VT arising from sub-aortic muscular outflow tract structures: In two patients with ventricular septal defects.

BACKGROUND: Outflow tract ventricular tachycardias (OTVT) most commonly occur in the absence of structural abnormalities. We present two cases in which a structural variant in the outflow tract was critical to the OTVT. CASES: Subaortic muscular bands were identified using intracardiac echocardiography (ICE) in each of our cases with history of VSD and VT. Mapping demonstrating their critical involvement to the tachycardia and ablation along the muscular bands rendered the ventricular tachycardias non-inducible. CONCLUSION: In rare instances, a structural variant may be involved in OTVTs. The use of ICE along with electroanatomic mapping can assist in successful ablation of these ventricular tachycardias.

Antibiotic Prescribing Patterns for Sinusitis Within a Direct-to-Consumer Virtual Urgent Care.

Background:Direct-to-consumer virtual visits are increasingly popular across both for-profit and nonprofit healthcare systems.Introduction:Virtual visits offer a convenient affordable way for patients to obtain medical care for simple conditions such as sinusitis and uncomplicated urinary tract infections. However, virtual visits have been associated with increased antibiotic utilization when compared with traditional in-person care.Methods:In this retrospective cohort study, antibiotic utilization for acute sinusitis was compared between patients treated through a direct-to-consumer virtual urgent care versus a matched cohort treated through traditional urgent care.Results:Fifty-seven patients were treated for acute sinusitis within the virtual care cohort, whereas 100 patients were treated in the traditional care arm. Antibiotic utilization for acute sinusitis was lower when care was delivered virtually using live-interactive video (67%) than when using traditional urgent care (92%) (p < 0.001). When care was delivered virtually, age, gender, and care delivery modality (telephone vs. video) were not associated with antibiotic utilization for acute sinusitis.Discussion:Concerns have been raised that care delivered virtually does not meet expected quality standards when compared with traditional care. Antibiotic utilization has been used as an example of this quality gap. In this study, we demonstrate that antibiotic utilization was lower in a virtual care cohort than when care was delivered by emergency medicine physicians based in an academic setting. This suggests that awareness and sensitivity to prescribing guidelines may be more important than care delivery modality as it relates to antibiotic utilization.Conclusions:It is possible to deliver care virtually for acute sinusitis without increasing antibiotic utilization.

Repeat ablation of refractory ventricular arrhythmias in patients with nonischemic cardiomyopathy: Impact of midmyocardial substrate and role of adjunctive ablation techniques.

INTRODUCTION: Multiple ablations are often necessary to manage ventricular arrhythmias (VAs) in nonischemic cardiomyopathy (NICM) patients. We assessed characteristics and outcomes and role of adjunctive, nonstandard ablation in repeat VA ablation (RAbl) in NICM. METHODS AND RESULTS: Consecutive NICM patients undergoing RAbl were analyzed, with characteristics of the last VA ablations compared between those undergoing 1 versus multiple-repeat ablations (1-RAbl vs. >1RAbl), and between those with or without midmyocardial substrate (MMS). VA-free survival was compared. Eighty-eight patients underwent 124 RAbl, 26 with > 1RAbl, and 26 with MMS. 1-RAbl and > 1-RAbl groups were similar in age (57 ± 16 vs. 57 ± 17 years; P = 0.92), males (76% vs. 69%; P = 0.60), LVEF (40 ± 17% vs. 40 ± 18%; P = 0.96), and amiodarone use (31% vs. 46%, P = 0.22). One-year VA freedom between 1-RAbl vs. > 1RAbl was similar (82% vs. 80%; P = 0.81); adjunctive ablation was utilized more in >1RAbl (31% vs. 11%, P = 0.02), and complication rates were higher (27% vs. 7%, P = 0.01), most due to septal substrate and anticipated heart block. >1-RAbl patients had more MMS (62% vs. 16%, P < 0.01). Although MMS was associated with worse VA-free survival after 1-RAbl (43% vs. 69%, P = 0.01), when >1RAbl was performed, more often with nonstandard ablation, VA-free survival was comparable to non-MMS patients (85% vs. 81%; P = 0.69). More RAbls were required in MMS versus non-MMS patients (2.00 ± 0.98 vs. 1.16 ± 0.37; P < 0.001). CONCLUSION: For NICM patients with recurrent, refractory VAs despite previous ablation, effective arrhythmia control can safely be achieved with subsequent ablation, although >1 repeat procedure with adjunctive ablation is often required, especially with MMS.

Adherence and outcomes to direct oral anticoagulants among patients with atrial fibrillation: findings from the veterans health administration.

BACKGROUND: The direct oral anticoagulants (DOACs) reduce the risk of stroke in moderate to high-risk patients with non-valvular atrial fibrillation (AF). Yet, concerns remain regarding its routine use in real world practice. We sought to describe adherence patterns and the association between adherence and outcomes to the DOACs among outpatients with AF. METHODS: We performed a retrospective cohort study of patients in the VA Healthcare System who initiated pharmacotherapy with dabigatran, rivaroxaban, or apixaban between November 2010 and January 2015 for non-valvular AF with CHA2DS2-VASc score ≥ 2. Adherence was determined using pharmacy refill data and estimated by the proportion of days covered (PDC) over the first year of therapy. Clinical outcomes, including all-cause mortality and stroke, were measured at 6 months and used to assess measures of adherence for each DOAC. RESULTS: A total of 2882 patients were included. Most were prescribed dabigatran (72.7%), compared with rivaroxaban (19.8%) or apixaban (7.5%). The mean PDC was 0.84 ± 0.20 for dabigatran, 0.86 ± 0.18 for rivaroxaban, and 0.89 ± 0.14 for apixaban (p < 0.01). The proportion of non-adherent patients, PDC <0.80, was 27.6% for all and varied according DOAC. Lower adherence to dabigatran was associated with higher risk of mortality and stroke (HR 1.07; 1.03-1.12 per 0.10 decline in PDC). CONCLUSIONS: In a real-world VA population being prescribed anticoagulation for AF, more than one quarter had sub-optimal adherence. Lower adherence was associated with a higher risk of mortality and stroke. Efforts identifying non-adherent patients, and targeted adherence interventions are needed to improve outcomes.

Adherence to dabigatran therapy and longitudinal patient outcomes: insights from the veterans health administration.

BACKGROUND: Dabigatran is a novel oral anti-coagulant (NOAC) that reduces risk of stroke in patients with non-valvular atrial fibrillation (NVAF). It does not require routine monitoring with laboratory testing which may have an adverse impact on adherence. We aimed to describe adherence to dabigatran in the first year after initiation and assess the association between non-adherence to dabigatran and clinical outcomes in a large integrated healthcare system. METHODS: We studied a national cohort of 5,376 patients with NVAF, initiated on dabigatran between October-2010 and September-2012 at all Veterans Affairs hospitals. Adherence to dabigatran was calculated as proportion of days covered (PDC) and association between PDC and outcomes was assessed using standard regression techniques. RESULTS: Mean age of the study cohort was 71.3 ± 9.7 years; 98.3% were men and mean CHADS2 score was 2.4 ± 1.2 (mean CHA2DS2VASc score 3.2 ± 1.4). Median PDC was 94% (IQR 76%-100%; mean PDC 84% ± 22%) over a median follow-up of 244 days (IQR 140-351). A total of 1,494 (27.8%) patients had a PDC <80% and were classified as non-adherent. After multivariable adjustment, lower adherence was associated with increased risk for combined all-cause mortality and stroke (HR 1.13, 95% CI 1.07-1.19 per 10% decrease in PDC). Adherence to dabigatran was not associated with non-fatal bleeding or myocardial infarction. CONCLUSIONS: In the year after initiation, adherence to dabigatran for a majority of patients is very good. However, 28% of patients in our cohort had poor adherence. Furthermore, lower adherence to dabigatran was associated with increased adverse outcomes. Concerted efforts are needed to optimize adherence to NOACs.

Medication adherence in patients with diabetes and dyslipidemia: associated factors and strategies for improvement.

Dyslipidemia and diabetes mellitus are commonly coincident, and together contribute to the development of atherosclerotic disease. Medication therapy is the mainstay of treatment for dyslipidemia. Optimal medication therapy for dyslipidemia in patients with diabetes reduces cardiovascular events but necessitates patients take multiple medications. As a result, sub-optimal adherence to medication therapy is common. Factors contributing to medication non-adherence in patients taking multiple medications are complex and can be grouped into patient-, social and economic-, medication therapy-, and health provider and health system-related factors. Strategies aimed at improving medication adherence may target the patient, health care providers, or health systems. Recent data suggest medication non-adherence contributes to racial health disparities. In addition, health literacy, cost-related medication non-adherence, and patient beliefs regarding medication therapy have all been recently described as factors affecting medication adherence. Data from within the last year support an important role for regular contact between patients and health care providers to effectively address these factors. Cost-related barriers to medication adherence have recently been addressed through examination of health system approaches to decreasing cost-related non-adherence.

Shape of the right ventricular Doppler envelope predicts hemodynamics and right heart function in pulmonary hypertension.

RATIONALE: Systolic deceleration or "notching" of the right ventricular outflow tract Doppler flow velocity envelope (FVE(RVOT)) relates to pathologic wave reflection in the setting of elevated pulmonary artery impedance. OBJECTIVES: We investigated whether simple visual assessment of FVE(RVOT) morphology aids in hemodynamic differentiation and detection of pulmonary vascular disease among a referral pulmonary hypertension (PH) cohort. METHODS: We reviewed hemodynamics, echocardiography, and clinical data for 88 patients referred for PH and 32 subjects with systolic heart failure and PH. The FVE(RVOT) was categorized as normal (no notch [NN]); late systolic notch (LSN); or midsystolic notch (MSN). MEASUREMENTS AND MAIN RESULTS: The pulmonary vascular resistance (PVR) was highest in the MSN group (9.2 ± 3.5 Wood's units [WU]; P < 0.001) versus the LSN (5.7 ± 3.1 WU) and NN (3.3 ± 2.4 WU) groups. The ratio of stroke volume to pulse pressure (compliance) also differed by FVE(RVOT) morphology (MSN = 1.2 ± 0.5; LSN = 1.7 ± 0.8; NN = 2.6 ± 1.7; P = 0.001 and 0.04, respectively, vs. NN). MSN was 96% specific and 71% sensitive for a PVR >5 WU (positive predictive value, 98%). The MSN group had severe right ventricular dysfunction (tricuspid annular plane systolic excursion 1.6 ± 0.5 cm) relative to the LSN and NN groups (tricuspid annular plane systolic excursion 1.9 ± 0.6 vs. 2.2 ± 0.6 cm; both P < 0.05). In the PH cohort, any FVE(RVOT) notching (MSN or LSN) was highly associated with PVR >3 WU (odds ratio, 22.3; 95% confidence interval, 5.2-96.4), whereas the NN pattern predicted a PVR less than or equal to 3WU and pulmonary artery wedge pressure greater than 15 mm Hg (odds ratio, 30.2; 95% confidence interval, 6.3-144.9). CONCLUSIONS: Visual inspection of the shape of the FVE(RVOT) provides insight into the hemodynamic basis of PH in a referral PH cohort. MSN is associated with the most severe pulmonary vascular disease and right heart dysfunction.

Use of cell phone adapters is associated with reduction in disparities in remote monitoring of cardiac implantable electronic devices.

BACKGROUND: Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is standard of care. However, it is underutilized. In July 2012, our institution began providing cell phone adapters (CPAs) to patients free of charge following CIED implantation to improve remote transmission (RT) adherence. METHODS: Patients in our institution's RM database from January 1, 2010, thru June 30, 2015, were retrospectively reviewed. There were 2157 eligible patients. Remote transmission proportion (RTP) and time to transmission (TT) were compared pre- and post-implementation of free CPA. Chi-squared analysis and Kruskal-Wallis tests were performed to compare RTP and TT. RESULTS: There was a significant increase in RTP (134 [18.4%] vs 99 [54.7%]; p < 0.001) and decrease in median TT in days (189[110-279] vs 58 [10-149]; p < 0.001) after CPAs were provided to patients. Caucasian patients were more likely than African Americans and Hispanics to use RM prior to CPAs (p = 0.04). After the implementation of CPAs, there was a significant increase in RTP for all racial groups (< 0.001) with no difference in RTP among racial groups (p = 0.18). The RTP for urban residents was significantly greater than non-urban residents with CPAs (p = 0.008). Patients greater than 70 years of age were significantly less likely to participate in RT before and after CPAs were provided (p = 0.03, p = 0.01, respectively). CONCLUSIONS: CPAs significantly improve RTP and reduce median TT for all patients regardless of race, geographic residence, and age (> 70 years old to lesser extent). Broad institution of CPAs following ICD implantation could potentially reduce disparity in RTP and deserves more study.

Switching warfarin to direct oral anticoagulants in atrial fibrillation: Insights from the NCDR PINNACLE registry.

BACKGROUND: Previous studies examining the use of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) have largely focused on patients newly initiating therapy. Little is known about the prevalence/patterns of switching to DOACs among AF patients initially treated with warfarin. HYPOTHESIS: To examine patterns of anticoagulation among patients chronically managed with warfarin upon the availability of DOACs and identify patient/practice-level factors associated with switching from chronic warfarin therapy to a DOAC. METHODS: Prospective cohort study of AF patients in the NCDR PINNACLE registry prescribed warfarin between May 1, 2008 and May 1, 2015. Patients were followed at least 1 year (median length of follow-up 375 days, IQR 154-375) through May 1, 2016 and stratified as follows: continued warfarin, switched to DOAC, or discontinued anticoagulation. To identify significant predictors of switching, a three-level multivariable hierarchical regression was developed. RESULTS: Among 383 008 AF patients initially prescribed warfarin, 16.3% (n = 62 620) switched to DOACs, 68.8% (n = 263 609) continued warfarin, and 14.8% (n = 56 779) discontinued anticoagulation. Among those switched, 37.6% received dabigatran, 37.0% rivaroxaban, 24.4% apixaban, and 1.0% edoxaban. Switched patients were more likely to be younger, women, white, and have private insurance (all P < .001). Switching was less likely with increased stroke risk (OR, 0.92; 95%CI, 0.91-0.93 per 1-point increase CHA2 DS2 -VASc), but more likely with increased bleeding risk (OR, 1.12; 95%CI, 1.10-1.13 per 1-point increase HAS-BLED). There was substantial variation at the practice-level (MOR, 2.33; 95%CI, 2.12-2.58) and among providers within the same practice (MOR, 1.46; 95%CI, 1.43-1.49). CONCLUSIONS: Among AF patients treated with warfarin between October 1, 2010 and May 1, 2016, one in six were switched to DOACs, with differences across sociodemographic/clinical characteristics and substantial practice-level variation. In the context of current guidelines which favor DOACs over warfarin, these findings help benchmark performance and identify areas of improvement.

Use of Cardiac Resynchronization Therapy Defibrillator in US Hospitals.

Importance: Cardiac resynchronization therapy (CRT) provides significant reduction in morbidity and mortality in select patients with left ventricular systolic dysfunction and specific parameters of electrocardiographic evidence of dyssynchrony. Relative to the 2012 American College of Cardiology/American Heart Association/Heart Rhythm Society guideline update for patient selection, little is known about the contemporary use of CRT in the United States. Objective: To describe the use of CRT defibrillator (CRT-D) in the period around guideline revision. Design, Setting, and Participants: All patients undergoing new CRT-D implantations in the National Cardiovascular Data Registry for implantable cardioverter-defibrillators from January 1, 2012, to December 31, 2015, at 1710 participating hospitals were identified for this population-based study. Rates of CRT-D implantation that were concordant and discordant with the 2012 American College of Cardiology/American Heart Association/Heart Rhythm Society update of the 2008 guidelines for device-based therapy were determined. Analysis began in January 2012. Main Outcomes and Measures: Increase in guideline-concordant CRT-D implantation. Results: Among 135 253 patients undergoing initial CRT-D implantation, 88 923 were included in the study cohort, of which 73 859 implants (83.1%) were guideline concordant. The proportion of guideline-concordant devices increased from 81.2% (16 710 of 20 481) in 2012 to 84.2% (20 515 of 24 356) in 2015 (P for trend < .001). Significant clustering was noted with 33% (565 of 1710) of hospitals accounting for greater than 70% (10 545 of 15 065) of guideline-discordant CRT-D implants. Conduction abnormalities, in particular, underlying right bundle branch block (3597 [23.9%] vs 7425 [10.1%]; P < .001) and nonspecific intraventricular conduction delay (3341 [22.2%] vs 4769 [6.5%]; P < .001) were more common in those who received guideline-discordant devices. Conclusions and Relevance: Rates of guideline-concordant CRT-D implantation increased during the study. The major fraction of guideline-discordant implants were clustered at a minority of hospitals. Conduction abnormalities, particularly non-left bundle branch block and nonspecific intraventricular conduction delay, correlated with guideline-discordant implants indicating continued opportunity for dissemination and understanding of guideline updates.