Variable exposure to echocardiography core competencies when applying minimum recommended procedural numbers for cardiology fellows in training.

BACKGROUND: The American College of Cardiology Core Cardiovascular Training Statement (COCATS) defined echocardiography core competencies and set the minimum recommend number of echocardiograms to perform (150) and interpret (300) for independent practice in echocardiography (level 2 training). Fellows may lack exposure to key pathologies that are relatively infrequent, however, even when achieving an adequate number of studies performed and interpreted. We hypothesized that cardiology fellows would lack exposure to 1 or more cardiac pathologies related to core competencies in COCATS when performing and interpreting the minimum recommend number of studies for level 2 training. METHODS: We retrospectively reviewed 11,250 reports from consecutive echocardiograms interpreted (7,500) and performed (3,750) by 25 cardiology fellows at a University tertiary referral hospital who graduated between 2015 and 2019. The first 300 echocardiograms interpreted and the first 150 echocardiograms performed by each fellow were included in the analysis. Echocardiography reports were reviewed for cardiac pathologies relating to core competencies defined in COCATS. RESULTS: All 25 fellows lacked exposure to 1 or more cardiac pathologies related to echocardiography core competencies despite meeting COCATS minimum recommended numbers for echocardiograms performed and interpreted. Pathologies for which 1 or more fellows encountered 0 cases despite meeting the minimum recommended numbers for both echocardiograms performed and interpreted included: pericardial constriction (16/25 fellows), aortic dissection (15/25 fellows), pericardial tamponade (4/25 fellows), valvular mass/thrombus (2/25 fellows), prosthetic valve dysfunction (1/25 fellows), and cardiac chamber mass/thrombus (1/25 fellows). CONCLUSIONS: Cardiology fellows who completed the minimum recommend number of echocardiograms performed and interpreted for COCATS level 2 training frequently lacked exposure to cardiac pathologies, even in a University tertiary referral hospital setting. These data suggest that fellowship programs should monitor pathology case counts for each fellow in training, in addition to the minimum recommend number of echocardiograms defined by COCATS, to ensure competency for independent practice in echocardiography.

The CADILLAC risk score accurately identifies patients at low risk for in-hospital mortality and adverse cardiovascular events following ST elevation myocardial infarction.

BACKGROUND: The CADILLAC risk score was developed to identify patients at low risk for adverse cardiovascular events following ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI). METHODS: We performed a single center retrospective review of STEMI hospitalizations treated with PPCI from 2014 to 2018. Patients were stratified using the CADILLAC risk score into low risk, intermediate risk and high risk groups. Patients presenting with cardiac arrest or cardiogenic shock were excluded from the study. The primary outcome was adverse clinical events during initial hospitalization. Secondary outcomes were adverse clinical events at 30 days and 1 year following index hospitalization. RESULTS: The study included 341 patients. Compared to patients with a low CADILLAC score, adverse clinical events were similar in the intermediate risk group during hospitalization (OR 1.23, CI 0.37-4.05, p 0.733) and at 30 days (OR 2.27, CI 0.93-5.56, p 0.0733) while adverse clinical events were significantly elevated in the high risk group during hospitalization (OR 4.75, CI 1.91-11.84, p 0.0008) and at 30 days (OR 8.73, CI 4.02-18.96, p < 0.0001). At 1 year follow-up, compared to the low risk CADILLAC group (9.4% adverse clinical event rate), cumulative adverse clinical events were significantly higher in the intermediate risk group (22.9% event rate, OR 2.86, CI 1.39-5.89, p 0.0044) and in the elevated risk group (58.6% event rate, OR 13.67, CI 6.81-27.43, p < 0.0001). The mortality rate was 0% for patients defined at low risk by CADILLAC score during hospitalization, as well up to 1 year follow up. On receiver operating curve analysis, discrimination of in-hospital adverse clinical events was fair using CADILLAC (C = 0.66, odds ratio 1.18; 95% CI 1.04-1.33; p = 0.0064) with somewhat better discrimination at 30-day follow-up (C = 0.719) and 1-year follow-up (C = 0.715). CONCLUSION: Patients defined as low risk by the CADILLAC score following a STEMI were associated with lower mortality and adverse clinical event rates during hospitalization and up to 1 year following STEMI when compared to those with an intermediate or high CADILLAC score.

Frequency and Predictors of Preoperative Cardiac Testing Overuse in Low-Risk Patients Before Laparoscopic Bariatric Surgery.

Adverse cardiac events after laparoscopic bariatric surgery are rare, yet preoperative cardiology evaluation and testing remain common, resulting in the overuse of cardiac testing in low-risk patients. Our objective was to assess the frequency of, and factors associated with, overuse of preoperative cardiac testing in patients at low cardiac risk before laparoscopic bariatric surgery. We retrospectively reviewed data from 1,094 adult patients who underwent laparoscopic bariatric surgery at our institution from January 1, 2015, through December 31, 2019. The cardiac risk was determined using the Revised Cardiac Risk Index (RCRI) and the National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest (NSQIP MICA) risk model. Multivariate logistic regression was used to evaluate risk factors associated with the overuse of cardiac testing in low-risk patients. Overall, 1,059 patients (96.8%) were estimated to be at low cardiac risk by the RCRI, and 1,094 (100%) were at low cardiac risk by NSQIP MICA. A total of 587 patients (51.8%) were referred to cardiology for preoperative evaluation, and 643 patients (56.7%) underwent one or more preoperative cardiac tests. Factors associated with overuse of preoperative cardiac testing in low-risk patients included preoperative cardiology referral (adjusted odds ratio 37.2, 95% confidence interval 25.3 to 54.7) and patient age (adjusted odds ratio 1.05, 95% confidence interval 1.03 to 1.07). Overuse of preoperative cardiac testing was common in patients at low cardiac risk before laparoscopic bariatric surgery. Preoperative referral to cardiology was the most significant risk factor associated with the overuse of preoperative cardiac testing. Application of risk models such as the RCRI or NSQIP MICA at the time of bariatric program enrollment may reduce unnecessary preoperative cardiac testing in low-risk patients.

Reevaluating the Cardiac Risk of Noncardiac Surgery Using the National Surgical Quality Improvement Program.

BACKGROUND: As surgical techniques evolve and patient outcomes improve over time, a renewed analysis of the cardiac risk of noncardiac surgeries is needed. The goal of this study was to investigate and categorize the cardiac risk of elective noncardiac surgeries. METHODS: This was a cohort study of surgical data and outcomes from the 2018 National Surgical Quality Improvement Program Participant Use Data File; 807,413 cases were analyzed after excluding non-elective, emergent, and cardiac surgeries. Postoperative major adverse cardiac events (MACE) were defined as 30-day all-cause mortality, myocardial infarction, or cardiac arrest. According to their 95% confidence intervals (CI) for postoperative MACE, surgeries were categorized as low risk (95% CI <1%), intermediate risk (95% CI above and below 1%), or elevated risk (95% CI ≥1%). Multivariable logistic regression analyses were performed to determine differences in the odds for postoperative MACE for the intermediate- and elevated-risk categories relative to the low-risk category while controlling for several risk factors of prognostic importance. RESULTS: Postoperative MACE occurred in 4047/807,413 cases (0.50%), including in 1708/667,735 (0.26%) of the low-risk category, in 516/53,499 (0.96%) of the intermediate-risk category, and in 1823/86,179 (2.12%) of the elevated-risk category. The elevated-risk category accounted for 10.7% of total procedures and 45.1% of total postoperative MACE. Compared with the low-risk category, the multivariable adjusted risk of postoperative MACE was increased in the intermediate-risk category (adjusted odds ratio 2.35; 95% CI, 2.12-2.62) and the elevated-risk category (adjusted odds ratio 3.15; 95% CI, 2.92-3.39). CONCLUSION: Categorization of noncardiac surgeries according to cardiac risk may help to identify populations who are most likely to benefit from preoperative cardiac evaluation when indicated.

Safety of bariatric surgery in patients with coronary artery disease.

BACKGROUND: Patients with obesity and established coronary artery disease (CAD) may benefit from surgical weight loss; however, its safety is unknown in this population. OBJECTIVE: To assess the association between CAD and the incidence of 30-day postoperative mortality and major adverse cardiac events (MACEs) in patients undergoing bariatric surgery. SETTINGS: Multicenter cohort study. METHODS: We used the 2017 MBSAQIP database to study patients undergoing bariatric surgery from accredited centers in the United States and Canada between Jan 1, 2017, and Dec 31, 2017. Multivariate logistic regression was used to determine whether established CAD was independently associated with 30-day mortality and MACE, a composite endpoint that included myocardial infarction and/or cardiac arrest. RESULTS: We reviewed data from 167,819 patients from 832 centers. There were 4172 patients with diagnosed CAD, and 163,647 without it. At 30-day follow-up, the endpoints of mortality, cardiac arrest, myocardial infarction, and MACE occurred in 172 (.10%), 82 (.05%), 57 (.03%), and 135 (.08%) patients, respectively. The endpoints occurred more significantly in patients with CAD compared with patients without CAD; 22 (.53%) versus 150 (.09%) for mortality, 13 (.31%) versus 69 (.04%) for cardiac arrest, 17 (.41%) versus 40 (.02%) for myocardial infarction, and 28 (.67%) versus 107 (.07%) for MACE (P < .001 for all comparisons). CONCLUSIONS: Postoperative mortality and MACE following bariatric surgery are higher in patients with CAD than those without; however, the absolute incidence is low (<1%). The decision to pursue bariatric surgery and/or preoperative cardiac testing in patients with CAD should include consideration of the overall incidence of adverse cardiac outcomes and the stability of CAD.

Juvenile Active Ossifying Fibroma.

A case of juvenile active ossifying fibroma affecting a 27 year-old man will be discussed. The characteristic radiologic and histologic features of the entity will be described.

Cholestatic liver injury associated with dietary supplements: a report of five cases in active duty service members.

The use of dietary supplements (DS) is common in the active duty population, often without physician knowledge or approval. DS have been associated with drug-induced liver injury, with rare cases resulting in liver failure or death. We report five cases of transient drug-induced liver injury temporally associated with the use of a total of six DS in active duty service members. All patients presented with elevated serum bilirubin and liver-associated enzymes: three patients had a cholestatic liver enzyme pattern, one had a hepatocellular pattern, and one had a mixed pattern. In all cases, percutaneous needle core biopsies of the liver were obtained and demonstrated a cholestatic pattern of injury with variable periportal fibrosis. Causality was considered highly probable for three cases, probable for one case, and possible for one case. Hepatotoxicity has been previously associated with four of the supplements in our cases. For the two remaining supplements, C4 Extreme and Animal Stak, we are unaware of any previous reports of hepatotoxicity. Health care professionals, in particular military physicians, should be aware of the potential risk of these supplements and be prepared to discuss these risks with their patients.