretation was TAAD with a thrombus present in the false lumen. The patient then presented to the Emergency Department. A computed tomographic angiography was performed, which subsequently confirmed the TAAD. The patient was admitted to the cardiovascular ICU and ultimately underwent a successful repair of the dissection. The patient had an unremarkable post-operative course and was ultimately discharged home. Our case demonstrated a diagnosis of TAAD by office-based TTE as the original imaging modality. While this was unconventional, a TAAD should remain on the differential diagnosis when being ordered for the patient's with uncontrolled hypertension with chest pain as a presenting symptom.

A Case of STEMI-Induced Euglycemic Diabetic Ketoacidosis in a Patient Receiving a Sodium Glucose Cotransporter-2 Inhibitor.

A 54-year-old female on sodium glucose cotransporter-2 inhibitor presented with ST-segment elevation myocardial infarction, nausea, and vomiting. Percutaneous intervention was performed to the right coronary artery. The chest pain resolved, but she continued to experience nausea and vomiting. Euglycemic diabetic ketoacidosis was diagnosed secondary to the ST-segment elevation myocardial infarction. After treatment for euglycemic diabetic ketoacidosis, her nausea and vomiting had resolved. (Level of Difficulty: Beginner.).

Mobile Atheroma in the Left Internal Carotid Artery: A Case of Impending Doom!

A 69-year-old male presented for evaluation of a carotid bruit. Carotid ultrasound demonstrated the unique finding of a large, highly mobile atheroma in the proximal left internal carotid artery. The presence of a mobile atheroma confers an even higher risk of stroke, so this presentation posed a dilemma in terms of endovascular versus open surgical management strategies. In patients with carotid artery disease, the risk of stroke is related to plaque rupture and distal embolization. The patient underwent successful carotid stenting without periprocedural complications. Our case reports the unusual occurrence of a highly mobile atheroma as the initial presentation of carotid artery disease treated safely with percutaneous carotid artery stenting.

Self-Induced Euglycemic Diabetic Ketoacidosis: When to Stop the Drip.

Diabetic ketoacidosis (DKA) is a well-known, serious complication that many patients with type 1 and 2 diabetes face due to either a relative or absolute insulin deficiency. Sodium-glucose cotransporter 2 (SGLT-2) inhibitors have gained increased popularity due to their diabetic, cardiovascular, and renal benefits. An associated complication of SGLT2 inhibitors is euglycemic DKA. A 56-year-old male with a history of type 2 diabetes mellitus and peripheral neuropathy presented with right foot pain secondary to a diabetic foot ulcer. The ulcer was present for one year, but the patient noticed increased pain and purulent discharge over the three days prior to presentation. While being treated inpatient for the foot ulcers, the patient repeatedly refused to receive standard hospital diabetes management of insulin injections. He instead insisted to take his home medications against medical advice, which were metformin and Glyxambi® (empagliflozin/linagliptin, Boehringer Ingelheim, Ingelheim am Rhein, Germany). His diabetic foot ulcer was medically managed with IV antibiotics.  On day 4 of admission, his anion gap increased to 23 mEq/L, and serum bicarbonate (CO2) decreased to 8 mEq/L, raising concerns of diabetic ketoacidosis. His glucose was 141 mg/dL, his beta-hydroxybutyrate was high at 5.5 mmol/L. An arterial blood gas (ABG) test demonstrated anion gap metabolic acidosis with secondary respiratory alkalosis. A urinalysis demonstrated glucose 1000 mg/dL and ketones of 150 mg/dL. The patient was diagnosed with euglycemic DKA. Due to the patient having normal glucose levels, an insulin drip and a 5% dextrose with 0.45% normal saline drip were started. Basic metabolic profiles were ordered every four hours, with glucose checks every hour. Once the anion gap was closed and his urinary ketones disappeared, the patient transitioned to subcutaneous insulin. He was able to be discharged home with basal subcutaneous insulin and metformin with instructions to avoid SGLT2 inhibitors in the future.  Unfortunately, there are currently no guidelines from endocrinology or internal medicine societies regarding the management of euglycemic DKA. As the typical DKA diagnostic criteria of elevated blood glucose level are not present, it is easy to overlook euglycemic DKA. As these SGLT2 inhibitors become more prevalent, careful monitoring of all potential side effects as well as the contraindications are prudent to successful management of complex disease states.

Evaluating the Appropriateness of Pulmonary Embolism Admissions in a Community Hospital Emergency Department.

Pulmonary embolism (PE) is a diagnosis on the broader spectrum of venous thromboembolic (VTE) disease. The diagnostic key for clinicians is detecting which patients have a "high risk" of complications or mortality and who are in the "low-risk" population. The Pulmonary Embolism Severity Index (PESI) and HESTIA scores are validated risk stratification tools to determine if patients diagnosed with PE can be successfully managed in the outpatient versus inpatient setting. We aimed to investigate the appropriateness of PE admissions to our institution based on the risk stratification recommendations from PESI and HESTIA scores. We retrospectively identified 175 patients admitted with a diagnosis of PE over one year at our hospital. Baseline demographics, length of admission, and admitting diagnoses were collected for all patients included in this study. PESI and HESTIA scores were then calculated for all included patients. The average PESI score was 91.65 (95% confidence interval: 86.33, 96.97). There were 87 patients (49.7%) that had a low or very low PESI score of fewer than 85 points. Fifty-seven patients (33.7%) presented with a HESTIA score of 0. The risk stratification score indicates these patients as low risk, and appropriate for outpatient management. However, they were instead admitted to the hospital which contributes to increased costs, risk of adverse events, etc. There were 0 mortalities reported for patients in the "low or very low risk" groups, with four reported mortalities in the "very high risk" groups.  In our cohort, 33.7%-49.7% of admissions for PE were risk-stratified as "low risk" and qualified for outpatient management based on HESTIA and PESI risk stratification scores, respectively. The underutilization of validated risk scores upon initial diagnosis of PE may lead to worse outcomes and increased healthcare expenditure.

Assessing the Impact of Intensified Hypertension (HTN) Treatment Guidelines: A Single Center Experience.

INTRODUCTION:  Hypertension (HTN) is an independent risk factor for heart disease, stroke, and premature death. In 2017 there was a shift in the definition of HTN by the American College of Cardiology (ACC), as well as the American Heart Association (ACC/AHA), resulting in lower blood pressure (BP) readings meeting criteria for diagnosis. Our study aimed to explore the impact the change had on a single cardiology practice's management of patients with HTN. METHODS: We performed a retrospective chart review of a single cardiology practice. We separated the time into two categories: 12 months before and 12 months after the reclassification of HTN categories in November 2017. A paired t-test analysis was done comparing averaged blood pressures (BPs) in each of the two time periods, as well as the number of medications in each time period and several subgroup analyses. RESULTS: A total of 441 patients were included in the final analysis. Patients were prescribed an average of 2.61 ± 1.20 medications at baseline, and 2.74 ± 1.22 medications post-reclassification (p < 0.0001). There was an average of 0.82 ± 1.28 medication changes per patient. The overall average BP was 133.7 ± 14.1/76.4 ± 9.5 at baseline, and 131.3 ± 13.1/76.7 ± 7.7 after the recategorization [Δ -2.41 (95% CI 1.18-3.63)/0.269 (95% CI -0.29 to 0.459); p<0.0001 for systolic blood pressure (SBP), p=0.467 for diastolic blood pressure (DBP)]. CONCLUSION: The change in definition of HTN significantly impacted this single cardiology practice. There was a statistically significant increase in antihypertensive medications prescribed with an expected decrease in BP observed in this study.

Burnout of Support Personnel in the Cardiac Catheterization Laboratory.

Background: Healthcare professionals experience stressors in the workplace, putting them at elevated risk for burnout. The cardiac catheterization lab is a dynamic environment with high-acuity patients; however, little has been published investigating burnout syndrome among healthcare workers. The aim of the study was to identify the prevalence, demographic, and workload factors, which contribute to burnout syndrome among this population. Methods: This is a multicenter cross-sectional study assessing burnout with the Maslach Burnout Inventory (MBI) among registered nurses and registered cardiac invasive specialists working in the catheterization/electrophysiology lab and cardiac observation unit at four hospital centers in the metro Detroit area. Results: Of the 48 participants, 69% (n = 33) were female. The overall prevalence of burnout syndrome was 33% (n = 16). Significantly more males experienced burnout than females (P < 0.05). Of the participants experiencing burnout, a greater proportion worked in the catheterization lab compared to the cardiac observation unit (93.8% vs. 6.3%). Burned-out participants worked on average more day shifts, ST-segment elevation myocardial infarction (STEMI) call shifts, and extended day shifts per month compared to those not experiencing burnout. The rate of burnout was significantly higher for individuals reporting increased stress during the pandemic (69% vs. 18%, P < 0.05). Conclusions: Registered nurses and registered cardiac invasive specialists working in the cardiac catheterization or electrophysiology lab experience elevated levels of burnout. Greater attention should be placed in identifying and optimizing workplace variables which contribute to burnout among this population.

Treatment of hypertriglyceridemia with fibric acid derivatives: impact on lipid subfractions and translation into a reduction in cardiovascular events.

This review investigates how the treatment of hypertriglyceridemia with fibric acid derivatives impacts lipid concentrations, lipid particle size, and the rate of cardiovascular events: expressly, to decide whether the use of fibric acid derivatives is an effective treatment option in the reduction of cardiovascular endpoints for patients with specific lipid parameters at baseline. Fibric acid derivatives reduce fasting triglyceride (TG) values by 15% to 50% (depending on baseline level) and low-density lipoprotein cholesterol (LDL-C) by 8%, and raise high-density lipoprotein cholesterol (HDL-C) by 9%. In conjunction with a statin, the amount of TG lowering is approximately doubled with the addition of the fibrate. When measured, fibrates decrease the TG concentration of very low-density lipoprotein cholesterol particles while increasing the TG content of LDL particles. The mean size of LDL particles increases and there is a substantial reduction in the number and proportion of small, dense LDL. In randomized trials in primary and secondary prevention populations, fibrates were associated with a significant reduction in nonfatal myocardial infarction in most studies. In the subgroup with elevated TG and/or depressed HDL-C at baseline, all trials have found statistically significant relative risk reductions of 27% to 65% in the primary cardiovascular endpoint of myocardial infarction and cardiovascular death.

Successful Medical Management of an Acute Ascending Aortic Dissection After Coronary Artery Bypass Graft Surgery.

Aortic dissection is an acute and life-threatening disease entity. Mortality rates increase every hour after the presentation. Typical treatment includes medical management of blood pressure and heart rate control followed by prompt transfer to an operating room for surgical repair. We present a case of medically managed Stanford type A aortic dissection in a postoperative coronary artery bypass graft (CABG) patient. A 77-year-old man with a past medical history of hypertension and hyperlipidemia presented after an outpatient nuclear stress test demonstrated a reversible inferior wall defect. He was subsequently referred to a cardio-thoracic surgeon and underwent coronary artery bypass graft (CABG) surgery. Three weeks later, the patient presented to the emergency department complaining of a productive cough, nausea, vomiting, and fever. He was diagnosed with sepsis secondary to pneumonia. A CT chest demonstrated a new 3.9 cm long segment of dissection in the ascending thoracic aorta. Due to postoperative recovery from recent CABG, a decision was made to treat the ascending thoracic aortic dissection (Stanford type A) medically. He was advised to continue intensive antihypertensive medications and close follow-up with a cardiologist and cardiothoracic surgeon on an outpatient basis. Subsequent follow-up CT chest angiography at one month, four months, and 12 months later did not demonstrate the progression of the ascending aortic dissection. Decisions to deviate from the usual care should best be taken in a multidisciplinary team approach. Patients should clearly be informed about the rationale behind these complex decisions.

Urban vs Suburban: Is the Door-to-Balloon Time Affected by Geographic, Socioeconomic, or Racial Differences? A Tale of Two Campuses.

BACKGROUND: In 2004, the ACC/AHA released guidelines in the treatment of ST-segment elevation myocardial infarction (STEMI) within a time window from the time a patient physically enters the hospital to the time of percutaneous coronary intervention (PCI). This time window is defined as the door-to-balloon time (DTB) and is recommended to be under 90 minutes to improve patient mortality. To add another layer of complexity, patients with varying socioeconomic status and racial differences experience large disparities in health. Our institution provides care for patients in two locations separated by approximately 30 miles within the Detroit metropolitan area. We aimed this study to investigate any differences between DTB times of our two campuses (urban versus suburban population) as well as any differences in the components that comprise DTB times. METHODS: We retrospectively collected data on all patients who presented to either Campus 1 or Campus 2 with a STEMI from 2016 to 17. DTB times, demographical, temporal, and anatomical data were collected and analyzed. Our search included 169 patients who met the full inclusion criteria. RESULTS: The combined average of the overall DTB time for both campuses was 81 minutes, 15 seconds (95% CI: 78:05, 84:25). The average DTB time in Campus 1 was 78 minutes and 41 seconds (95% CI: 73:05, 84:18) versus 82 minutes and 46 seconds (95% CI: 78:55, 86:38) for Campus 2 (p=0.24). There were no statistically significant differences between either campuses within the separate metrics that comprise DTB times. CONCLUSIONS: Our study demonstrated that we have been able to provide high-quality care to all of our patients presenting with STEMI at either campus, regardless of socioeconomic differences in the populations they serve. Additionally, each campus has demonstrated DTB well below the nationally recommended guidelines.

The Burden of Unnecessary Testing From a Regularly Ordered Laboratory Assay: Age-Adjusted d-Dimer Quality Improvement Study.

Diagnosing acute pulmonary embolism (PE) involves clinical suspicion in combination with sequential diagnostic tests including d-dimer laboratory assays. Although the sensitivity of this assay is well validated and thoroughly tested, a false-positive result can lead to unnecessary and costly testing. The age-adjusted d-dimer (AADD) has been suggested in the literature to improve the usefulness of d-dimer cutoffs and safely decrease iodine and radiation exposure associated with definitively ruling out PE with computed tomographic angiography (CTA).1 We present an internal retrospective review utilizing the novel AADD cutoff to rule out PE and evaluate the potential extent of unnecessary testing with CTA. Using the AADD cutoff would have led to a 21.2% reduction in computerized tomography pulmonary embolus protocol. This internal quality improvement study suggests that changing our institutional conventional d-dimer to the novel AADD would provide a superior quality and cost-benefit.

Is there still a role for renal artery stenting in the management of renovascular hypertension - A single-center experience and where do we stand?

BACKGROUND: Renal artery (RA) stenosis has been implicated in the pathophysiological mechanism for resistant hypertension. Despite the increasingly diagnosed frequency of hemodynamically significant lesions, the value of RA revascularization remains controversial. Our group had previously demonstrated significant blood pressure (BP) reduction in a retrospective cohort of appropriately selected patients undergoing RA stenting up to 18-months of follow-up. We herein present long-term clinical outcomes data 5-years post revascularization on 26 subjects who continued follow-up at our institution. METHODS: Retrospective analysis was performed on subjects who underwent RA stenting at our institution for hemodynamically significant (≥70%) RA stenosis and systolic hypertension on ≥3 antihypertensive agents. Clinical outcome data for systolic blood pressure (SBP), diastolic blood pressure (DBP), creatinine level and number of antihypertensive drugs was assessed prior to and then later at 6-12 months and 3-5 years post RA stenting. RESULTS: Mean age was 69 ±â€¯9 years; 27% (7/26) were male. Median follow-up was 5.1 years. Blood pressure reduction was sustained at long-term follow-up (135/70 ±â€¯18/11 mmHg) compared to initial reduction noted at 6-months (136/69 ±â€¯16/8 mmHg; p ≤0.01 for both) and from baseline (162/80 ±â€¯24/18 mmHg; p ≤0.001 for both). The number of antihypertensive agents also decreased from 4.1 ±â€¯1.0 to 2.7 ±â€¯2.1 (p = 0.002) at 6-months and was sustained at long-term follow-up, 3.4 ±â€¯1.2 (p = 0.03) with no difference in renal function between short- and long-term follow-up compared to baseline. CONCLUSIONS: This study shows sustained benefit of RA stenting in BP reduction in an appropriately selected cohort with significant stenosis ≥70% and uncontrolled hypertension on multiple medications on long-term follow-up.

Modelling the Functional Comorbidity Index as a predictor of health-related quality of life in patients with glenoid labrum disorders.

BACKGROUND/AIM: Health-related quality of life (HRQoL) is increasingly assessed within orthopaedic research. For those patients presenting with glenoid labral pathologies, there is little information on how baseline comorbidities affect long-term outcomes and HRQoL. This study aimed to investigate a model, including baseline comorbidities and demographics, to predict change in 2-year HRQoL scores in adult patients with glenoid labral tears or degenerations. METHODS: Participants provided Functional Comorbidity Index (FCI) scores and self-completed the Western Ontario Rotator Cuff (WORC) index at 6, 12 and 24 months. Univariable and multivariable linear regressions were performed to assess predictive quality of baseline comorbidities and demographics on the primary outcome measure of interest (change in WORC score). RESULTS: Multivariate regression with a continuous scaled FCI (ß=617.8, p=0.042), age (by decade) (ß=297, p<0.01), surgical group (ß=-476.69, p<0.01) and an interaction term between FCI and age (ß=-103.65, p=0.03) were significant predictors of change in WORC scores at 2-year follow-up (r2=0.293858). Multivariate regression with FCI scaled categorically reported only patients with three comorbidities (ß=-454.06, p=0.057) and age (by decade) (ß=156.87, p=0.04) as the only significant predictors of change in WORC scores at 2-year follow-up (r2=0.1279). CONCLUSION: The continuous FCI model is better suited to predict future WORC and HRQoL scores among this patient population. Patients reporting with higher numbers of baseline comorbidities improved significantly more than patients with fewer comorbidities. This information on expected change in HRQoL scores among patients with a wide range of FCI scores at baseline may help guide treatment decisions based on these criteria.

Outcomes in patients with glenoid labral lesions: a cohort study.

BACKGROUND/AIM: For patients presenting with glenoid labral pathologies, there is little information on how operative interventions affect long-term outcomes and health-related quality of life (HRQoL). This study evaluated outcomes in operative and non-operative patients presenting with labral tears versus labral degenerations. METHODS: Participants completed a pain Visual Analogue Scale (VAS), the Veterans RAND 12-item Health Survey, Western Ontario Rotator Cuff Index, American Shoulder and Elbow Surgeons instrument, Scapular Assistance Test (SAT), Shoulder Activity Level, and Single Assessment Numeric Evaluation at baseline and at 6-month, 12-month and 2-year follow-ups. χ2and Student's t-test were used to test the differences between categorical and continuous variables. Analysis of variance investigated the differences between groups, and linear regression analyses explored the relationship of baseline characteristics with outcome scores. RESULTS: After 2 years, the operative cohort (n=68) significantly improved in all measures. The non-operative cohort (n=55) showed significant improvements in all scores except the mental component summary (MCS) and pain VAS. Labral tear patients (n=52) within the operative group (n=28) significantly improved in all measures except MCS. Non-operative labral tear patients (n=24) indicated significant improvements in all measures except MCS, VAS and SAT. Labral degeneration patients (n=71) within the operative group (n=27) significantly improved in all measures except MCS and SAT. Non-operative labral degeneration patients (n=44) indicated significant improvements in all measures except the physical component summary, MCS, VAS and SAT. CONCLUSION: Patients who were surgically treated for labral tears or degenerations had significantly improved outcomes and HRQoL scores after 2 years compared with the non-operative cohort.