Variations and inequities in access to cardiac diagnostic services in Ontario Canada.

OBJECTIVES: Echocardiography is an essential diagnostic modality known to have wide regional utilization variations. This study's objectives were to quantify regional variations and to examine the extent to which they are explained by differences in population age, sex, cardiac disease prevalence (CDP), and social determinants of health (SDH) risk. METHODS: This is an observational study of all echocardiography exams performed in Ontario in 2019/20 (n = 695,622). We measured regional variations in echocardiography crude rates and progressively standardized rates for population age, sex, CDP, and SDH risk. RESULTS: After controlling for differences in population age, sex, and CDP, Ontario's highest rate regions had echocardiography rates 57% higher than its lowest rate regions. Forty eight percent of total variation was not explained by differences in age, sex, and CDP. CDP increased with SDH risk. Access to most cardiac diagnostics was negatively correlated with SDH risk, while cardiac catheterization rates were positively correlated with SDH risk. CONCLUSION: Variations analysis that adjusts for age and sex only without including clinical measures of need are likely to overestimate the unwarranted portion of total variation. Substantial variations persisted despite a mandatory provider accreditation policy aimed at curtailing them. The associations between variations and SDH risks imply a need to redress access and outcome inequities.

A Prospective Study Evaluating the Feasibility and Accuracy of Post-operative Laryngeal Ultrasonography (LUSG) in Assessment of Vocal Cord Function After Esophagectomy.

BACKGROUND: Vocal cord paresis (VCP) is a serious complication after esophagectomy. Conventional diagnosis of VCP relies on flexible laryngoscopy (FL), which is invasive. Laryngeal ultrasonography (LUSG) is non-invasive and convenient. It has provided accurate VC evaluation after thyroidectomy but it is unclear if it is just as accurate following esophagectomy. This prospective study evaluated the feasibility and accuracy of LUSG in VC assessment on day-1 after esophagectomy. METHODS: Consecutive patients from a tertiary teaching hospital who underwent elective esophagectomy were prospectively recruited. All received pre-operative FL, and post-operative LUSG and FL on Day-1, each performed by a blinded, independent assessor. The primary outcomes were feasibility and accuracy of LUSG in the diagnosis of VCP on Day-1 post-esophagectomy. The accuracy of voice assessment (VA) was analyzed. RESULTS: Twenty-six patients were eligible for analysis. The median age was 70 years (66-73). Majority were male (84.6%). Twenty-five (96.2%) received three-phase esophagectomy. Twenty-four (96%) had same-stage anastomosis at the neck. Three (11.5%) developed temporary and one (3.8%) developed permanent unilateral VCP. Overall VC visualization rate by LUSG was 100%; sensitivity, specificity, positive predictive value, negative predictive value (NPV) and accuracy of LUSG were 75.0%, 100%, 100%, 98.0%, 98.1% respectively, and superior to VA. Combining LUSG with VA findings could pick up all VCPs i.e. improved sensitivity and NPV to 100%. CONCLUSION: LUSG is a highly feasible, accurate and non-invasive method to evaluate VC function early after esophagectomy. Post-operative FL may be avoided in patients with both normal LUSG and voice.

Combining Aortic Size With Arterial Hemodynamics Enhances Assessment of Future Thoracic Aortic Aneurysm Expansion.

BACKGROUND: Thoracic aortic aneurysm (TAA) is a deadly disease whose current method for risk stratification (aneurysm size) is imperfect. We sought to evaluate whether combining aortic size with hemodynamic measures that reflect the aorta's function was superior to aortic size alone in the assessment of TAA expansion. METHODS: One hundred thirty-seven nonoperated participants with TAA were followed prospectively. Aortic stiffness and pulsatile hemodynamics were noninvasively assessed at baseline with a combination of arterial tonometry with echocardiography using validated methodology. Aneurysm growth was calculated from standard imaging modalities. Multivariable linear regression models adjusted for potential confounders evaluated the association of aneurysm size and arterial hemodynamics, alone and in combination, with TAA growth. RESULTS: Sixty-nine percent of participants were male. Mean ± SD age, baseline aneurysm size, follow-up, and aneurysm expansion were, respectively, 62.2 ± 11.4 years, 45.9 ± 4.0 mm, 4.5 ± 1.9 years, and 0.41 ± 0.46 mm/year. In the linear regression models, the standardised ß (ß∗) for the association of aneurysm size with aneurysm expansion was 0.178 (P = 0.044). This was improved by combining aortic size with most measures of aortic function, with ß∗ ranging from 0.192 (for aneurysm size combined with central diastolic blood pressure) to 0.484 (for aneurysm size combined with carotid-femoral pulse-wave velocity) (P ≤ 0.05 for each). CONCLUSIONS: Combining aneurysm size with measures of arterial function improves assessment of aneurysm growth over TAA size alone, which is the standard for clinical decisions in TAA. Thus, combining aneurysm size with measures of aortic function provides a clinical advantage in the assessment of TAA disease activity.

Bundled interventions for consumption management and monitoring of personal protective equipment in COVID-19 pandemic in Hong Kong local hospitals.

Since the outbreak of COVID-19 in December 2019, there had been global shortage of personal protective equipment (PPE) supply due to the breakage of supply chain and also the forbidding of PPE exported by various countries. This situation had greatly affected the healthcare services in local hospitals of Hong Kong. To maintain the availability of PPE for healthcare workers in high-risk clinical settings, the cluster management of New Territories West Cluster, Hospital Authority, had implemented a bundle of interventions in controlling and managing the PPE consumption and ensuring its proper use. A Taskforce on Management of PPE was set up in February 2020 with the aim to monitor and manage the use of PPE in five local hospitals and eight general outpatient clinics of New Territories West Cluster, which were governed in a cluster basis, under the COVID-19 epidemic. Interventions including cutting down non-essential services, implementing telecare, monitoring PPE consumption at unit level and PPE stock at the Cluster Central Distribution Centre and forming mobile infection teams were implemented. The updated PPE standards and usage guidelines to clinical staff were promulgated through forums, newsletters and unit visits. The PPE consumption rates of individual unit were reviewed. Significant decrease in PPE consumption rates was noted when comparing with the baseline data. Comparing the data between 20 February and 1 June 2020, the overall PPE consumption rates were reduced by 64% (r=-0.841; p<0.001) while the PPE consumption rates in anaesthesia and operating theatres, and isolation and surveillance wards were reduced by 47% (r=-0.506; p=0.023) and 49% (r=-0.810; p<0.001), respectively. A bundled approach, including both administrative measures and staff education, is effective in managing PPE consumption during major infection outbreaks especially when PPE supply is at risk.

Echocardiographic Assessment of Young Male Draft-Eligible Elite Hockey Players Invited to the Medical and Fitness Combine by the National Hockey League.

The "athletic heart" is characterized by hypertrophy and dilation of the heart, in addition to functional and electrical remodeling. The aim of this study was to provide reference 2-dimensional (2DE) and 3-dimensional (3DE) echocardiographic measurements in a large database on draft-eligible elite ice hockey players and to determine the frequency of occult cardiac anomalies in this cohort of athletes. In this prospective cohort study, we performed a comprehensive cardiac assessment of the 100 top draft picks selected by the National Hockey League. Complete 2DE and 3DE examinations were performed to obtain comprehensive measurements of cardiac structure and function at rest, which were compared with nonathlete controls. A total of 592 athletes were evaluated (mean age 18 ± 0.5 years) from 2009 to 2014 at the National Hockey League combine. 2DE and 3DE ventricular, atrial dimensions, and left ventricular mass were significantly greater in the athletes compared with controls. Abnormalities were identified in 15 hockey players (2.5%) consisting of a bicuspid aortic valve in 10 (1.7%), patent ductus arteriosus in 1 (0.2%), low normal left ventricular systolic function in 2 (0.3%), an idiopathic pericardial effusion in 1 (0.2%), and posterior mitral valve prolapse in 1 (0.2%). In conclusion, intense ice hockey training is associated with typical myocardial adaptations and the frequency of cardiac anomalies found in this cohort of young elite hockey players is low and does not differ significantly from the reported incidences in the general population.

Echocardiography in the Assessment of Patients with Rheumatologic Diseases.

Cardiovascular disease is an important extra-articular manifestation of rheumatologic diseases leading to considerable mortality and morbidity. Echocardiography emerges as a useful non-invasive technique for the screening and evaluation of cardiac involvement in these patients. With the technological advancement in echocardiographic techniques, we have gained a greater appreciation of the prevalence and nature of the cardiac involvement in these patients, as detection of subclinical disease is increasingly feasible. This review discusses cardiac involvement in patients with rheumatoid arthritis, systemic lupus erythematosus, anti-phospholipid antibody syndrome, systemic sclerosis and ankylosing spondylitis, and the role of different echocardiographic modalities in their evaluation.

Routine versus selective cardiac magnetic resonance in non-ischemic heart failure - OUTSMART-HF: study protocol for a randomized controlled trial (IMAGE-HF (heart failure) project 1-B).

BACKGROUND: Imaging has become a routine part of heart failure (HF) investigation. Echocardiography is a first-line test in HF given its availability and it provides valuable diagnostic and prognostic information. Cardiac magnetic resonance (CMR) is an emerging clinical tool in the management of patients with non-ischemic heart failure. Current ACC/AHA/CCS/ESC guidelines advocate its role in the detection of a variety of cardiomyopathies but there is a paucity of high quality evidence to support these recommendations.The primary objective of this study is to compare the diagnostic yield of routine cardiac magnetic resonance versus standard care (that is, echocardiography with only selective use of CMR) in patients with non-ischemic heart failure. The primary hypothesisis that the routine use of CMR will lead to a more specific diagnostic characterization of the underlying etiology of non-ischemic heart failure. This will lead to a reduction in the non-specific diagnoses of idiopathic dilated cardiomyopathy and HF with preserved ejection fraction. DESIGN: Tertiary care sites in Canada and Finland, with dedicated HF and CMR programs, will randomize consecutive patients with new or deteriorating HF to routine CMR or selective CMR. All patients will undergo a standard clinical echocardiogram and the interpreter will assign the most likely HF etiology. Those undergoing CMR will also have a standard examination and will be assigned a HF etiology based upon the findings. The treating physician's impression about non-ischemic HF etiology will be collected following all baseline testing (including echo ± CMR). Patients will be followed annually for 4 years to ascertain clinical outcomes, quality of life and cost. The expected outcome is that the routine CMR arm will have a significantly higher rate of infiltrative, inflammatory, hypertrophic, ischemic and 'other' cardiomyopathy than the selective CMR group. DISCUSSION: This study will be the first multicenter randomized, controlled trial evaluating the role of CMR in non-ischemic HF. Non-ischemic HF patients will be randomized to routine CMR in order to determine whether there are any gains over management strategies employing selective CMR utilization. The insight gained from this study should improve appropriate CMR use in HF. TRIAL REGISTRATION: NCT01281384.

Impact of blood pressure on the Doppler echocardiographic assessment of severity of aortic stenosis.

OBJECTIVE: To investigate the impact of blood pressure (BP) on the Doppler echocardiographic (Doppler-echo) evaluation of severity of aortic stenosis (AS). METHODS: Handgrip exercise or phenylephrine infusion was used to increase BP in 22 patients with AS. Indices of AS severity (mean pressure gradient (DeltaP(mean)), aortic valve area (AVA), valve resistance, percentage left ventricular stroke work loss (% LVSW loss) and the energy loss coefficient (ELCo)) were measured at baseline, peak BP intervention and recovery. RESULTS: From baseline to peak intervention, mean (SD) BP increased (99 (8) vs 121 (10) mm Hg, p<0.001), systemic vascular resistance (SVR) increased (1294 (264) vs 1552 (372) dynexs/cm(5), p<0.001) and mean (SD) transvalvular flow rate (Q(mean)) decreased (323 (67) vs 306 (66) ml/s, p = 0.02). There was no change in DeltaP(mean) (36 (13) vs 36 (14) mm Hg, p = NS). However, there was a decrease in AVA (1.15 (0.32) vs 1.09 (0.33) cm(2), p = 0.02) and ELCo (1.32 (0.40) vs 1.24 (0.42) cm(2), p = 0.04), and an increase in valve resistance (153 (63) vs 164 (74) dynexs/cm(5), p = 0.02), suggesting a more severe valve stenosis. In contrast, % LVSW loss decreased (19.8 (6) vs 16.5 (6)%, p<0.001), suggesting a less severe valve stenosis. There was an inverse relationship between the change in mean BP and AVA (r = -0.34, p = 0.02); however, only the change in Q(mean) was an independent predictor of the change in AVA (r = 0.81, p<0.001). CONCLUSIONS: Acute BP elevation due to increased SVR can affect the Doppler-echo evaluation of AS severity. However, the impact of BP on the assessment of AS severity depends primarily on the associated change in Q(mean), rather than on an independent effect of SVR or arterial compliance, and can result in a valve appearing either more or less stenotic depending on the direction and magnitude of the change in Q(mean).

Comparison of real-time 3-dimensional echocardiography with conventional 2-dimensional echocardiography in the assessment of structural heart disease.

We evaluated the diagnostic use of a real-time 3-dimensional (3D) echocardiographic system in 106 patients referred for echocardiography during a 4-month period. Real-time 3D echocardiography was performed and recorded in parallel with a routine, comprehensive 2-dimensional (2D) study. The diagnoses were exclusively on the basis of 2D findings. The 3D volumes were sliced offline in the 3 dimensions to selectively display specific cardiac structures and reviewed independent of the 2D findings. The 3D studies were graded as: A, new finding not on 2D studies; B, useful anatomic perspective; C, equivalent to 2D studies; or D, missed 2D findings. Compared with 2D echocardiography, 3D echocardiography was graded A in 7 (7%), B in 19 (18%), C in 65 (61%), and D in 15 (14%) cases. In the 26 grade-A and grade-B studies, mitral valve disease and congenital heart disease accounted for 16 (61%) cases. Suboptimal image quality was present in 7 (47%) of the 15 grade-D studies. Thus, real-time 3D echocardiography yields anatomic information comparable with conventional 2D echocardiography in the majority of patients. It can provide new and useful anatomic insight, particularly in patients with mitral valve disease and congenital heart disease. Suboptimal image quality remains a problem for real-time 3D echocardiography in some patients.

Economic impact of contrast stress echocardiography on the diagnosis and initial treatment of patients with suspected coronary artery disease.

OBJECTIVE: To estimate the impact of contrast stress echocardiography on resource use in the treatment of patients with suspected coronary artery disease (CAD). METHODS: Fifty-nine patients with suspected CAD underwent nuclear perfusion imaging and contrast echocardiography examination. Further treatment was planned after each test and a final treatment was recommended after reviewing the results of both examinations. Medical resources and productivity losses were then collected for a 3-month follow-up period. RESULTS: Diagnosis was possible in 96.6% of patients with nuclear perfusion imaging and 93.2% with contrast echocardiography, resulting in a cost per successful diagnosis of $637 (Can) and $476 (Can), respectively. For the majority of patients (74%), both tests provided the same result, but for 12 patients nuclear imaging suggested abnormal perfusion, whereas contrast echocardiography indicated normal function and for 2 patients it was the opposite situation. Per-patient costs for the total patient population decreased from $316 (Can) after nuclear perfusion imaging to $250 (Can) when results from both tests were known. Three-month follow-up societal costs were $441 (Can) per patient, with hospitalization contributing 58% of this total cost. CONCLUSION: Contrast echocardiography has a similar success rate to nuclear perfusion imaging in diagnosing CAD, but has a 28% lower cost and has the potential of additional cost savings through the elimination of further diagnostic tests.