'We are somehow fixated on this being a diabetes drug': a qualitative study exploring the views of cardiologists and nephrologists about sodium-glucose cotransporter 2 inhibitor initiation.

BACKGROUND: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are now indicated for heart failure and chronic kidney disease (CKD), irrespective of the presence of diabetes. Hence, cardiologists and nephrologists have an important role in initiating these drugs. AIMS: To explore cardiologists' and nephrologists' perspectives regarding initiating SGLT2i and their safety monitoring practices when initiating SGLT2i. METHODS: Purposive and snowball approaches were used to recruit participants working in diverse areas in New South Wales, Australia. Semi-structured interviews were conducted with 12 cardiologists and 12 nephrologists. Interviews were conducted until thematic saturation was reached. Emergent themes were identified from transcripts. An iterative general inductive approach was used for data analysis. RESULTS: There was a reluctance amongst most non-heart-failure subspecialist cardiologists to initiate SGLT2i. Reasons included the perception of SGLT2i as diabetes drugs, concern about side effects, lack of experience and issues with follow-up. In contrast, nephrologists reported feeling confident to initiate SGLT2i. Nephrologists varied in their opinions about the severity of CKD at which SGLT2i initiation was reasonable and monitoring of renal function following initiation. Government subsidisation was an important factor in the decision to prescribe SGLT2i to people without diabetes. CONCLUSIONS: Our findings highlight the complex transition from the perception of SGLT2i as diabetes drugs to cardiometabolic and reno-protective agents. Interdisciplinary collaboration may enable greater confidence amongst specialists to initiate SGLT2i, including in patients with CKD. Additionally, there is a need for clear and detailed guidance about SGLT2i prescription in patients with renal dysfunction and renal function monitoring following SGLT2i initiation.

Wait Times for Scheduling Appointments for Prevention of Macrovascular and Microvascular Complications of Diabetes: Cross-Sectional Descriptive Study.

BACKGROUND: Diabetes is a chronic disease that requires lifelong management and care, affecting around 422 million people worldwide and roughly 37 million in the United States. Patients newly diagnosed with diabetes must work with health care providers to formulate a management plan, including lifestyle modifications and regular office visits, to improve metabolic control, prevent or delay complications, optimize quality of life, and promote well-being. OBJECTIVE: Our aim is to investigate one component of system-wide access to timely health care for people with diabetes in New York City (NYC), namely the length of time for someone with newly diagnosed diabetes to obtain an appointment with 3 diabetes care specialists: a cardiologist, an endocrinologist, and an ophthalmologist, respectively. METHODS: We contacted the offices of 3 different kinds of specialists: cardiologists, endocrinologists, and ophthalmologists, by telephone, for this descriptive cross-sectional study, to determine the number of days required to schedule an appointment for a new patient with diabetes. The sampling frame included all specialists affiliated with any private or public hospital in NYC. The number of days to obtain an appointment with each specialist was documented, along with "time on hold" when attempting to schedule an appointment and the presence of online booking capabilities. RESULTS: Of the 1639 unique physicians affiliated with (private and public) hospitals in the 3 subspecialties, 1032 (cardiologists, endocrinologists, and ophthalmologists) were in active practice and did not require a referral. The mean wait time for scheduling an appointment was 36 (SD 36.4; IQR 12-51.5) days for cardiologists; 82 (SD 47; IQR 56-101) days for endocrinologists; and 50.4 (SD 56; IQR 10-72) days for ophthalmologists. The median wait time was 27 days for cardiologists, 72 days for endocrinologists, and 30 days for ophthalmologists. The mean time on hold while attempting to schedule an appointment with these specialists was 2.6 (SD 5.5) minutes for cardiologists, 5.4 (SD 4.3) minutes for endocrinologists, and 3.2 (SD 4.8) minutes for ophthalmologists, respectively. Over 46% (158/341) of cardiologists enabled patients to schedule an appointment on the web, and over 55% (128/228) of endocrinologists enabled patients to schedule an appointment on the web. In contrast, only approximately 25% (117/463) of ophthalmologists offered web-based appointment scheduling options. CONCLUSIONS: The results indicate considerable variation in wait times between and within the 3 specialties examined for a new patient in NYC. Given the paucity of research on wait times for newly diagnosed people with diabetes to obtain an appointment with different specialists, this study provides preliminary estimates that can serve as an initial reference. Additional research is needed to document the extent to which wait times are associated with complications and the demographic and socio-economic characteristics of people served by different providers.

Association of Neighborhood-Level Material Deprivation With Atrial Fibrillation Care in a Single-Payer Health Care System: A Population-Based Cohort Study.

BACKGROUND: There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care. METHODS: This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply. RESULTS: Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]). CONCLUSIONS: Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.

Few geriatric heart failure patients investigated according to clinical guidelines: a retrospective review of patient records.

BACKGROUND: Research on heart failure (HF) has often focused on younger patients. The aim of this study was to analyze extent of investigation and treatment among older patients prior to referral to inpatient geriatric care for worsening of HF. METHODS: Data on etiology, ejection fraction (EF) by echocardiography (ECHO), level of functioning according to New York Heart Association (NYHA), analysis of N-terminal-pro-brain natriuretic peptide (NT-Pro-BNP), ongoing treatment, adherence to guidelines, and information from previous caregiver were collected from patient records prior to admission from a sample of 134 patients. RESULTS: Few patients had been examined by a cardiologist (14%) during the year prior to referral. EF assessment had been performed in 78% (n = 105). The patients were categorized as having HF with reduced (HFrEF 28%), preserved (HFpEF 53%) or mid-range (HFmrEF 19%) EF. HFpEF patients had older EF assessments (mean 517 days) than those with HFrEF (385 days). In 61% (n = 82) at least one assessment with NT-Pro-BNP had been performed, being older among patients with HFpEF (290 days vs 16 days). There was a strong positive correlation (OR 4.9, p = 0.001) between having recent assessments of EF and NT-Pro-BNP (n = 30, 21%) and being presented with etiology in the referral, adjusted for EF, age, sex, and comorbidity. Among the HFrEF patients, 78% were treated with ACEI/ARB and BB according to ESC guidelines but reaching only half of target doses. In the HFpEF group the corresponding treatment was 46%. Among patients with EF ≤ 35% only 14% were treated with mineral receptor antagonists, ie low adherence to guidelines. CONCLUSIONS: HF care in this population of older individuals showed deficiencies. There was little contact with cardiologists, lack of information of etiology in referrals and low adherence to treatment guidelines. Improving adherence to HF guidelines regarding investigation and treatment for HF in older people is therefore urgent and calls for more collaboration between specialists in cardiology and geriatric medicine.

Factors influencing adherence to clinical practice guidelines in patients with suspected chronic coronary syndrome: a qualitative interview study in the ambulatory care sector in Germany.

BACKGROUND: Chronic coronary syndrome (CCS) is a potentially progressive clinical presentation of coronary artery disease (CAD). Clinical practice guidelines (CPGs) are available for prevention, diagnosis, and treatment. Embedded in the "ENLIGHT-KHK" healthcare project, a qualitative study was conducted to identify factors that influence guideline adherence from the perspective of general practitioners (GPs) and cardiologists (CA) in the ambulatory care sector in Germany. METHODS: GPs and CAs were surveyed via telephone using an interview guide. The respondents were first asked about their individual approach to caring for patients with suspected CCS. Subsequently, the accordance of their approach with guideline recommendations was addressed. Finally, potential measures for assisting with guideline adherence were discussed. The semi-structured interviews were transcribed verbatim and analysed using a qualitative content analysis in accordance with Kuckartz and Rädiker. Factors influencing adherence to CPGs were categorised by assessing whether they (i) inhibited or facilitated guideline adherence, (ii) played a role in patients at risk of CCS or with suspected or known CCS, (iii) were mentioned in implicit or explicit thematic reference to CPGs, and (iv) were declared a practical problem. RESULTS: Based on interviews with ten GPs and five CAs, 35 potential influencing factors were identified. These emerged at four levels: patients, healthcare providers, CPGs, and the healthcare system. The most commonly cited barrier to guideline adherence among the respondents was structural aspects at the system level, including reachability of providers and services, waiting times, reimbursement through statutory health insurance (SHI) providers, and contract offers. There was a strong emphasis on interdependencies between factors acting at different levels. For instance, poor reachability of providers and services at the system level may result in inexpedience of guideline recommendations at the CPG level. Likewise, poor reachability of providers and services at the system level may be aggravated or alleviated by factors such as diagnostic preferences at the patient level or collaborations at the provider level. CONCLUSIONS: To assist with adherence to CPGs regarding CCS, promoting measures may be needed that account for interdependencies between barriers and facilitators at various healthcare levels. Respective measures should consider medically justified deviations from guideline recommendations in individual cases. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00015638; Universal Trial Number (UTN): U1111-1227-8055.

Assessment of real-time electrocardiogram effects on interpretation quality by emergency physicians.

BACKGROUND: Electrocardiogram (ECG) is one of the most commonly performed examinations in emergency medicine. The literature suggests that one-third of ECG interpretations contain errors and can lead to clinical adverse outcomes. The purpose of this study was to assess the quality of real-time ECG interpretation by senior emergency physicians compared to cardiologists and an ECG expert. METHODS: This was a prospective study in two university emergency departments and one emergency medical service. All ECGs were performed and interpreted over five weeks by a senior emergency physician (EP) and then by a cardiologist using the same questionnaire. In case of mismatch between EP and the cardiologist our expert had the final word. The ratio of agreement between both interpretations and the kappa (k) coefficient characterizing the identification of major abnormalities defined the reading ability of the emergency physicians. RESULTS: A total of 905 ECGs were analyzed, of which 705 (78%) resulted in a similar interpretation between emergency physicians and cardiologists/expert. However, the interpretations of emergency physicians and cardiologists for the identification of major abnormalities coincided in only 66% (k: 0.59 (95% confidence interval (CI): 0.54-0.65); P-value = 1.64e-92). ECGs were correctly classified by emergency physicians according to their emergency level in 82% of cases (k: 0.73 (95% CI: 0.70-0.77); P-value ≈ 0). Emergency physicians correctly recognized normal ECGs (sensitivity = 0.91). CONCLUSION: Our study suggested gaps in the identification of major abnormalities among emergency physicians. The initial and ongoing training of emergency physicians in ECG reading deserves to be improved.

Career perspectives for young cardiologists in the Netherlands: a steady increase in temporary positions.

In the Netherlands, concerns have been raised regarding the high unemployment rates and the lack of permanent positions for young medical specialists. In the current study, we present data on contemporary early career perspectives in the field of cardiology. We conducted a survey among 304 young cardiologists who completed their training between 2015 and 2020; the response rate was 91%. Our analysis revealed a low unemployment rate (0.3%). One, 3 and 5 years after registration, 81%, 41% and 18% of the respondents, respectively, had not gained a permanent position. Having conducted a fellowship significantly delayed the time to permanent position (hazard ratio (HR): 0.48; 95% confidence interval (CI): 0.34-0.67). For those who had conducted a fellowship, holding a PhD degree (HR: 1.95; 95% CI: 1.10-3.44), age (per year increase, HR: 0.90; 95% CI: 0.82-0.99) and training in an academic hospital (HR: 1.97; 95% CI: 1.10-3.52) were of significant influence on the likelihood of having a permanent position at 3 years of follow-up. These results showed a disturbing increase in time to permanent position compared with an earlier analysis. This trend justifies close monitoring of the labour market in the coming years. Solutions for this multifactorial problem in the field of cardiology and across the entire medical specialty spectrum should be explored.

Opinion seeking behaviour of healthcare providers in ambulatory cardiovascular care in Germany: a cross-sectional study.

BACKGROUND: Healthcare providers' inclination to seek or lead other providers' opinions on clinical topics may influence healthcare practices, particularly regarding their alignment across different providers in controversial domains. This study aimed to explore opinion-seeking behaviours of general practitioners and their impacts on clinical opinions in ambulatory cardiovascular care in Germany. METHODS: Between 2019 and 2021, we performed a written survey in two samples of general practitioners and one sample of self-employed cardiologists in three German states. The general practitioners were asked to identify a person they deemed influential on their views on cardiovascular conditions. Their self-perceived opinion leadership and opinion seeking behaviours were then measured, using a validated 12-item-questionnaire. General practitioners and cardiologists were requested to indicate their agreement with three potentially controversial aspects of cardiovascular ambulatory care. Potential impacts on the general practitioners' views, including local cardiologists' opinions, were examined using multi-level linear regression models. RESULTS: A total of 129 general practitioners and 113 cardiologists returned the questionnaire. 68.50% of general practitioners named an opinion leader, mainly cardiologists outside of their practice. General practitioners perceived themselves as opinion seeking and as opinion leading at the same time. Views on the presented controversial topics were mixed among both general practitioners and cardiologists. Self-reported opinion leadership behaviour of general practitioners was associated with their views on one of the three topics. No such associations were found for opinion seeking behaviours and the views of local cardiologists. CONCLUSION: While most general practitioners named a cardiovascular opinion leader and saw themselves as opinion seeking regarding cardiovascular issues, they simultaneously perceived themselves as opinion leading, suggesting that opinion leadership and opinion seeking are not mutually exclusive concepts. The views of local cardiologists were not associated with the general practitioners' view, suggesting that local medical specialists do not necessarily influence the surrounding opinion seekers' views per se. TRIAL REGISTRATION: We registered the study prospectively on 7 November 2019 at the German Clinical Trials Register (DRKS, www.drks.de ) under ID no. DRKS00019219.

Measuring continuity of ambulatory cardiovascular care: a cross-sectional study on the applicability of the Nijmegen Continuity Questionnaire in Germany.

BACKGROUND: Chronic cardiovascular diseases demand continuous care from general practitioners and medical specialists. Especially in fragmented healthcare systems, such as in Germany, a large body of research is devoted to the improvement of care continuity. Meanwhile, measuring continuity of care itself has been a challenge due to the absence of validated instruments. In 2011, the Dutch Nijmegen Continuity Questionnaire (NCQ) was developed and validated to measure continuity of care across care settings from the patients' perspectives in the Netherlands. Its applicability in other countries and health systems, however, has rarely been tested. We therefore aimed at assessing the applicability of the Nijmegen Continuity Questionnaire to the German health care context.  METHODS: We translated and applied the original NCQ to an ambulatory cardiovascular care setting in Germany. Qualitative interview data and quantitative survey data on our adaptation were collected from patients in 27 general practices within the German states of Baden-Wuerttemberg and Rhineland-Palatinate. Qualitative data on understandability and clearness of the questionnaire was obtained using semi-structured telephone interviews and think aloud-protocols. Quantitative data was obtained through an anonymous written questionnaire containing the translated NCQ items to assess applicability of our translation. We performed confirmatory and exploratory factor analyses based on the original NCQ-structure mapped to general practitioners and an aggregated analysis of general practitioners and cardiologists combined. RESULTS: A total of 6 patients participated in the interviews and a total of 435 patients participated in the written survey. The interviews showed that, overall, patients had little difficulties comprehending and answering to our translation of the NCQ. The confirmatory factor analyses then showed that the structure of the original NCQ with 12 items and 3 latent factors can also be found in the German context. However, a simpler 2-factor-structure would also fit well with the data. CONCLUSION: A German translation of the NCQ yielded a factor structure comparable to the original version and proved to be understandable for patients. TRIAL REGISTRATION: The project underlying the study was registered on November 7, 2019 in the German Clinical Trials Register ( www.drks.de ) under ID: DRKS00019219.

Career perspectives for young cardiologists in the Netherlands: a steady increase in temporary positions.

In the Netherlands, concerns have been raised regarding the high unemployment rates and the lack of permanent positions for young medical specialists. In the current study, we present data on contemporary early career perspectives in the field of cardiology. We conducted a survey among 304 young cardiologists who completed their training between 2015 and 2020; the response rate was 91%. Our analysis revealed a low unemployment rate (0.3%). One, 3 and 5 years after registration, 81%, 41% and 18% of the respondents, respectively, had not gained a permanent position. Having conducted a fellowship significantly delayed the time to permanent position (hazard ratio (HR): 0.48; 95% confidence interval (CI): 0.34-0.67). For those who had conducted a fellowship, holding a PhD degree (HR: 1.95; 95% CI: 1.10-3.44), age (per year increase, HR: 0.90; 95% CI: 0.82-0.99) and training in an academic hospital (HR: 1.97; 95% CI: 1.10-3.52) were of significant influence on the likelihood of having a permanent position at 3 years of follow-up. These results showed a disturbing increase in time to permanent position compared with an earlier analysis. This trend justifies close monitoring of the labour market in the coming years. Solutions for this multifactorial problem in the field of cardiology and across the entire medical specialty spectrum should be explored. Supplementary Information: The online version of this article (10.1007/s12471-022-01736-1) contains supplementary material, which is available to authorized users.

Palpitation referrals from primary care to a secondary care cardiology outpatient clinic: assessing adherence to guidelines.

BACKGROUND AND AIMS: Palpitations are a common presentation in primary care. Guidelines have been developed to identify patients with palpitations who require further assessment by a cardiologist in secondary care. However, patients that do not meet guideline thresholds for referrals are still referred to secondary care services. This audit evaluated the adherence to referral guidelines at our trust and assessed the characteristics of patients who were referred appropriately versus those referred without meeting guideline referral thresholds (inappropriate referral). RESULTS: Palpitation referrals to a single cardiology outpatient clinic were assessed (n = 66). Half the patients referred for palpitations were referred inappropriately (n = 34, 51.5%). Patients referred inappropriately were more likely to have a benign diagnosis after assessment (91.2%). These patients also had significantly fewer investigations [mean difference of 1.1 (confidence interval: 0.6-1.6)]. Specialist investigations, such as cardiac event recorders (P < 0.05) and cardiac magnetic resonance imaging (P < 0.05) were less likely to be used in inappropriately referred patients. CONCLUSIONS: The results from this audit provide early evidence that there are a significant number of patients who are being referred that could be managed in primary care. Further studies are needed to confirm our findings in larger cohorts and to establish the underlying reasons for inappropriate referrals.

Healthcare professionals' perceptions of impacts of the Covid-19-pandemic on outpatient care in rural areas: a qualitative study.

BACKGROUND: Measures to manage the COVID-19 pandemic have led to impacts on healthcare systems and providers worldwide. Outpatient healthcare professionals (HCPs) provide the majority of patient care. Insight into their experiences during a pandemic is rare. Therefore, we explored how primary and secondary care HCPs in a rural area in Germany experienced their work during the pandemic and what health-related outcomes they perceived in their patients. In this context, we also examined the impact on access to and utilization of healthcare and working conditions. METHODS: We conducted a qualitative interview study with outpatient HCPs. We recruited by e-mail, telephone, professional networks and personal contacts. Data were collected between August 2020 and January 2021. All interviews were audio recorded, transcribed, and analysed using qualitative content analysis. RESULTS: Our sample consisted of 28 HCPs (15 family physicians, 7 cardiologists, and 6 non-physician assistants, 12 female) from Saxony-Anhalt, Germany. HCPs experienced fewer consultations as well as cancellations by hospitals and secondary care physicians, especially at the beginning of the Covid-19-pandemic, while they continued throughout to provide outpatient care. They quickly adopted changes in practice organisation and healthcare provision. There was a shift towards telephone consultations, home visits as well as unconventional consultations e.g. through the practice window. Family physicians used personal relationships to support utilization of healthcare and to avoid health-related effects. Social tension and burden seemed to interact with a perceived lack of preparedness, the pandemic-related changes in their working condition as well as access to and utilization of healthcare. Chronic disease monitoring was postponed, which could have consequences in the course of disease of patients. HCPs experienced effects on patients' psychological well-being. CONCLUSION: Our study demonstrates the impacts of Covid-19-pandemic on outpatient care in rural areas and emphasizes its importance. HCPs experienced impacts on access to and utilization of healthcare, working conditions and health-related outcomes. Health policy should create a framework for healthcare to support outpatient care in rural areas with a looming undersupply of primary and secondary care in order to maintain healthcare and reduce pandemic impacts.

Prevention of Infective Endocarditis of Oral Origin in Children: A Call for Pediatric Dentists-Pediatric Cardiologists' Collaboration in Egypt.

AIM: To assess knowledge and practices of some Egyptian pediatric dentists and pediatric cardiologists/cardiac surgeons regarding prevention of infective endocarditis (IE) from oral origin in children. MATERIALS AND METHODS: Pediatric dentists or pediatric cardiologists/cardiac surgeons having their practice in Egypt were conveniently selected. An online questionnaire was constructed for each specialty practitioner in English using a web-based platform. Each survey tool collected data about demographics, knowledge, and practices concerning the prevention of IE of oral origin. Surveys were disseminated to potential respondents using direct messaging or posting surveys' links on high-traffic areas (blogs, groups, or pages) of commonly known social media platforms. RESULTS: Two-hundred and thirty-nine pediatric dentists and 71 pediatric cardiologists/cardiac surgeons' responses were included in analysis. Some shortage in oral health knowledge and deviations in management protocol from known guidelines were evident in cardiologists' responses, whereas 66.2 and 64.8% reported encountering IE of oral origin or canceling a cardiac surgery due to oral infection, respectively. Most pediatric dentists (65.7%) rely on physician referral before managing children at risk of IE despite following recognized guidelines for IE prevention which may reflect difficulty in understanding such guidelines. Ninety percent of children with heart diseases visit a dentist due to oral complaint and not for checkup. CONCLUSION: Identification of disparities and pitfalls in management of children with heart diseases, if appropriately addressed by pediatric dentists and cardiologists, may reduce the risk of IE from an oral origin. CLINICAL SIGNIFICANCE: Health education of both specialists and development of national guidelines based on national epidemiology and clinical experience of cardiologists are strongly needed to decrease oral disease burden, allow for a consensus of patient management, and minimize the need for cross-referral, thus facilitating dental management without undue delays.

Young Vasospastic Angina Patients Less Than 20 Years Old.

BACKGROUND: Japanese Circulation Society (JCS) guidelines do not include adolescents with coronary artery spasm.Methods and Results:We recruited 18 adolescents less than 20 years old with vasospastic angina (VSA): 11 were Japanese and 3 had chest symptoms for >12 months before admission. ST-segment elevation was observed in 11 patients and none of the 18 patients had a fixed stenosis. Spasm provocation tests were performed in 9 patients and two-thirds had multiple spasms; 6 suffered from acute myocardial infarction and ventricular fibrillation occurred in 2 patients; 1 patient died and the remaining 17 patents survived. CONCLUSIONS: Clinical status of adolescents with VSA was as severe as in adults with refractory VSA. Cardiologists should cooperate with pediatricians to diagnose and treat adolescents with VSA. There is a need to establish the additional issues for adolescents with coronary spasm in the JCS guidelines.

Patient involvement in consultation for atrial fibrillation - the cardiologists' perspective.

PURPOSE: The purpose of this paper is to analyse the accounts of Swedish cardiologists concerning patient involvement in consultations for atrial fibrillation (AF). The questions were: how cardiologists handle and provide scope for patient involvement in medical consultations regarding AF treatment and how cardiologists describe their familiarity with shared decision-making. DESIGN/METHODOLOGY/APPROACH: A descriptive study was designed. Ten interviews with cardiologists at four Swedish hospitals were held, and a qualitative content analysis was performed on the collected data. FINDINGS: The analysis shows cardiologists' accounts of persuasive practice, protective practice, professional role and medical craftsmanship when it comes to patient involvement and shared decision-making. The term "shared decision-making" implies a concept of not only making one decision but also ensuring that it is finalised with a satisfactory agreement between both parties involved, the patient as well as the cardiologist. In order for the idea of patient involvement to be fulfilled, the two parties involved must have equal power, which can never actually be guaranteed. RESEARCH LIMITATIONS/IMPLICATIONS: Methodologically, this paper reflects the special contribution that can be made by the research design of descriptive qualitative content analysis (Krippendorff, 2004) to reveal and understand cardiologists' perspectives on patient involvement and participation in medical consultation and shared decision-making. The utility of this kind of analysis is to find what cardiologists said and how they arrived at their understanding about patient involvement. Accordingly, there is no quantification in this type of research. PRACTICAL IMPLICATIONS: Cardiologists should prioritise patient involvement and participation in decision-making regarding AF treatment decisions in consultations when trying to meet the request of patient involvement. ORIGINALITY/VALUE: Theoretically, the authors have learned that the patient involvement and shared decision-making requires the ability to see patients as active participants in the medical consultation process.