Cardiovascular surgery and cardiology, current status of two sister specialties in Spain: the CARDIOXCARDIO study.

In recent years, there has been a notable shift in cardiovascular clinical practice within cardiology and surgery. The CARDIOXCARDIO study aimed to identify professionals' opinions on working practices and relations between specialties. A survey was simultaneously sent to the 4442 members of the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) and the Spanish Society of Cardiology (SEC), yielding 385 valid responses. More than half (59%) of respondents were men, mostly specialists (7.3% residents), and 74.8% worked in the field of cardiology, predominantly in public centers (88.3%). Using a Likert scale ranging from 1 to 5 (worst to best), respondents rated relations between surgery and cardiology with an average of 3.57±0.9 points. Cardiologists rated surgeons with a mean score of 3.83±0.8, while surgeons gave cardiologists a mean score of 3,92±0.72. In addition, respondents provided numerous suggestions for improvement, which are discussed in detail, highlighting certain discrepancies in criteria between specialties. Implementing strategies based on the suggestions of professionals, together with a proactive approach to continuous improvement, could substantially enhance the quality of cardiovascular care in Spain.

Awareness, diagnosis and treatment of heterozygous familial hypercholesterolemia (HeFH) - Results of a US national survey.

BACKGROUND: HeFH is a common inherited disorder that leads to markedly elevated LDL-cholesterol from birth and premature cardiovascular disease. HeFH is frequently underdiagnosed and undertreated. OBJECTIVE: To compare how well primary care physicians and cardiologists recognize and treat HeFH. METHODS: The National Lipid Association surveyed 500 primary care physicians and 500 cardiologists in the US who have patients with baseline LDL-cholesterol ≥ 190 mg/dL. The survey was conducted between August 29 and September 30, 2019. RESULTS: For a hypothetical case of HeFH, 57% of cardiologists versus 43% of primary care physicians made the correct diagnosis (P<0.001). Among respondents, 21% of cardiologists versus 29% of primary care physicians have never made a diagnosis of HeFH in a patient with an LDL-cholesterol ≥ 190 mg/dL (P<0.004). Only 7% of cardiologists versus 5% of primary care physicians would refer to a lipid specialist (P=0.05). For additional LDL-cholesterol lowering after statins, 58% of cardiologists versus 48% of primary care physicians would prescribe a PCSK9 inhibitor (P=0.004); however, 30% of cardiologists versus 53% of primary care physicians have never prescribed a PSCK9 inhibitor in an HeFH patient (P<0.001). CONCLUSION: Although cardiologists compared to primary care physicians are somewhat more likely to recognize and treat HeFH patients according to guidelines, both physician specialties do not adequately recognize or treat HeFH. There is a need for more education and training in recognizing and treating HeFH, greater access to lipid specialists, and fewer barriers for PCSK9 inhibitor use.

Clinician needs and perceptions about cardioneuroablation for recurrent vasovagal syncope: An international clinician survey.

BACKGROUND: Cardioneuroablation (CNA) targets the intrinsic cardiac autonomic nervous system ganglionated plexi located in the peri-atrial epicardial fat. There is increasing interest in CNA as a treatment of vasovagal syncope (VVS), despite no randomized clinical trial (RCT) data. OBJECTIVE: The purpose of this study was to poll the opinion on CNA) for VVS. METHODS: A REDCap (Research Electronic Data Capture) survey was administered to international physicians treating patients with VVS on their opinion about patient selection criteria, ablation approach, RCT design, and most appropriate end points for CNA procedures. RESULTS: The survey was completed by 118 physicians; 86% were cardiac electrophysiologists. The majority of respondents (79%) would consider referring a patient with refractory VVS for CNA, and 27% have performed CNA for VVS themselves. Most felt patient selection should require a head-up tilt test with a cardioinhibitory response (67%) and suggest a minimum age of 18 years with a median of 3 (interquartile range 2-5) episodes in the past year. There were differences in patient selection between physicians who have performed CNA themselves and those who have not. The majority felt that the ablation strategy should include both atria (70%) with an anatomical approach in combination with autonomic stimulation (85%). Performing a sham procedure in the control arm was supported by 56% of respondents, providing equipoise in RCT design. The preferred primary outcome was freedom from syncope within 1 year of follow-up. CONCLUSION: There is widespread support for well-designed RCTs to confirm the hypothesized clinical benefit of CNA, provide data to guide the risk-benefit equations during patient selection, and appropriately estimate the placebo effect.

[Assessment of the practices and knowledge among cardiologists regarding radiation protection in Tunisia]. / Évaluation des pratiques et connaissances en radioprotection des cardiologues en Tunisie.

INTRODUCTION: interventional cardiology procedures have become complex and expensive in time with a higher risk of exposure to ionizing radiations. The purpose of our study was to assess radiation protection knowledge and practices among Tunisian cardiologists exposed to X-rays. METHODS: we conducted a descriptive, analytical study in October 2019. An anonymous survey on the knowledge and practices regarding radiation protection was sent to all Tunisian cardiologists exposed to X-rays. RESULTS: among 126 cardiologists exposed to X-rays and having received the survey, 58 physicians responded to the survey (48%), with a male predominance (72%, n=42). Thirty-eight physicians (65%) were public sector workers. Average years of working experience were 12.02 years (SD 6.88 years). Half of doctors had a knowledge score of less than 50%. The average practice score was 43.83 (SD 13.95%). Wearing a lead apron, thyroid shield, dosimeter, lead glasses, lead cap accounted for 100% (n=58), 86.2% (n=50), 30.7% (n=18), 12.1% (n=7) and 1.7% (n=1) respectively. There was no correlation between scores and doctor's age as well as the length of working experience. There was no statistical differences between knowledge scores of males and females (p=0.06) or between public sector and private sector (p=0.9). Practice score was significantly higher among men (0.007) and interventional cardiologists compared to rhythmologists and pediatric cardiologists (p<0.001). CONCLUSION: the level of knowledge and practices among Tunisian cardiologists regarding radiation protection is generally insufficient. Then, health authorities should implement regular training programs.

Burnout and distress among physicians in a cardiovascular centre of a quaternary hospital network: a cross-sectional survey.

BACKGROUND: Burnout and distress have a negative impact on physicians and the treatment they provide. Our aim was to measure the prevalence of burnout and distress among physicians in a cardiovascular centre of a quaternary hospital network in Canada, and compare these outcomes to those for physicians at academic health science centres (AHSCs) in the United States. METHODS: We conducted a survey of physicians practising in a cardiovascular centre at 2 quaternary referral hospitals in Toronto, Ontario, between Nov. 27, 2018, and Jan. 31, 2019. The survey tool included the Well-Being Index (WBI), which measures fatigue, depression, burnout, anxiety or stress, mental and physical quality of life, work-life integration, meaning in work and distress; a score of 3 or higher indicated high distress. We also evaluated physicians' perception of the adequacy of staffing levels and of fair treatment in the workplace, and satisfaction with the electronic health record. We carried out standard univariate statistical comparisons using the χ2, Fisher exact or Kruskal-Wallis test as appropriate to perform univariate comparisons in the sample of respondents. We assessed the relation between a WBI score of 3 or higher and demographic characteristics. We compared univariate associations among WBI data for physicians at AHSCs in the US who completed the WBI to responses from our participants. RESULTS: The response rate to the survey was 84.1% (127/151). Of the 127 respondents, 83 (65.4%) reported burnout in the previous month, and 68 (53.5%) reported emotional problems. Sixty-nine respondents (54.3%) had a WBI score of 3 or higher. Respondents were more likely to have a WBI score of 3 or higher versus a score less than 3 if they perceived insufficient staffing levels (52/69 [75%] v. 26/58 [45%], p = 0.02) or unfair treatment (23/69 [33%] v. 8/58 [14%], p = 0.03), or were anesthesiologists (26/35 [74%] v. 43/92 [47%] for other specialists, p = 0.005). Compared to 21 594 physicians in practice at AHSCs in the US, our respondents had a higher mean WBI score (2.4 v. 1.8, p = 0.004) and reported a higher prevalence of burnout (65.4% v. 56.6%, p = 0.048). INTERPRETATION: Physicians in this study had high levels of burnout and distress, driven by the perception of inadequate staffing levels and being treated unfairly in the workplace. Addressing these institutional factors may improve physicians' work experience and patient outcomes.

Frequência e características dos respondedores a uma intervenção educacional para redução de testes cardíacos inapropriados: um subestudo do Echo WISELY Trial / Frequency and characteristics of responders to an educational intervention to reduce inappropriate heart testing: a sub-study of the Echo WISELY Trial

Introdução: O Echo WISELY Trial é um estudo controlado, randomizado, multicêntrico, cego pelo investigador, que avaliou uma intervenção educacional com base nos critérios de uso apropriado para ecocardiografia para redução da proporção de ecocardiogramas raramente apropriados realizados ambulatorialmente. Objetivo: Descrever a prevalência e identificar preditores de responsividade de médicos respondedores submetidos à intervenção educacional no Echo WISELY Trial. Métodos: Médicos do grupo intervenção receberam um programa educacional multifacetado. O médico respondedor foi definido como aquele que apresentou redução >2,5% na média proporcional de exames raramente apropriados solicitados entre o primeiro trimestre (linha de base) e qualquer um dos seguintes trimestres (segundo ao sexto). Foram comparadas as características do médico (sexo, tempo de formação, especialidade médica e local de trabalho) com as classificações dos ecocardiogramas (apropriado, talvez apropriado e raramente apropriado) e razões clínicas para ecocardiogramas solicitados utilizando teste do qui-quadrado. A significância estatística foi indicada por p < 0,05 bicaudal. Resultados: Foram analisados 4.605 exames solicitados nos seis hospitais participantes de Ontário e randomizados para o braço intervenção. Dentre os 36 médicos incluídos, 26 (72%) foram classificados como respondedores. Entre as variáveis analisadas, não houve diferença significativa entre médicos respondedores e não respondedores à intervenção educacional. O número de exames raramente apropriados solicitados pelos respondedores foi significativamente menor que o de não respondedores (234; 8,67% versus 261; 13,8%; p < 0,0001). Conclusão: A prevalência de médicos respondedores é alta, porém não foram identificados preditores de responsividade à intervenção educacional entre as variáveis analisadas. Isso pode decorrer de aspectos psicológicos e características pessoais dos médicos, que não foram incluídos nesta pesquisa.(AU)

Introduction: The Echo WISELY Trial is a controlled randomized multicenter investigator-blinded study that evaluated an educational intervention based on the criteria for appropriate use of echocardiography to reduce the proportion of rarely appropriate outpatient echocardiograms performed. Objective: To describe the prevalence and identify predictors of the responsiveness of responding physicians subjected to an educational intervention in the Echo WISELY Trial. Methods: The intervention group physicians received a multifaceted educational program. A responding physician was defined as one who had a >2.5% reduction in the proportional mean of rarely appropriate tests requested between the first trimester (baseline) and any of the following trimesters (second to sixth). Physician characteristics (sex, time since graduation, medical specialty, and workplace) were compared to the echocardiogram ratings (appropriate, maybe appropriate, and rarely appropriate) and clinical reasons for the requested echocardiograms using the chi-square test. Statistical significance was indicated by a two-tailed p < 0.05. Results: A total of 4,605 tests requested at the six participating hospitals in Ontario were analyzed and randomized for the intervention arm Of the 36 included physicians, 26 (72%) were classified as responders. Of the variables analyzed, there was no significant difference in the outcomes of the responders versus non-responders to the educational intervention. The number of rarely appropriate tests requested by the responders was significantly lower than that of the non-responders (234 [8.67%] versus 261 [13.8%]; p < 0.0001). Conclusion: The prevalence of responder physicians was high, but predictors of responsiveness to educational intervention were not identified among the analyzed variables. This may be a result of the psychological aspects and personal characteristics of the physicians, which were not included in this research. (AU)

Comparison of Heart Team vs Interventional Cardiologist Recommendations for the Treatment of Patients With Multivessel Coronary Artery Disease.

Importance: Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown. Objective: To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease. Design, Setting, and Participants: In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center's database). A total of 237 patients were included in the final virtual heart team analysis. Treatment decisions (which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy) were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were then compared with pooled-majority treatment decisions made by 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020. Main Outcomes and Measures: The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist. Results: Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%-36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; P = .006). The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; P < .001). When the heart team agreed with the original treatment decision, there was more agreement between the heart team interventional cardiologist and the original treating interventional cardiologist (138 of 163 cases [84.7%]) compared with when the heart team disagreed with the original treatment decision (14 of 71 cases [19.7%]); P < .001). Those with an original treatment of coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy, 32 of 148 patients [22.3%], 32 of 71 patients [45.1%], and 6 of 15 patients [40.0%], respectively, received a different treatment recommendation from the heart team than the original treating interventional cardiologist; the difference across the 3 groups was statistically significant (P = .002). Conclusions and Relevance: The heart team's recommended treatment for patients with multivessel coronary artery disease differed from that of the original treating interventional cardiologist in up to 30% of cases. This subset of cases was associated with a lower frequency of unanimous decisions within the heart team and less concordance between the interventional cardiologists; discordance was more frequent when percutaneous coronary intervention or medication therapy were considered. Further research is needed to evaluate whether heart team decisions are associated with improvements in outcomes and, if so, how to identify patients for whom the heart team approach would be beneficial.

Expert Opinion Regarding Appropriately Timing Dermatological Surgeries in Patients With Recent Myocardial Infarctions.

BACKGROUND: There is limited data on the risk of perioperative myocardial infarctions (MIs) in patients with a recent MI who undergo dermatologic surgeries. OBJECTIVE: Present the recommendations of dermatologic surgeons and cardiologists to determine the safety of dermatologic surgeries after a recent MI. METHODS: An electronic survey was distributed to Mohs surgeons and cardiologists to infer the risk of major adverse cardiac events (MACE) inherent to dermatologic surgery and determine timing of dermatologic surgery in patients with a recent MI. RESULTS: One hundred twenty Mohs surgeons and 30 cardiologists were surveyed. Ninety-seven percent of cardiologists and 87% of Mohs surgeons deemed cutaneous excisions and Mohs micrographic surgery as low-risk procedures with less than one-percent chance of MACE. Seventy-seven percent of cardiologists and 46% of Mohs surgeons stated dermatologic surgery should either not be delayed or be delayed up to 1 month after an MI. Responses between cardiologists and Mohs surgeons did not significantly differ. CONCLUSION: A preponderance of surveyed experts believe that most dermatologic surgeries may be safely performed in patients with a history of an MI within 1 month. The decision to implement urgent dermatologic surgery in patients with a recent MI should account for all clinically significant factors.

Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults.

BACKGROUND/OBJECTIVES: Guideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties. DESIGN: National cross-sectional survey. SETTING: Ambulatory. PARTICIPANTS: Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians. MEASUREMENTS: Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases. RESULTS: In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists). CONCLUSIONS: While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication. J Am Geriatr Soc 68:78-86, 2019.

Cost conscious care: preoperative evaluation by a cardiologist prior to low-risk procedures.

Background: Preoperative testing before low-risk procedures remains overutilised. Few studies have looked at factors leading to increased testing. We hypothesised that consultation to a cardiologist prior to a low-risk procedure leads to increased cardiac testing. Methods and results: 907 consecutive patients who underwent inpatient endoscopy/colonoscopy at a single academic centre were identified. Of those patients, 79 patients (8.7%) received preoperative consultation from a board certified cardiologist. 158 control patients who did not receive consultation from a cardiologist were matched by age and gender. Clinical and financial data were obtained from chart review and hospital billing. Logistic and linear regression models were constructed to compare the groups. Patients evaluated by a cardiologist were more likely to receive preoperative testing than patients who did not undergo evaluation with a cardiologist (OR 47.5, (95% CI 6.49 to 347.65). Specifically, patients seen by a cardiologist received more echocardiograms (60.8% vs 22.2%, p<0.0001) and 12-lead electrocardiograms (98.7% vs 54.4%, p<0.0001). There was a higher rate of ischaemic evaluations in the group evaluated by a cardiologist, but those differences did not achieve statistical significance. Testing led to longer length of stay (4.35 vs 3.46 days, p=0.0032) in the cohort evaluated by a cardiologist driven primarily by delay to procedure of 0.76 days (3.14 vs 2.38 days, p=0.001). Estimated costs resulting from the longer length of stay and increased testing was $10 624 per patient. There were zero major adverse cardiac events in either group. Conclusion: Preoperative consultation to a cardiologist before a low-risk procedure is associated with more preoperative testing. This preoperative testing increases length of stay and cost without affecting outcomes.

The Profile of the Brazilian Cardiologist - A Sample of Members of the Brazilian Society of Cardiology / O Perfil do Cardiologista Brasileiro - Uma Amostra de Sócios da Sociedade Brasileira de Cardiologia

Abstract Background: Data from the international literature have shown changes in the profile of cardiologists and in their medical practices. However, there is no data on this in Brazilian cardiologists. Objective: To evaluate professional and personal characteristics of a sample of Brazilian cardiologists. Methods: This was a cross-sectional study; a questionnaire was sent by e-mail to cardiologists, active members of the Brazilian Society of Cardiology in 2017. The results were analyzed, and the level of significance set at p < 0.05. Results: The questionnaire was sent to 13,462 cardiologists, with 2,101 (15.6%) respondents, mostly men (71.8% versus 28.2%). Age distribution and marital status were significantly different between the sexes (p < 0.001). The number of cardiologists without children was higher among women (40.5% versus 16.1%; p < 0.001). The most common place of work was the public hospital (46.5%), followed by private hospital (28.5%) and private office (21.1%). The office was the main place of work for 23.9% of men and 14% of women (p < 0.001), with predominance of individuals older than 50 years (31.7% versus 10.1%, respectively; p < 0.001). Most cardiologists (64.2%) worked more than 40 hours a week (69% of them men and 51.9% of the women; p < 0.001). Eighty-eight percent of the sample earned more than BRL 11,000 (US$ 3,473.43), and 66.5% of the men earned more than BRL 20,000 (US$ 6,315.32) per month, versus 31.2% of the women (p < 0.001). A high level of work-related stress was reported by 11.3% of respondents. Conclusion: Most cardiologists were men, who showed higher workload and higher income; 11.3% of the cardiologists perceived stress as a great deal.

Resumo Fundamento: Dados internacionais mostram mudanças no perfil e nas características da atuação dos cardiologistas. No entanto, não há na literatura dados acerca da realidade brasileira. Objetivo: Avaliar as características profissionais e pessoais de amostra de cardiologistas brasileiros. Método: Estudo transversal realizado por meio de questionário enviado via e-mail para os cardiologistas adimplentes da Sociedade Brasileira de Cardiologia em 2017. Os resultados foram analisados considerando nível de significância de p < 0,05. Resultados: Foram enviados 13.462 questionários, havendo 2.101 (15,6%) respostas, com predominância de homens (71,8% versus 28,2%). A distribuição etária e o estado civil foram significativamente diferentes entre os gêneros (p < 0,001). O número de cardiologistas sem filhos foi maior entre as mulheres (40,5% versus 16,1%; p < 0,001). O local de trabalho mais frequente foi hospital público (46,5%), seguido por hospital privado (28,5%) e consultório privado (21,1%). O consultório é a principal atividade de 23,9% dos homens e 14% das mulheres (p < 0,001), predominantemente entre aqueles com mais de 50 anos (31,7% versus 10,1%, respectivamente; p < 0,001). A maioria (64,2%) trabalha mais de 40 horas semanais (69% dos homens e 51,9% das mulheres; p < 0,001). A renda mensal de 88% é superior a R$ 11.000 (US$ 3,473.43), e 66,5% dos homens recebem mais que R$ 20.000,00 (US$ 6,315.32) mensais, contra 31,2% das mulheres (p < 0,001). Nível elevado de estresse foi relatado por 11,3%. Conclusões: Os homens são maioria entre os cardiologistas, têm maior carga de trabalho e renda superior à das mulheres. A taxa de estresse em grande proporção foi de 11,3%.

IMPACT OF THE TABLE HEIGHT AND THE OPERATOR'S HEIGHT ON THE LEVEL OF RADIATION DELIVERED TO INTERVENTIONAL CARDIOLOGISTS.

Interventional cardiologists count among the health professionals that are most exposed to ionising radiation. To minimise exposure, it is recommended that the patient be placed at the maximum distance possible from the X-ray source, but this recommendation has not been clinically validated. We aimed to investigate the impact of the average table height on the level of radiation delivered to cardiologists performing coronary interventions. The population for analysis included all invasive coronary procedures performed in our centre from March to June 2017. The primary endpoint was operator radiation exposure, as assessed using personal electronic dosimeters located on the operator's left arm. In total, 225 invasive coronary procedures were analysed. When the average table height was 1126 mm or more, the operators received a radiation dose that was, on average, 53% lower than when the table was lower than 1126 mm. This reduction remained significant by multivariate analysis adjusted for the operator.

Real-world treatment patterns of sacubitril/valsartan: a longitudinal cohort study in Germany.

AIMS: To analyse real-world treatment patterns of sacubitril/valsartan (sac/val) using data from a pharmacy database in Germany. METHODS AND RESULTS: A retrospective cohort study of 26 191 adult patients (aged ≥ 18 years) in the IMS® longitudinal prescriptions database in Germany who were dispensed sac/val from January 2016 to June 2017 was conducted. The analysis included sac/val dose titration assessed in the 6 months from first sac/val prescription; prescriptions of concomitant cardiovascular medications in the 6 months pre- and post-index and compliance and persistence during 12 months post-index. Two-thirds of patients were prescribed the lowest sac/val dose of 50 mg twice daily (b.i.d.) at index and up-titration during the first 6 months was attempted in 41% of these patients. Ten percent of patients prescribed 200 mg b.i.d. at index had to be stably down-titrated; among patients prescribed 50 or 100 mg b.i.d. at index that were up-titrated, > 80% remained on the higher dose. Overall, the mean daily diuretic dose decreased by 25% after initiation of sac/val. High compliance and persistence rates were observed across sac/val doses, increasing with higher sac/val dose at index. Prior dose of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker had only minor impact on first sac/val dose, compliance and persistence. CONCLUSIONS: Most patients prescribed sac/val are not initiated on the recommended dose nor up-titrated as recommended by the EU Summary of Product Characteristics. Initiation of sac/val was associated with high persistence and compliance and a dose reduction of diuretics. Barriers to up-titration must be explored.

[Smoking cessation: A challenge for cardiologists and pulmonologists]. / Sevrage tabagique : un défi pour les cardiologues et les pneumologues.

In addition to public health measures that need to be strongly supported politically, smoking is also a major medical issue. Tobacco dependence is a chronic disease, and, given its extremely addictive nature, treatment for tobacco dependence must be addressed actively by all health professionals. Because smoking is a major contributor to many of the pathologies their specialties address, cardiologists and pulmonologists must be at the forefront of this care. In this review we analyse the current state of smoking cessation treatment and its inadequacies, the limiting impact that doctors' own smoking has, as well as the misconceptions held by smokers and sometimes by doctors as well, which act as brakes on smoking cessation. Smoking cessation must become a treatment delivered in real clinical practice and any doctor must know how to manage it fluently. Do not be satisfied with simply advising smokers to quit. Learn how to approach the subject with smokers effectively, know how the various pharmacotherapies are used and know how to organize smoking cessation follow-up, an essential guarantee of success. If optimal management of this major pathological factor is a role for all doctors, it is of course especially so for our two specialties. It's up to us, cardiologists and pulmonologists, to take up this challenge.

Screening for Opioid Misuse in the Nonhospitalized Seriously Ill Patient.

Background: Responding to an epidemic of opioid-related deaths, guidelines and laws have been implemented to promote safe opioid prescribing practices. Objective: This study evaluates differences in screening practices and knowledge of laws between oncologists and cardiologists who prescribe opiates. Design: Surveys regarding screening practices and knowledge of opioid prescribing laws were distributed in March 2017 to oncology and congestive heart failure (CHF) clinicians at the University of Virginia. Chi-square and Wilcoxon rank sum tests were used. Results: Forty-six of 129 (35.6%) oncology providers and 7 of 14 (50%) CHF providers reported prescribing opiates in their clinic with usable survey results. The majority of oncology (65.22%) and cardiology (85.71%) providers report screening for substance abuse "when indicated" (p = 0.053). Only 19.6% of oncologists reported always using the prescription monitoring program (PMP), while 71.43% of cardiologists reported using it always (p = 0.014). Of the oncology providers, 66.67% report never using the urine drug screen (UDS), while 86.7% of cardiologists reported using it "when indicated" (p = 0.0086). Up to 34.78% of the oncologists and 57.14% of the cardiologists reported of never screening the family members for misuse (p = 0.317). Knowledge of laws was similar between groups, with 14.29% of cardiology and 17.39% of oncology providers reporting no knowledge of opioid prescribing laws (p = 0.2869). Conclusions: Routine screening for substance misuse risk was uncommon for both groups, but cardiology providers were more likely to use the PMP or UDS. Knowledge gaps regarding Virginia laws were noted in both groups. Improved education regarding best practices and laws, as well as programs to promote screening, is needed for all providers.

Prevalence of Lens Opacity in Interventional Cardiologists and Professional Working in the Hemodynamics in Brazil / Prevalência de Opacidades do Cristalino em Cardiologistas Intervencionistas e Profissionais Atuantes na Área de Hemodinâmica no Brasil

Abstract Background: Posterior subcapsular cataract is a tissue reaction commonly found among professionals exposed to ionizing radiation. Objective: To assess the prevalence of cataract in professionals working in hemodynamics in Brazil. Methods: Professionals exposed to ionizing radiation (group 1, G1) underwent slit lamp examination with a biomicroscope for lens examination and compared with non-exposed subjects (group 2, G2). Ophthalmologic findings were described and classified by opacity degree and localization using the Lens Opacities Classification System III. Both groups answered a questionnaire on work and health conditions to investigate the presence of risk factors for cataract. The level of significance was set at 5% (p < 0.05). Results: A total of 112 volunteers of G1, mean age of 44.95 (±10.23) years, and 88 volunteers of G2, mean age of 48.07 (±12.18) years were evaluated; 75.2% of G1 and 85.2% of G2 were physicians. Statistical analysis between G1 and G2 showed a prevalence of posterior subcapsular cataract of 13% and 2% in G1 and G2, respectively (0.0081). Considering physicians only, 38% of G1 and 15% of G2 had cataract, with the prevalence of posterior subcapsular cataract of 13% and 3%, respectively (p = 0.0176). Among non-physicians, no difference was found in the prevalence of cataract (by types). Conclusions: Cataract was more prevalent in professionals exposed to ionizing radiation, with posterior subcapsular cataract the most frequent finding.

Resumo Fundamento: A catarata subcapsular posterior é uma reação tecidual encontrada com frequência nos profissionais expostos à radiação ionizante. Objetivo: Avaliar a prevalência de catarata nos profissionais que atuam na área de hemodinâmica no Brasil. Métodos: Profissionais expostos à radiação ionizante (grupo 1, G1) foram submetidos ao exame biomicroscópico com lâmpada de fenda para avaliação do cristalino, e comparados aos não expostos (grupo 2, G2). Os achados foram descritos e classificados quanto ao grau de opacidade e localização por meio do Lens opacities classification system III. Ambos os grupos responderam questionário sobre condições de trabalho e de saúde para afastar fatores de risco para catarata, e foram comparados quanto aos achados. Foi utilizado um nível de significância de 5% (p < 0,05). Resultados: Foram avaliados 112 voluntários (G1) com média de idade 44,95 (±10,23) anos e 88 voluntários (G2) com média de 48,07 (±12,18) anos. Desses, 75,2% (G1) e 85,2% (G2) eram médicos. A análise estatística entre os grupos G1 e G2 mostrou uma prevalência da catarata no grupo G1 de 33% comparada ao G2 de 16% (p = 0,0058), sendo a catarata subcapsular posterior presente em 13% no G1 e 2% no G2 (p = 0,0081). Considerando apenas os médicos, 38% no G1 e 15% no G2 (p = 0,0011) apresentaram catarata, sendo a subcapsular posterior 13% e 3% (p = 0,0176), respectivamente. No grupo dos profissionais não médicos, não houve diferença estatisticamente significativa na prevalência dos achados oftalmológicos. Conclusões: A catarata esteve mais presente no grupo de profissionais expostos à radiação ionizante, sendo que a catarata subcapsular posterior foi o dano tecidual mais encontrado.

Practice variation in the management of patent ductus arteriosus in extremely low birth weight infants in the United States: Survey results among cardiologists and neonatologists.

BACKGROUND: Patent ductus arteriosus (PDA) is highly prevalent in extremely low birth weight (ELBW), preterm infants. There are diverse management approaches for the PDA in ELBW infants. The objectives of this research were to identify current PDA management practices among cardiologists and neonatologists in the United States, describe any significant differences in management, and describe areas where practices align. METHODS: A survey of 10 questions based on the management of PDA in ELBW infants was conducted among 100 prominent neonatologists from 74 centers and 103 prominent cardiologists from 75 centers. Among the cardiologists, approximately 50% were interventionists who perform transcatheter PDA closures (TCPC). Fisher's exact test was performed to compare practice variations among neonatologists and cardiologists. A potentially biased audience including a combination of health care providers belonging to cardiology, neonatology, and surgery were also surveyed during the International PDA Symposium. The results of this survey were not included for statistical comparison, due to this audience being potentially influenced by the Symposium. RESULTS: Statistically significant differences were identified between neonatologists and cardiologists regarding the impact of PDA closure on morbidity and mortality, with 80% cardiologists responding that it does vs 54% of neonatologists (P < 0.001), the need for PDA closure (P < .001), and the preferred method of PDA closure if indicated (P < .001). There was agreement between neonatologists and cardiologists on symptomatic therapy; however more neonatologists favored watchful waiting over intervention in contrast to more cardiologists favoring intervention over observation (77% vs 95%, P < .001). Survey responses also identified a need for further training and research on TCPC. CONCLUSION: Neonatologists and cardiologists have notable differences in managing PDA, and continued discussion across cardiology and neonatology has the potential to facilitate more of a consensus on best management practices. Further investigation is needed to identify outcomes in transcatheter PDA closure, particularly in ELBW infants.

[Evaluation of cardiovascular risk and perioperative management of patients undergoing noncardiac surgery. Results of an ANMCO web survey]. / Valutazione del rischio cardiovascolare e della gestione perioperatoria del paziente candidato a chirurgia non cardiaca. I risultati della web survey ANMCO.

BACKGROUND: Cardiovascular risk stratification and perioperative management of subjects undergoing non-cardiac surgery have recently been updated in the 2014 European Society of Cardiology guidelines. Nevertheless, and notwithstanding the epidemiological relevance of this condition, an underevaluation of the importance of perioperative risk stratification is a common feeling. METHODS: The ANMCO Cardiovascular Prevention Area organized, last year, a web-based survey with 15 questions to investigate perioperative management and care pathways in non-cardiac surgery and to evaluate guideline adherence of Italian cardiologists. Participation in the survey was anonymous. RESULTS: Respondents had a homogeneous geographical, as well as working (coronary care unit, post-intensive care unit, ambulatory service) distribution. Among respondents, 38% evaluated more than 20 patients each month, and 25% more than 20 patients aged >75 years. Local diagnostic guidelines were available according to 60% of respondents. Despite guideline recommendations, cardiological evaluation preceded the anesthesiologic one according to 36% of respondents, and 42% reported that it was performed independent of baseline risk. In addition, perioperative use of risk scores was low (1%), and functional capacity was reported from only 56% of respondents. Half of them used bridge therapy with heparin after stopping direct oral anticoagulants. CONCLUSIONS: The results of the ANMCO web-based survey confirm the need to promote educational programs on risk stratification and to raise awareness of Italian cardiologists on this matter in order to improve guideline adherence.

The Impact of Formal Training and Certification on the Relationship Between Volume and Outcomes in Percutaneous Coronary Interventions.

BACKGROUND: Little data are available on the impact of formal training and certification on the relationship between volumes and outcome in percutaneous coronary interventions (PCIs).The objective of this report is to study the relationship between PCI volume and outcome for a formally trained interventional cardiologist who is certified by the American Board on Internal Medicine - Interventional Cardiology subspecialty board. METHODS: The operator witnessed 3 different PCI volumes/yr over a 15-year practice period (2000-2014): <50 PCI/yr (years 2000-2006; n = 179), 50-100 PCI/yr (years 2007-2010; n = 256), and >100 PCI/yr (years 2011-2014; n = 427). Angiographic and procedural success rates were compared between the 3 volume groups, as well as in-hospital cardiovascular events (death, recurrent myocardial infarction, repeat PCI, stroke, or coronary artery bypass surgery). RESULTS: The in-hospital mortality rate throughout the study period was 0.8% and was not statistically significant among the 3 volume groups. There was also no significant difference among the 3 groups with respect to recurrent myocardial infarction or repeat PCI. There was a slightly higher rate of same-stay elective coronary artery bypass grafting in the early low-volume period compared with the other 2 groups (2.2% vs. 0.8% vs. 0.2%; P = 0.04). The overall angiographic and procedural success rates were 97.3% and 96.5%, and they were not significantly different among the 3 groups. CONCLUSIONS: Our study shows that the angiographic and procedural success rates of PCI, as well as the in-hospital mortality, do not seem to be dependent on the annual volume for formally trained and certified interventional cardiologists.