Myeloperoxidase Inhibition in Heart Failure With Preserved or Mildly Reduced Ejection Fraction: SATELLITE Trial Results.

BACKGROUND: Inflammation is a key driver of heart failure with preserved left ventricular ejection fraction. AZD4831 inhibits extracellular myeloperoxidase, decreases inflammation, and improves microvascular function in preclinical disease models. METHODS AND RESULTS: In this double-blind phase 2a study (Safety and Tolerability Study of AZD4831 in Patients With Heart Failure [SATELLITE]; NCT03756285), patients with symptomatic heart failure, left ventricular ejection fraction of ≥40%, and elevated B-type natriuretic peptides were randomized 2:1 to once-daily oral AZD4831 5 mg or placebo for 90 days. We aimed to assess target engagement (primary end point: myeloperoxidase specific activity) and safety of AZD4831. Owing to coronavirus disease 2019, the study was terminated early after randomizing 41 patients (median age 74.0 years, 53.7% male). Myeloperoxidase activity was decreased by more than 50% from baseline to day 30 and day 90 in the AZD4831 group, with a placebo-adjusted decreased of 75% (95% confidence interval, 48, 88, nominal P < .001). No improvements were noted in secondary or exploratory end points, apart from a trend in Kansas City Cardiomyopathy Questionnaire overall summary score. No deaths or treatment-related serious adverse events occurred. AZD4831 treatment-related adverse events were generalized maculopapular rash, pruritus, and diarrhea (all n = 1). CONCLUSIONS: AZD4831 inhibited myeloperoxidase and was well tolerated in patients with heart failure and left ventricular ejection fraction of 40% or greater. Efficacy findings were exploratory owing to early termination, but warrant further clinical investigation of AZD4831. LAY SUMMARY: Few treatments are available for patients with the forms of heart failure known as heart failure with preserved or mildly reduced ejection fraction. Current treatments do not target inflammation, which may play an important role in this condition. We tested a new drug called AZD4831 (mitiperstat), which decreases inflammation by inhibiting the enzyme myeloperoxidase. Among the 41 patients in our clinical trial, AZD4831 had a good safety profile and inhibited myeloperoxidase by the expected amount. Results mean we can conduct further trials to see whether AZD4831 decreases the symptoms of heart failure and improves patients' ability to participate in physical exercise.

The DANish randomized, double-blind, placebo controlled trial in patients with chronic HEART failure (DANHEART): A 2 × 2 factorial trial of hydralazine-isosorbide dinitrate in patients with chronic heart failure (H-HeFT) and metformin in patients with chronic heart failure and diabetes or prediabetes (Met-HeFT).

OBJECTIVES: The DANHEART trial is a multicenter, randomized (1:1), parallel-group, double-blind, placebo-controlled study in chronic heart failure patients with reduced ejection fraction (HFrEF). This investigator driven study will include 1500 HFrEF patients and test in a 2 × 2 factorial design: 1) if hydralazine-isosorbide dinitrate reduces the incidence of death and hospitalization with worsening heart failure vs. placebo (H-HeFT) and 2) if metformin reduces the incidence of death, worsening heart failure, acute myocardial infarction, and stroke vs. placebo in patients with diabetes or prediabetes (Met-HeFT). METHODS: Symptomatic, optimally treated HFrEF patients with LVEF ≤40% are randomized to active vs. placebo treatment. Patients can be randomized in either both H-HeFT and Met-HeFT or to only one of these study arms. In this event-driven study, it is anticipated that 1300 patients should be included in H-HeFT and 1100 in Met-HeFT and followed for an average of 4 years. RESULTS: As of May 2020, 296 patients have been randomized at 20 centers in Denmark. CONCLUSION: The H-HeFT and Met-HeFT studies will yield new knowledge about the potential benefit and safety of 2 commonly prescribed drugs with limited randomized data in patients with HFrEF.

May Measurement Month 2018: an analysis of blood pressure screening from Kenya.

Hypertension (HTN) is highly prevalent and the leading cardiovascular risk factor for death globally. A large proportion of individuals with high blood pressure (BP) are unaware leading to under treatment and poor control. To address this, the International Society of Hypertension (ISH) initiated a global mass screening campaign, the May Measurement Month 2017 (MMM17), in which Kenya participated. Following the success of the campaign, its successor MMM18 was launched. Here, we present the Kenyan results for MMM18. Opportunistic screening of consenting adults was done in various sites across Kenya in May 2018, by volunteers trained using ISH material, under the co-ordination of the Kenya Cardiac Society. Blood pressure, pulse rate, weight, and height were measured by standard methods. Definitions of HTN and statistical methods all adhered to the standard MMM protocol. We screened 49 548 subjects, mean age 39.95 (15.3) years. In total, 49.4% had never had a BP measurement taken. After multiple imputation, 17.1% were hypertensive and of those who were hypertensive, 30.7% were aware, 26.6% were on antihypertensive treatment, and 13.0% had controlled BP. Alcohol use, excess weight, and treatment for HTN were associated with higher BP. The Kenyan MMM18 sites successfully screened more than three times the number screened in 2017, hence improving public awareness. Less than half the population had ever had a BP check. Less than a third of the hypertensives were aware with correspondingly poor treatment and control rates. Opportunistic mass screening is useful in raising public awareness.

May Measurement Month 2017: the results of blood pressure screening of 14 845 individuals in Kenya-Sub-Saharan Africa.

Elevated blood pressure (BP) is a growing burden worldwide leading to over 10 million deaths each year. Sub-Saharan Africa has the highest age-adjusted prevalence of hypertension. In Kenya, 24.5% of adults have elevated BP with lack of awareness being the main barrier to achieving satisfactory control rates. May Measurement Month (MMM17) is a global initiative aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programmes worldwide. An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2017. Screening was coordinated by the Kenya Cardiac Society in 17 sites across the country. Blood pressure measurements, the definition of hypertension and statistical analysis followed the standard MMM protocol. A total of 14 847 individuals were screened. After multiple imputation, 3647 (24.6%) had hypertension. Of individuals not receiving any antihypertensive medication, 2019 (15.3%) were hypertensive. Of individuals receiving antihypertensive medication, 740 (45.5%) had uncontrolled BP. Being diabetic and having a body mass index (BMI) ≥25 kg/m2 were associated with higher BP. Lack of awareness and poor control in those identified is a major challenge in Kenya. The MMM project demonstrated that mass screening for elevated BP is feasible, even in settings with limited resources. The presence of hypertension in a quarter of Kenyan adults with poor awareness and control rates demonstrates the need for programmes to raise awareness in the community.

Heart Failure in Late Pregnancy and Postpartum: Incidence and Long-Term Mortality in Sweden From 1997 to 2010.

BACKGROUND: Heart failure (HF) in late pregnancy and postpartum (HFPP), of which peripartum cardiomyopathy (PPCM) constitutes the larger part, is still a rare occurrence in Sweden. Population-based data are scarce. Our aim was to characterize HFPP and determine the incidence and mortality in a Swedish cohort. METHODS AND RESULTS: Through merging data from the National Inpatient, Cause of Death, and Medical Birth Registries, we identified ICD-10 codes for HF and cardiomyopathy within 3 months before delivery to 6 months postpartum. Each case was assigned 5 age-matched control subjects from the Medical Birth Registry. From 1997 to 2010, 241 unique HFPP case subjects and 1063 matched control subjects were identified. Mean incidence was 1 in 5719 deliveries. HFPP was strongly associated with preeclampsia (odds ratio [OR] 11.91, 95% confidence interval [CI] 7.86-18.06), obesity (OR 2.5, 95% CI 1.7-3.7), low- and middle-income country (LMIC) of origin (OR 1.73, 95% CI 1.14-2.63), and twin deliveries (OR 4.39 CI 95% 2.24-8.58). By the end of the study period deaths among cases were >35-fold those of controls: 9 cases (3.7 %) and 1 control (0.1 %; P < .0001). Among control subjects, 17.9% of mortalities occurred within 3 years, of diagnosis compared with 100% among cases. CONCLUSIONS: The mean incidence and mortality among women with HFPP in Sweden from 1997 to 2010 was low but carried a marked excess risk of death compared with control subjects and was strongly linked to preeclampsia, obesity, multifetal births, and LMIC origin of the mother.

Heart failure in young adults: 20-year trends in hospitalization, aetiology, and case fatality in Sweden.

AIMS: To describe trends in incidence and case fatality among younger (18-54 years) and older (55-84 years) Swedish patients with heart failure (HF). METHODS AND RESULTS: Through linking the Swedish national hospital discharge and the cause-specific death registries, we identified patients aged 18-84 years that were discharged 1987-2006 with a diagnosis of HF. Age-specific mean incidence rates per 100 000 person-years were calculated in four 5-year periods. Kaplan-Meier survival curves were plotted up to 3 years. From 1987 to 2006, there were 443 995 HF hospitalizations among adults 18-84 years. Of these, 4660 (1.0%) and 13 507 (3.0%) occurred in people aged 18-44 and 45-54 years (31.6% women), respectively. From the first to the last 5-year period, HF incidence increased by 50 and 43%, among people aged 18-34 and 35-44 years, respectively. Among people ≥45 years, incidence peaked in the mid-1990s and then decreased. Heart failure in the presence of cardiomyopathy increased more than two-fold among all age groups. Case fatality decreased for all age groups until 2001, after which no further significant decrease <55 years was observed. CONCLUSION: Increasing HF hospitalization in young adults in Sweden opposes the general trend seen in older patients, a finding which may reflect true epidemiological changes. Cardiomyopathy accounted for a substantial part of this increase. High case fatality and lack of further case fatality reduction after 2001 are causes for concern.

Thoracentesis to alleviate pleural effusion in acute heart failure: study protocol for the multicentre, open-label, randomised controlled TAP-IT trial.

INTRODUCTION: Pleural effusion is present in half of the patients hospitalised with acute heart failure. The condition is treated with diuretics and/or therapeutic thoracentesis for larger effusions. No evidence from randomised trials or guidelines supports thoracentesis to alleviate pleural effusion due to acute heart failure. The Thoracentesis to Alleviate cardiac Pleural effusion Interventional Trial (TAP-IT) will investigate if a strategy of referring patients with acute heart failure and pleural effusion to up-front thoracentesis by pleural pigtail catheter insertion in addition to pharmacological therapy compared with pharmacological therapy alone can increase the number of days the participants are alive and not hospitalised during the 90 days following randomisation. METHODS AND ANALYSIS: TAP-IT is a pragmatic, multicentre, open-label, randomised controlled trial aiming to include 126 adult patients with left ventricular ejection fraction ≤45% and a non-negligible pleural effusion due to heart failure. Participants will be randomised 1:1, stratified according to site and anticoagulant treatment, and assigned to referral to up-front ultrasound-guided pleural pigtail catheter thoracentesis in addition to standard pharmacological therapy or to standard pharmacological therapy only. Thoracentesis is performed according to local guidelines and can be performed in participants in the pharmacological treatment arm if their condition deteriorates or if no significant improvement is observed within 5 days. The primary endpoint is how many days participants are alive and not hospitalised within 90 days from randomisation and will be analysed in the intention-to-treat population. Key secondary outcomes include 90-day mortality, complications, readmissions, and quality of life. ETHICS AND DISSEMINATION: The study has been approved by the Capital Region of Denmark Scientific Ethical Committee (H-20060817) and Knowledge Center for Data Reviews (P-2021-149). All participants will sign an informed consent form. Enrolment began in August 2021. Regardless of the nature, results will be published in a peer-reviewed medical journal. TRIAL REGISTRATION NUMBER: NCT05017753.

Clinical course and therapy optimization of patients after discharge from a specialized heart failure clinic.

Aim: We aimed to describe the clinical course of patients with heart failure with reduced ejection fraction (HFrEF) after discharge from the heart failure clinics (HFC). Patients & methods: We reviewed the hospital's records of 610 patients that were discharged between 2013 and 2018 from the HFC at a single centre. Patients with no recurrent contact to ambulatory cardiac care were invited to an echocardiographic assessment. Results: Of the survivors, 72% were re-referred after discharge. Nearly 30% of the patients with no recurrent contact with ambulatory cardiac care had persistent HFrEF and further therapeutical optimizations were indicated in half of them. Conclusion: This highlights the importance to identify high-risk patients that would benefit from extended management in the HFC.

What is this summary about? In Denmark, it is standard practice to discharge patients with heart failure from heart failure clinics to primary care after achieving optimized guideline-directed medical therapy. However, little is known about their subsequent clinical course and whether their treatment could be further optimized. To answer that question, we reviewed the hospital's records of heart failure patients that were discharged between 2013 and 2018. What were the results? Of the 610 heart failure patients that were discharged from our clinic, 30% had died; 72% of the survivors were re-referred to cardiac clinics in the interim period. Nearly 30% of the patients with no recurrent contact with cardiac clinics had persistent heart failure and further therapeutical optimizations were indicated in half of them. What do the results mean? Deaths and re-referral to cardiac clinics accounted for the majority of the heart failure patients that were initially discharged; while further intervention was indicated in half of the stable patients that had no recurrent contact with cardiac ambulatory care. This highlights the challenges in identifying high-risk patients that would benefit from an extended management programme in the heart failure clinic and the importance of following up heart failure patients despite initial optimized therapy.

Myeloperoxidase Inhibition Reverses Biomarker Profiles Associated With Clinical Outcomes in HFpEF.

BACKGROUND: Systemic microvascular dysfunction and inflammation are postulated to play a pathophysiologic role in heart failure with preserved ejection fraction (HFpEF). OBJECTIVES: This study aimed to identify biomarker profiles associated with clinical outcomes in HFpEF and investigate how inhibition of the neutrophil-derived reactive oxygen species-producing enzyme, myeloperoxidase, affects these biomarkers. METHODS: Using supervised principal component analyses, the investigators assessed the associations between baseline plasma proteomic Olink biomarkers and clinical outcomes in 3 independent observational HFpEF cohorts (n = 86, n = 216, and n = 242). These profiles were then compared with the biomarker profiles discriminating patients treated with active drug vs placebo in SATELLITE (Safety and Tolerability Study of AZD4831 in Patients With Heart Failure), a double-blind randomized 3-month trial evaluating safety and tolerability of the myeloperoxidase inhibitor AZD4831 in HFpEF (n = 41). Pathophysiological pathways were inferred from the biomarker profiles by interrogation of the Ingenuity Knowledge Database. RESULTS: TNF-R1, TRAIL-R2, GDF15, U-PAR, and ADM were the top individual biomarkers associated with heart failure hospitalization or death, and FABP4, HGF, RARRES2, CSTB, and FGF23 were associated with lower functional capacity and poorer quality of life. AZD4831 downregulated many markers (most significantly CDCP1, PRELP, CX3CL1, LIFR, VSIG2). There was remarkable consistency among pathways associated with clinical outcomes in the observational HFpEF cohorts, the top canonical pathways being associated with tumor microenvironments, wound healing signaling, and cardiac hypertrophy signaling. These pathways were predicted to be downregulated in AZD4831 relative to placebo-treated patients. CONCLUSIONS: Biomarker pathways that were most strongly associated with clinical outcomes were also the ones reduced by AZD4831. These results support the further investigation of myeloperoxidase inhibition in HFpEF.

Sequencing and titrating approach of therapy in heart failure with reduced ejection fraction following the 2021 European Society of Cardiology guidelines: an international cardiology survey.

AIMS: In symptomatic patients with heart failure and reduced ejection fraction (HFrEF), recent international guidelines recommend initiating four major therapeutic classes rather than sequential initiation. It remains unclear how this change in guidelines is perceived by practicing cardiologists versus heart failure (HF) specialists. METHODS AND RESULTS: An independent academic web-based survey was designed by a group of HF specialists and posted by email and through various social networks to a broad community of cardiologists worldwide 1 year after the publication of the latest European HF guidelines. Overall, 615 cardiologists (38 [32-47] years old, 63% male) completed the survey, of which 58% were working in a university hospital and 26% were HF specialists. The threshold to define HFrEF was ≤40% for 61% of the physicians. Preferred drug prescription for the sequential approach was angiotensin-converting enzyme inhibitors or angiotensin receptor-neprilysin inhibitors first (74%), beta-blockers second (55%), mineralocorticoid receptor antagonists third (52%), and sodium-glucose cotransporter 2 inhibitors (53%) fourth. Eighty-four percent of participants felt that starting all four classes was feasible within the initial hospitalization, and 58% felt that titration is less important than introducing a new class. Age, status in training, and specialization in HF field were the principal characteristics that significantly impacted the answers. CONCLUSION: In a broad international cardiology community, the 'historical approach' to HFrEF therapies remains the preferred sequencing approach. However, accelerated introduction and uptitration are also major treatment goals. Strategy trials in treatment guidance are needed to further change practices.

Bleeding complications in patients on new oral anticoagulants for venous thromboembolism in Kenya.

BACKGROUND: The incidence of bleeding complications in patients with venous thromboembolism (VTE) on new oral anticoagulants (NOACs) has not been widely studied in contemporary clinical practice in Africa. The purpose of this study was to determine the rates of major bleeding, clinically relevant non-major bleeding (CRNM) and minor bleeding associated with NOAC use. METHODS: A retrospective review was carried out of patients diagnosed with venous thromboembolism and treated with NOACs at the Aga Khan University Hospital, Nairobi, from January 2014 to December 2019. Clinical and outcome data were collected from medical records and the hospital mortality database. All patients with VTE aged > 18 years and initiated on NOACS were recruited. Patients with missing information were excluded. They were followed up from the time of commencement of oral anticoagulation to completion of therapy, or to the time of the first major bleed, CRNM or minor bleeding. Data on bleeding were obtained from the hospital database and through telephone interviews. Unadjusted rates of the first major bleeding event or CRNM were calculated as the number of bleeding events per 100 person-years. RESULTS: Two hundred and forty-three patients with VTE were recruited and 222 (91.4%) were initiated on rivaroxaban, 12 (4.9%) on dabigatran and nine (3.7%) on apixaban, with a median follow up of 213 [interquartile range (IQR): 119-477] days. The median age of the patients was 57 (IQR: 45-71) years. A total of 64 bleeding events were identified in 50 (20.6%) patients. Overall, the incidence rate for bleeding events was 17.24 per 100 patient-years. The incidence rate of major bleeding was 3.79 per 100 person-years. Gastrointestinal bleeding was the most common major bleeding site. There were more females with bleeding events (70.7%) compared to males. Anaemia and the use of aspirin and other antiplatelets were associated with a higher incidence of major and CRNM bleeding [relative risk (RR) = 3.77, confidence interval (CI) = 1.37-10.39, p = 0.005 and RR = 8.89, CI = 2.06-38.33, p = 0.0003, respectively]. CONCLUSIONS: Most of these bleeds were minor, with the gastrointestinal tract being the most common source of major bleeding and menorrhagia being the commonest cause of bleeding. Anaemia and the use of aspirin were associated with a higher incidence of major bleeding.

The joint 15th Pan-African Society of Cardiology and Kenya Cardiac Society congress proceedings, 2021.

The 15th biennial Pan-African Society of Cardiology (PASCAR) congress held in Mombasa, Kenya, in November 2021, convened in its legacy of being the largest Pan-African conference on cardiovascular diseases (CVDs). The congress brough together members of cardiovascular societies from across the continent in the shared mission of advancing cardiovascular health in Africa. In partnership with the Kenyan Cardiac Society (KCS), the specific aims of the PASCAR conference were to (1) advance knowledge on CVDs in the region; (2) share local data, clinical cases, challenges and solutions and reinforce collaborative capacity initiatives in research and workforce training; (3) engage with policy makers to address health-system issues affecting access to CVD care in Africa; and (4) bring together local and international thought leaders in cardiovascular medicine to strengthen the partnerships between PASCAR, KCS, other African cardiac societies and key global stakeholders. Due to the COVID-19 pandemic, this congress demonstrated great success in providing both an in-person and a virtual platform of attendance, therefore making this an inaugural hybrid PASCAR congress, with inclusive and widespread participation from across the globe. We highlight the key areas of focus, various educational programmes and innovative initiatives that shaped the 15th PASCAR congress, including expert consensus on the future directions for advancing CVD care in Africa.

Increased arterial stiffness and reduced left ventricular long-axis function in patients recovered from peripartum cardiomyopathy.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is idiopathic pregnancy-associated heart failure (HF) with reduced left ventricular ejection fraction (LVEF). We aimed to assess arterial stiffness and left ventricular (LV) function in women recovered from PPCM compared with controls. METHODS: Twenty-two PPCM patients were compared with 15 age-matched controls with previous uncomplicated pregnancies. Eleven of the patients were at inclusion in the study recovered and off medication since at least 6 months and still free from cardiovascular symptoms with normal LVEF and normal NT-proBNP. All underwent echocardiography, including LV strain, left atrial (LA) reservoir strain and tissue Doppler early diastolic velocity (e´) and non-invasive assessment for arterial stiffness and central aortic systolic blood pressure (AoBP) at rest and immediately postexercise. RESULTS: The patients off medication showed alterations compared with controls. AoBP was higher (120 ± 9 mm Hg vs. 104 ± 13 mm Hg; p = .001), a difference which persisted postexercise. The arterial elastance was higher (1.9 ± 0.4 mm Hg/ml vs. 1.3 ± 0.2 mm Hg/ml; p < .001), while there were lower e´ septal (8.9 ± 1.7 cm/s vs. 11.0 ± 1.1 cm/s; p = 0. 002), LV global strain (18.7 ± 3.9% vs. 23.1 ± 1.6%; p = .004) and LA reservoir strain (24.8 ± 9.1% vs. 37.7 ± 6.3%; p = .002). CONCLUSIONS: Compared with healthy controls, PPCM patients considered recovered and off medication had increased arterial stiffness, decreased LV longitudinal function and reduced LA function.

Long-Term Outcomes and Factors Associated with Mortality in Patients with Moderate to Severe Pulmonary Hypertension in Kenya.

Background: Pulmonary hypertension is poorly studied in Africa. The long-term survival rates and prognostic factors associated with mortality in patients with moderate to severe pulmonary hypertension (PH) in Africa are not well described. Objectives: To determine the causes of moderate to severe PH in patients seen in contemporary hospital settings, determine the patients' one-year survival and the factors associated with mortality following standard care. Methods: A retrospective review of patients diagnosed with moderate to severe PH at Aga Khan University Hospital (AKUHN) from August 2014 to July 2017 was carried out. Clinical and outcome data were collected from medical records and the hospital mortality database. Telephone interviews were conducted for patients who died outside the hospital. Survival analysis was done using Kaplan-Meier, and log-rank tests were used to assess differences between subgroups. Cox regression modelling with multivariable adjustment was used to identify factors associated with all-cause mortality. Results: A total of 659 patients with moderate to severe PH were enrolled. Median follow-up time was 626 days. The survival rates of the patients at 1 and 2 years were 73.8% and 65.9%, respectively. The following variables were significantly associated with mortality: diabetes mellitus [adjusted HR 1.52, 95% CI (1.14-2.01)], WHO functional class III/IV [adjusted HR 3.49, 95% CI (2.46-4.95)], atrial fibrillation [adjusted HR 1.53, 95% CI (1.08-2.17)], severe PH [adjusted HR 1.72, 95% CI (1.30-2.27)], right ventricular dysfunction [adjusted HR 2.42, 95% CI (1.76-3.32)] and left ventricular dysfunction [adjusted HR 1.91, 95% CI (1.36-2.69)]. Obesity [adjusted HR 0.68, 95% CI (0.50-0.93)] was associated with improved survival. Conclusion: Pulmonary hypertension is associated with poor long-term outcomes in African patients. Identification of prognostic factors associated with high-risk patients will assist in patient management and potentially improved outcomes.

Building focused cardiac ultrasound capacity in a lower middle-income country: A single centre study to assess training impact.

BACKGROUND: In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agreement between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training programme locally. METHODS: This was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were assessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen's kappa >0.6 indicative of good inter-rater agreement. RESULTS: Knowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties. CONCLUSIONS: Although knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives.

Outcomes in patients with acute coronary syndrome in a referral hospital in sub-Saharan Africa.

BACKGROUND: Coronary artery disease and its acute presentation are being increasingly recognised and treated in sub-Saharan Africa. It is just over a decade since the introduction of interventional cardiology for coronary artery disease in Kenya. Local and regional data, and indeed data from sub-Saharan Africa on long-term outcomes of acute coronary syndromes (ACS) are lacking. METHODS: A retrospective review of all ACS admissions to the Aga Khan University Hospital, Nairobi (AKUHN) between January 2012 and December 2013 was carried out to obtain data on patient characteristics, treatment and in-patient outcomes. Patient interviews and a review of clinic records were conducted to determine long-term mortality rates and major adverse cardiovascular events. RESULTS: A total of 230 patients were included in the analysis; 101 had a diagnosis of ST-segment myocardial infarction (STEMI), 93 suffered a non-ST-segment myocardial infarction (NSTEMI), and 36 had unstable angina (UA). The mean age was 60.5 years with 81.7% being male. Delayed presentation (more than six hours after symptom onset) was common, accounting for 66.1% of patients. Coronary angiography was performed in 85.2% of the patients. In-hospital mortality rate was 7.8% [14.9% for STEMI and 2.3% for non-ST-segment ACS (NSTE-ACS, consisting of NSTEMI and UA)], and the mortality rates at 30 days and one year were 7.8 and 13.9%, respectively. Heart failure occurred in 40.4% of STEMI and 16.3% of NSTE-ACS patients. Re-admission rate due to recurrent myocardial infarction, stroke or bleeding at one year was 6.6%. CONCLUSIONS: In our series, the in-hospital, 30-day and one-year mortality rates following ACS remain high, particularly for STEMI patients. Delayed presentation to hospital following symptom onset is a major concern.

Symptomatic recovery and pharmacological management in a clinical cohort with peripartum cardiomyopathy.

AIM: We aimed to characterize the clinical course with focus on pharmacological management of peripartum cardiomyopathy (PPCM) in Sweden. METHODS: Twenty-four consecutive patients were retrospectively identified among women presenting with PPCM in Western Sweden. Of these, 14 had concomitant preeclampsia. There was only one fatality. The mean (standard deviation) left ventricular ejection fraction (LVEF) at diagnosis was 35.0 ± 9.9%. Ten women, 47.6%, required intensive care unit (ICU) admission. All patients received ß-blockers (BB) and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACE-I/ARB), which were tapered off over a mean/median period of 3.3/2.5 years with only one case of worsening heart failure. The mean follow-up for medication was 7.9 ± 2.6 years. Early and late/non-recovery was defined as New York Heart Association (NYHA) functional class I and NYHA II-IV at one year, respectively. Late recovery was associated with larger LVEDD at diagnosis (56.8 versus 62.4 mm) was associated with late recovery, p = .02. RESULTS AND CONCLUSIONS: PPCM had an overall good prognosis in this cohort. Left ventricular dilation at presentation was a predictor of worse prognosis. Concurrent preeclampsia was common, but was associated with better prognosis. Medication was safely discontinued in 75% of patients.

Symptoms in women with Peripartum Cardiomyopathy: A mixed method study.

OBJECTIVE: Peripartum Cardiomyopathy is a form of cardiac disease often associated with cardiac failure, occurring in late pregnancy or after childbirth. The anatomical and physiological changes in the mother associated with normal pregnancy are profound, and this may result in symptoms and signs that overlap with Peripartum Cardiomyopathy, leading to missed or delayed diagnosis. Women's experiences of Peripartum Cardiomyopathy symptoms remain poorly studied. The aim of this study was to explore and describe women's experiences of symptoms in Peripartum Cardiomyopathy. DESIGN: A triangulation of methods with individual interviews and data from medical records. SETTING: Mothers with Peripartum Cardiomyopathy diagnosis were recruited from Western Sweden as a part of research project. PARTICIPANTS: 19 women were interviewed and medical records were reviewed by authors. DATA ANALYSIS: All interview transcripts were analysed using qualitative inductive content analysis to identify key themes. RESULTS: The main theme, meaning of onset and occurrence of symptoms is captured in the metaphor: being caught in a spider web, comprising subthemes, invasion of the body by experienced symptoms and feeling of helplessness. Symptoms related to Peripartum Cardiomyopathy started for 17 women during pregnancy and in two post partum and time from symptoms to diagnosis varied between three and 190 days (median 40). The physical symptoms were:shortness of breath, excessive fatigue and swelling, bloatedness, nausea, palpitation, coughing, chest tightness, bodily pain, headache, fever, tremor, dizziness, syncope, restless and tingly body and reduced urine output. Emotional symptoms were: fear, anxiety, feelings of panic, and thoughts of impending death. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Symptoms of Peripartum Cardiomyopathy were debilitating, exhausting and frightening for the women interviewed in this study. Health care professionals responsible for the antenatal care, especially midwives, need skills to identify initial symptoms of Peripartum Cardiomyopathy for early referral and treatment by a specialist. In order to give optimal care more research is needed to show how to improve midwives' knowledge of Peripartum Cardiomyopathy.

What change in outcomes after cardiac arrest is necessary to change practice? Results of an international survey.

BACKGROUND: Efficient trials of interventions for patients with out-of-hospital cardiac arrest (OHCA) should have adequate but not excess power to detect a difference in outcomes. The minimum clinically important difference (MCID) is the threshold value in outcomes observed in a trial at which providers should choose to adopt a treatment. There has been limited assessment of MCID for outcomes after OHCA. Therefore, we conducted an international survey of individuals interested in cardiac resuscitation to define the MCID for a range of outcomes after OHCA. METHODS: A brief survey instrument was developed and modified by consensus. Included were open-ended responses. The survey included an illustrative example of a hypothetical randomized study with distributions of outcomes based on those in a public use datafile from a previous trial. Elicited information included the minimum significant difference required in an outcome to change clinical practice. The population of interest was emergency physicians or other practitioners of acute cardiovascular research. RESULTS: Usable responses were obtained from 160 respondents (50% of surveyed) in 46 countries (79% of surveyed). MCIDs tended to increase as baseline outcomes increased. For a population of patients with 25% survival to discharge and 20% favorable neurologic status at discharge, the MCID were median 5 (interquartile range [IQR] 3, 10) percent for survival to discharge; median 5 (IQR 2, 10) percent for favorable neurologic status at discharge, median 4 (IQR 2, 9) days of ICU-free survival and median 4 (IQR 2, 8) days of hospital-free survival. CONCLUSION: Reported MCIDs for outcomes after OHCA vary according to the outcome considered as well as the baseline rate of achieving it. MCIDs of ICU-free survival or hospital-free survival may be useful to accelerate the rate of evidence-based change in resuscitation care.