The impact of a community-based heart failure multidisciplinary team clinic on healthcare utilization and costs.

AIMS: Multidisciplinary team (MDT) management in heart failure (HF) is recommended to reduce mortality and HF hospitalization. We investigated whether an MDT in a community-based HF unit (HFU) impacted patients' healthcare utilization (HCU) and costs. METHODS AND RESULTS: A retrospective cohort study was conducted among HF patients who visited at least once in a regional community-based HFU, established for ambulatory specialist care for New York Heart Association Functional Classes III and IV, between January 2012 and August 2019. HCU data were obtained from the health maintenance organization's claims data for 12 months before and after first HFU visit. Multivariable generalized estimating equation models were specified for the annual average change in total healthcare utilization and hospitalization costs. Our cohort consisted of 962 patients, of whom 843 (87.6%) completed at least 12 months of follow-up (Group A) and 119 (12.4%) died within 12 months following their first visit (Group B). Both groups were comparable regarding sex, socio-economic status, Charlson Comorbidity Index, ischaemic heart disease, and/or carotid artery disease. Those who died within 12 months were older and had more hypertension, diabetes, chronic renal disease, and malignancy. There was a significant reduction in the total average annual HCU costs of the entire study population 12 months after the first HFU visit [$12 675 (±17 210) after vs. $13 188 (±15 011) before, P = 0.014]. This was driven by a reduction in costs among patients who completed 12 months of follow-up [$11 955 (±17 352) after vs. $13 112 (±15 268) before, P < 0.001], whereas an increase in these costs was observed among patients who died during follow-up [$17 774 (±15 292) after vs. $13 728 (±13 093) before, P = 0.015]. These opposite trends stem mainly from a decrease [$3540 (±8991) after vs. $4941 (±6806) before, P < 0.001] vs. increase [$10 932 (±11 660) after vs. $6733 (±7215) before, P = 0.002] in hospitalization costs of these groups, respectively. The multivariable models revealed that patients who died within 12 months following the first visit to the HFU demonstrated a significant increase of 57% in hospitalization costs following their first visit [relative risk (RR) = 1.57, 95% confidence interval (CI): 1.20-2.05, P = 0.001], whereas there was a decrease of 34% in the hospitalization costs of patients who completed 12 months of follow-up after their first visit (RR = 0.66, 95% CI: 0.54-0.81, P < 0.001). The entire cohort demonstrated 27% decrease in hospitalization costs following their first HFU visit (RR = 0.73, 95% CI: 0.62-0.87, P < 0.001). CONCLUSIONS: Intensification of therapy by a dedicated MDT significantly reduced healthcare utilization and costs, predominantly due to a decrease in hospitalizations.

Pulmonary artery hypertension following coronary artery bypass grafting: a case report.

Post-operative pulmonary complications in coronary artery bypass grafting (CABG) surgery are mostly reversible. We report a patient who developed pulmonary arterial hypertension (PAH) post-CABG and did not have pulmonary hypertension prior to surgery. PAH Group 1 was diagnosed after right and left heart catheterization. To the best of our knowledge, this is the only reported case of a patient developing PAH post-CABG surgery. This could be explained by immunological and/or haemostatic changes triggered by cardiopulmonary bypass. We hope that as more knowledge is gained regarding the pathophysiology of PAH, cases like these could be better understood.

Angiogenic Imbalance and Residual Myocardial Injury in Recovered Peripartum Cardiomyopathy Patients.

BACKGROUND: Recent studies suggest that angiogenic imbalance during pregnancy may lead to acute peripartum cardiomyopathy (PPCM). We propose that angiogenic imbalance and residual cardiac dysfunction may exist even after recovery from PPCM. METHODS AND RESULTS: Twenty-nine women at least 12 months after presentation with PPCM, who exhibited recovery of left ventricular (LV) ejection fraction (≥50%), were included in the study (mean age 35±6 years, LV ejection fraction 61.0±3.9%). The number of circulating endothelial progenitor cells (EPCs) and plasma levels of proangiogenic vascular endothelial growth factor and of soluble vascular endothelial growth factor receptor Flt1 (sFlt1) were measured. All patients underwent comprehensive cardiac function assessment, including tissue Doppler imaging and 2-dimensional (2D) strain echocardiography. All measurements were compared with healthy controls. Patients with a history of PPCM have significantly higher sFlt1 concentrations (median [25th-75th percentile]; 149.57, [63.14-177.89] versus 20.29, [15.00-53.89] pg/mL, P<0.001) and significantly decreased vascular endothelial growth factor/sFlt1 ratio (P=0.012) compared with controls, with a trend toward lower concentration of circulating CD34+/KDR+ levels. In addition, patients with PPCM had lower early velocities E' septal (9.9±2.1 versus 11.0±1.5 cm/s, P=0.02), with a significantly lower systolic velocity S' septal (7.6±1.2 versus 8.5±1.2 cm/s, P=0.003) by tissue Doppler imaging. Significantly lower LV global longitudinal (-19.1±3.3 versus -22.7±2.2%, P<0.001) and apical circumferential 2D strain (-16.6±4.9 versus -21.2±7.9, P=0.02) were present in patients with PPCM compared with controls. CONCLUSIONS: Higher concentration of sFlt1 with concomitant decreased circulating endothelial progenitor cell levels along with inappropriate attenuated vascular endothelial growth factor levels may imply an angiogenic imbalance that exists even after recovery and may thus predispose to PPCM. In addition, tissue Doppler imaging and 2D strain were able to identify residual myocardial injury in post-PPCM women with apparent recovery of LV systolic function. Both angiogenic imbalance and residual myocardial injury may play an important role in the recurrence of LV dysfunction during subsequent pregnancies.

Angiographic Characteristics of Catheter-Induced Spasm of the Left Main Coronary Artery.

Spasm of the left main coronary artery (LM) is considered to be rare. We investigated the angiographic characteristics of the LM in patients with combined LM and disease involving additional vessels, who underwent coronary artery bypass grafting (CABG) and underwent repeat coronary angiography within 5 years of the CABG, to examine the apparent frequency of spasm of the LM on initial angiography and its possible predictors. A retrospective analysis was performed of patients who underwent coronary angiography in our institute, who were found to have significant LM stenosis and disease involving additional vessels, underwent CABG and repeat coronary angiography within 5 years of the CABG. Data on angiographic characteristics of the LM on the initial angiogram were investigated. Of 84 patients, 17 (20%) were found to have a normal LM on repeat angiography (group A), and 67 (80%) demonstrated significant stenosis (group B). The degree of LM stenosis was milder in the initial angiogram in group A than in group B (64 ± 15% vs 72 ± 14%, p = 0.047). Most patients in group A demonstrated tubular LM stenosis at initial catheterization in comparison to group B (71% vs 18%). Using multivariate analysis, the only predictor for a normal LM at repeat catheterization was found to be tubular stenosis at initial catheterization (odds ratio 123, 95% confidence interval 4.0 to 3696). In conclusion, LM coronary spasm is a common finding, particularly in those with the appearance of tubular stenosis, and it should be excluded even in patients with additional coronary disease in certain instances to prevent unnecessary CABG.

How long do your angiographically normal coronary arteries remain normal? A pilot study.

Coronary atherosclerosis is a progressive disease. We sought to determine whether this fact also applies to patients at an advanced age with normal coronary arteries (NCAs) undergoing repeat catheterization at least 5 years later. Of the 189 patients who were found to have NCAs, 154 (81%) remained with NCAs and 35 (19%) developed obstructive coronary artery disease (OCAD). Development of OCAD was observed at all ages. Isolated risk factors were not associated with the appearance of OCAD, but the combination of diabetes mellitus with age >65 years or with smoking was associated with the appearance of OCAD (P = .04 for both). In conclusion, the finding of angiographically NCAs in elderly individuals does not prevent the later development of OCAD.

Predicting survival with reperfusion arrhythmias during primary percutaneous coronary intervention for acute myocardial infarction.

BACKGROUND: The significance of arrhythmia occurring after successful recanalization of an occluded artery during treatment following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction is controversial. OBJECTIVES: To study the association of reperfusion arrhythmia with short and long-term survival. METHODS: We used a prospective registry of consecutive STEMI patients undergoing PPCI. Patients with an impaired epicardial flow (TIMI flow grade < 3) at the end of the procedure were excluded. RESULTS: Of the 688 patients in the study group, 22% were women. Mean (+/- SD) age of the cohort was 61 (+/- 14) years and frequent co-morbidities included diabetes mellitus (25%), dyslipidemia (55%), hypertension (43%) and smoking (41%). RA was recorded in 200 patients (29%). Patients with RA had lower rates of diabetes (16% vs. 30%, P < 0.01) and hypertension (48% vs. 62%, P < 0.01), and a shorter median pain-to-balloon time (201 vs. 234 minutes, P < 0.01) than patients without RA. Thirty day mortality was 3.7% and 8.3% for patients with and without RA, respectively (P = 0.04). After controlling for age, gender and pain-to-balloon time the hazard ratio for mortality for patients with RA during a median follow-up period of 466 days was 0.46 (95% confidence interval 0.23-0.92). CONCLUSIONS: The occurrence of RA immediately following PPCI for acute STEMI is associated with better clinical characteristics and identifies a subgroup with a particularly favorable prognosis.

Do the recently modified pacemaker guidelines for neurocardiogenic syncope also apply to young patients? Analysis based on five-year follow-up of israeli soldiers with syncope and a positive tilt test.

To assess the classification of neurocardiogenic syncope (NCS) as a IIA indication for pacemaker implantation in the recent American College of Cardiology/American Heart Association Task Force on Practice Guidelines/North American Society for Pacing and Electrophysiology guidelines, we performed chart reviews and follow-up interviews in a cohort of 45 consecutive young Israeli soldiers (age 18-24 years) with a history of syncope (mean of 9 prior syncopal episodes) and a positive tilt test treated with drug therapy. Asystole longer than 5 s during tilt testing occurred in 11 patients. Five years later, we found that only 2 patients were still taking medications, only 1 patient (2%) still reported frequent syncopal or near-syncopal episodes and 3 patients (7%) had rare symptoms (no more than one syncopal episode during the past 2 years), while the remaining 40 (89%) were symptom free off medications. Thus, NCS in young patients, even with prolonged asystole during tilt testing, a history of frequent syncopal episodes and other high- risk factors described in the guidelines, is often a self-limiting disorder, perhaps stress related or situational in nature; an overwhelming number of patients become asymptomatic and stop taking medications within 1-2 years. These patients do not require long-term therapy; thus, our data would suggest that the IIA pacing indication for NCS should be restricted to older patients.