Comparative effectiveness of cardiac resynchronization therapy in older patients with heart failure: Systematic review and meta-analysis.

BACKGROUND: Pivotal CRT trials enrolled patients with HFrEF significantly younger than the typical contemporary patient with HFrEF. Thus, the risks and benefits in this older population with HFrEF are largely unknown. We sought to perform meta-analyses comparing safety and effectiveness of cardiac resynchronization therapy (CRT) in older vs younger patients with heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS: PubMed, The Cochrane Library, Scopus, and Web of Science were queried for comparative effectiveness studies of CRT in older patients with HFrEF. Title, abstract, and full-text screening was performed to identify studies comparing at least 1 prespecified end point between older and younger adult patients with at least 50 participants. Random effects meta-analysis in the left ventricular ejection fraction (LVEF) mean difference (older minus younger) and the relative risk (RR) of death, improvement in New York Heart Association (NYHA) functional class, and complications are reported along with estimates of heterogeneity. In 7 studies, there was similar LVEF improvement between groups (mean difference 1.14, 95% confidence interval [CI] -0.04 to 2.32, P = .06, I2 = 53%). Older patients were equally likely as younger patients to see an improvement in NYHA functional class of at least 1 in 6 studies (RR 0.99, 95% CI 0.93-1.06, P = .76, I2 = 25%). No significant differences in the incidence of hematoma, pneumothorax, lead dislodgment, cardiac perforation, or infection requiring explant was observed. The RR of mortality in 11 studies demonstrated higher risk of all-cause mortality in older patients (RR 1.05, 95% CI 1.03-1.08, P < .01, I2 = 0%). CONCLUSIONS: Compared with younger patients, older patients receiving CRT were equally likely to experience improvement in LVEF, left ventricular end-diastolic diameter, and NYHA functional class. There was no difference in procedural complications. The higher rate of all-cause mortality in older patients likely reflects a greater underlying risk of death from competing causes.

Pragmatic Study of Clinician Use of a Personalized Patient Decision Aid Integrated into the Electronic Health Record: An 8-Year Experience.

Background: Patient decision aids (PDAs) facilitate shared decision-making (SDM) and are delivered in a variety of formats, including printed material or instructional videos, and, more recently, web-based tools. Barriers such as time constraints and disruption to clinical workflow are reported to impede usage in routine practice. Introduction: This pragmatic study examines use of PDAs integrated (iPDAs) into the electronic health record (EHR) over an 8-year period. Methods: A suite of iPDAs that personalize decision-making was integrated into an academic health system EHR. Clinician use was tracked using patient and clinician encrypted information, enabling identification of clinician types and unique uses for an 8-year period. Clinician feedback was obtained through survey. Results: Over 8 years, 1,209 identifiable clinicians used the iPDAs at least once ("aware"). Use increased over time, with 2,415 unique uses in 2010, and 23,456 in 2017. Clinicians who used an iPDA with at least 5 patients ("adopters"), increased by 82 clinicians each year (range 56-108); of clinicians who used the tool once, 54.3% became adopters. Of 261 primary care clinicians, 93.5% were aware, 86.2% were adopters, and 80.5% used the tools in the last 90 days. Clinicians perceived the iPDAs to be convenient, efficient, and encouraging of SDM. Discussion: We demonstrate that use of decision aids integrated into the EHR result in repeated use among clinicians over time and have the potential to overcome barriers to implementation. We noted a high degree of clinician satisfaction, without a sense of increase in visit time. Conclusion: Integration of PDAs into the EHR results in sustained use. Further research is needed to assess the impact of iPDAs on decisional quality.

Opposing forces of cardiogenic shock: left ventricular outflow obstruction, severe mitral regurgitation, and left ventricular dysfunction in Takotsubo cardiomyopathy.

Rates of stress (Takotsubo) cardiomyopathy have increased during the coronavirus pandemic due to social stressors, even in patients who are not infected with the virus. At times, Takotsubo cardiomyopathy (TC) may present as cardiogenic shock. Herein, we present a case during the pandemic of shock from TC secondary to left ventricular outflow tract obstruction (LVOTO), mitral regurgitation (MR), and left ventricular (LV) dysfunction. The contrasting management strategy of LVOTO, MR, and LV failure was cause for clinical challenge, and we highlight the balance of treating these opposing forces.

Predicting When Women Will Achieve Equitable Representation in Four Specialties: The WHEN Study.

BACKGROUND: For 2 decades, women have made up nearly half of medical school graduates, yet this has not translated to equity in promotion. We compare historical trends in the academic career pipeline among 4 specialties by sex. METHODS: Using the Association of American Medical Colleges database, faculty sex and rank were examined in oncology, gastroenterology, cardiovascular medicine, and general surgery for the years 2000 and 2020. RESULTS: Cardiovascular medicine, gastroenterology, and general surgery all had similar lower representation of women faculty in 2000 (17%, 17%, and 15%, respectively) compared with oncology (26%). Cardiovascular medicine and general surgery have seen smaller increases in representation over the last 20 years compared with gastroenterology and oncology. Oncology and gastroenterology are projected to reach sex parity in 2024 and 2029, followed by general surgery in 2054. At the current rate, cardiovascular medicine will not reach sex parity until 2070. CONCLUSION: Oncology and gastroenterology, compared with cardiovascular medicine and general surgery, have seen larger gains in representation of women over the past 2 decades, including at Professor rank. Disparities persist in specific fields; lessons may be learned from other specialties in which women are more likely to be promoted to leadership positions.

Racial and ethnic differences in implantable cardioverter-defibrillator patient selection, management, and outcomes.

Racial and ethnic differences in treatment-cardiovascular and otherwise-have been documented in many aspects of the American health care system and can be seen in implantable cardioverter-defibrillator (ICD) patient selection, counseling, and management. ICDs have been demonstrated to be a powerful tool in the prevention of sudden cardiac death, yet uptake across all eligible patients has been modest. Although patients who do not identify as White are disproportionately eligible for ICDs in the United States, they are less likely to see specialists, be counseled on ICDs, and ultimately have an ICD implanted. This review explores racial and ethnic differences demonstrated in ICD patient selection, outcomes including shock effectiveness, and postimplantation monitoring for both primary and secondary prevention devices. It also highlights barriers for uptake at the health system, physician, and patient levels and suggests areas of further research needed to clarify the differences, illuminate the driving forces of these differences, and investigate strategies to address them.

Women in procedural leadership roles in cardiology: The Women In Local Leadership (WILL) observational study.

BACKGROUND: Although 50% of U.S. medical students are women, this percentage fails to translate to cardiology. Gender disparities are striking in interventional cardiology (IC) and electrophysiology (EP) and in leadership. Left atrial appendage closure with the WATCHMAN device, as a novel procedure, is a lens into inequities. OBJECTIVE: The purpose of this study was to identify the characteristics and prevalence of women (1) as early WATCHMAN implanters and (2) in related leadership. METHODS: Data were collected on WATCHMAN implanters and hospitals from January 2017 to December 2018. The gender of physicians in leadership positions was identified via survey as Director of IC, Director of EP, and Chief of Cardiology. The Firth logistic model controlling for covariates modeled the rare event of a woman implanter. RESULTS: Data were obtained for 100% of the cohort. Men comprised 97% of implanters (860/886). No differences in subspecialty or implants by gender were observed. There were 414 hospitals performing WATCHMAN: 24% academic, 97% urban, and most medium/large size (94%). EP made up 61% of implanters. Only 4.8% of hospitals had women in selected leadership roles. Women represented <1% of Directors of IC and only 2.6% of both Directors of EP and Chiefs of Cardiology. Hospitals with a woman in leadership had a 4 times greater odds of a woman implanter (odds ratio 4.24; 95% confidence interval 1.16-15.41; P = .028). CONCLUSION: Women are underrepresented in cardiology procedural subspecialties in the use of novel technology and in key leadership roles. There was a greater odds of women early implanters of WATCHMAN if a woman led locally. Increasing women in leadership may improve gender diversity through visibility of role models.

Funding of Studies Supporting IA Guideline Recommendations in Cardiovascular Medicine-A Systematic Review.

Each guideline recommendation from the American Heart Association and the American College of Cardiology includes an indication of the level of supporting evidence and the associated strength of recommendation with "IA" recommendations representing those with the highest quality supporting evidence and the least amount of uncertainty for benefit. In this analysis, study type and funding sources were systematically tabulated across these IA guideline recommendations over the past 5 years. Nearly half of studies supporting IA guideline recommendations were randomized controlled trials (45%). Overall, about one third of studies supporting IA recommendations were publicly funded (34.9%) with slightly more funded through industry sources (43.5%). Funding sources varied based on the type of intervention being studied with randomized controlled trials of device, diagnostic, and pharmacological interventions reflecting predominantly industry-funded studies. Over time, studies supporting IA cardiology guideline are funded by industry about twice as often as public sources. Thus, data of adequate quality to support cardiovascular guideline recommendations come from a variety of sources.

Personalized, Electronic Health Record-Integrated Decision Aid for Stroke Prevention in Atrial Fibrillation: A Small Cluster Randomized Trial and Qualitative Analysis of Efficacy and Acceptability.

BACKGROUND: Shared decision-making in cardiology is increasingly recommended to improve patient-centeredness of care. Decision aids can improve patient knowledge and decisional quality but are infrequently used in real-world practice. This mixed-methods study tests the efficacy and acceptability of a decision aid integrated into the electronic health record (Integrated Decision Aid [IDeA]) and delivered by clinicians for patients with atrial fibrillation considering options to reduce stroke risk. We aimed to determine whether the IDeA improves patient knowledge, reduces decisional conflict, and is seen as acceptable by clinicians and patients. METHODS: A small cluster randomized trial included 6 cardiovascular clinicians and 66 patients randomized either to the IDeA (HealthDecision) or usual care (clinician discretion) during a clinical encounter when stroke prevention treatment options were discussed. The primary outcome was patient knowledge of personalized stroke risk. Exploratory outcomes included decisional conflict, values concordance, trust, the presence of a shared decision-making process, and patient knowledge related to time spent using the IDeA. Additionally, we conducted semistructured interviews with clinicians and patients who used the IDeA were conducted to assess acceptability and predictions of future use. RESULTS: The IDeA significantly increased patients' knowledge of their stroke risk (odds ratio, 3.88 [95% CI, 1.39-10.78]; P<0.01]). Patients had less uncertainty about their final decision (P=0.04). There were no significant differences in values concordance, trust in clinician or shared decision-making. Despite training, each clinician used the IDeA differently. Qualitative analysis revealed patients prefer using the IDeA earlier in their diagnosis. Clinicians were satisfied with the IDeA, yet varied in the contexts in which they planned to use it in the future. CONCLUSIONS: Using an Integrated Decision Aid, or IDeA, increases patient knowledge and lessens uncertainty for decision-making around stroke prevention in atrial fibrillation. Qualitative data provide insight into potential implementation strategies in real-world practice.

The Learning Curve for Shared Decision-making in Symptomatic Aortic Stenosis.

Importance: Shared decision-making (SDM) is widely advocated for patients with valvular heart disease yet is not integrated into the heart team model for patients with symptomatic aortic stenosis. Decision aids (DAs) have been shown to improve patient-centered outcomes and may facilitate SDM. Objective: To determine whether the repeated use of a DA by heart teams is associated with greater SDM, along with improved patient-centered outcomes and clinician attitudes about DAs. Design, Setting, and Participants: This mixed-methods study included a nonrandomized pre-post intervention and clinician interviews. It was conducted between April 30, 2015, and December 7, 2017, with quantitative analysis performed between January 12, 2017, and May 26, 2017, within 2 academic medical centers in northern New England among 35 patients with symptomatic aortic stenosis who were at high to prohibitive risk for surgery. The qualitative analysis was performed between August 6, 2018, and May 7, 2019. The Severe Aortic Stenosis Decision Aid was delivered by 6 clinicians, with patients choosing between transcatheter aortic valve replacement and medical management. Main Outcomes and Measures: Clinician SDM performance was measured using the Observer OPTION5 scale with dual-independent coding of audiotaped clinic visits. Previsit and postvisit surveys measured the patient's knowledge, satisfaction, and decisional conflict. Audiotaped clinician interviews were coded, and qualitative thematic analysis was performed. Results: Six male clinicians and 35 patients (19 of 34 women [55.9%; 1 survey was missing]; mean [SD] age, 85.8 [7.8] years) participated in the study. Shared decision-making increased stepwise with repeated use of the DA (mean [SD] Observer OPTION5 scores: usual care, 17.9 [7.6]; first use of a DA, 60.5 [30.9]; fifth use of a DA, 79.0 [8.4]; P < .001 for comparison between usual care and fifth use of DA). Multiple uses of the DA were associated with increased patient knowledge (mean difference, 18.0%; 95% CI, 1.2%-34.8%; P = .04) and satisfaction (mean difference, 6.7%; 95% CI, 2.5%-10.8%; P = .01) but not decisional conflict (mean [SD]: usual care, 96.0% [9.4%]; first use of DA, 93.8% [12.5%]; fifth use of DA, 95.0% [11.2%]; P = .60). Qualitative analysis of clinicians' interviews revealed that clinicians perceived that they used an SDM approach without DAs and that the DA was not well understood by elderly patients. There was infrequent values clarification or discussion of stroke risk. Conclusion and Relevance: In a mixed-methods pilot study, use of a DA for severe aortic stenosis by heart team clinicians was associated with improved SDM and patient-centered outcomes. However, in qualitative interviews, heart team clinicians did not perceive a significant benefit of the DA, and therefore sustained implementation is unlikely. This pilot study of SDM clarifies new research directions for heart teams.

Heart sounds: a pilot randomised trial to determine the feasibility and acceptability of audio recordings to improve discharge communication for cardiology inpatients protocol.

Introduction: Ineffective hospital discharge communication can significantly impact patient understanding, safety and treatment adherence. This may be especially true for cardiology inpatients who leave the hospital with complex discharge plans delivered in a time-pressured discharge discussion. The goal of this pilot trial was to determine if providing supplemental audio-recorded discharge instructions is feasible and to explore its impact on cardiology patients' ability to understand and self-manage their care . Methods and analysis: We will conduct a parallel-group, randomised controlled trial in adult cardiology inpatients with balanced blocking by a physician. Patients (n=50) will be randomised to usual care (verbal discussion and written summary) or intervention (usual care, plus audio-recorded discharge discussion provided to patients on a portable electronic recording device). Enrolled patients will complete study assessments immediately prior to the discharge discussion, immediately postdischarge discussion and 1 week after hospital discharge by telephone. Primary outcomes include the proportion of eligible providers and inpatients who agree to take part in the trial, the proportion of inpatients who receive the audio recording in accordance with a fidelity checklist, and the proportion who use the audio recording. We will analyse preliminary data about the impact of audio recording on patient activation, health confidence, provider communication ability, adherence and 30-day readmissions. Ethics and dissemination: This trial was approved by The Committee for the Protection of Human Subjects (CPHS) at Dartmouth College (CPHS# 00031211). Findings will be disseminated in scientific journals and at meetings. Trial registration number: NCT03735342. Protocol version: 1.0.