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1.
J Card Fail ; 24(12): 835-841, 2018 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-30012360

RESUMEN

BACKGROUND: Guyana is a small developing country with a high burden of cardiovascular disease and extensive barriers to optimal care delivery. We investigated the effectiveness of a newly established multidisciplinary inpatient cardiology service in this setting. METHODS: We performed an interrupted time-series cohort study of heart failure (HF) patients admitted to the Georgetown Public Hospital Corporation from January to December 2015 and July 2016 to December 2017. The primary outcome was discharge on guideline-directed medical therapy (GDMT). Secondary outcomes included length of hospitalization and all-cause mortality. RESULTS: We identified 740 patients, 347 (46.9%) of whom were admitted after service implementation. The postimplementation cohort was more likely to be discharged on a beta-blocker (66.6% vs 41.7%; P < .01) and mineralocorticoid receptor antagonist (31.7% vs 15.3%; P = .01). They were also more likely to undergo echocardiography (60.8% vs 40.5%; P < .01) and chest x-rays (70.6% vs 46.6%; P < .01). Hospitalization length (10.0 ± 13.1 vs 9.8 ± 10.1 days) and readmissions within 90 days (19.0% vs 19.1%) were not significantly different. There were fewer deaths in the postimplementation cohort compared with the preimplementation cohort (12/347 vs 28/393). CONCLUSIONS: Establishment of a multidisciplinary inpatient cardiology service demonstrated increased adherence to GDMT without extending length of hospitalization.


Asunto(s)
Cardiología/normas , Adhesión a Directriz , Insuficiencia Cardíaca/terapia , Hospitalización/tendencias , Pacientes Internos , Evaluación de Resultado en la Atención de Salud , Causas de Muerte/tendencias , Países en Desarrollo , Femenino , Estudios de Seguimiento , Guyana/epidemiología , Insuficiencia Cardíaca/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia/tendencias
4.
Glob Heart ; 19(1): 20, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38404615

RESUMEN

Background: Although there is evidence of peer support in high-income countries, the use of peer support as an intervention for cardiometabolic disease management, including type 2 diabetes (T2DM), in low- and middle-income countries (LMICs), is unclear. Methods: A scoping review methodology was used to search the databases MEDLINE, Embase, Emcare, PsycINFO, LILACS, CDSR, and CENTRAL. Results: Twenty-eight studies were included in this scoping review. Of these, 67% were developed in Asia, 22% in Africa, and 11% in the Americas. The definition of peer support varied; however, peer support offered a social and emotional dimension to help individuals cope with negative emotions and barriers while promoting disease management. Conclusions: Findings from this scopingreview highlight a lack of consistency in defining peer support as a component of CMD management in LMICs. A clear definition of peer support and ongoing program evaluation is recommended for future research.


Asunto(s)
Países en Desarrollo , Diabetes Mellitus Tipo 2 , Humanos , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/terapia , Renta , Evaluación de Programas y Proyectos de Salud , Asia
5.
Glob Heart ; 19(1): 33, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38549727

RESUMEN

Rheumatic and congenital heart disease, cardiomyopathies, and hypertensive heart disease are major causes of suffering and death in low- and lower middle-income countries (LLMICs), where the world's poorest billion people reside. Advanced cardiac care in these counties is still predominantly provided by specialists at urban tertiary centers, and is largely inaccessible to the rural poor. This situation is due to critical shortages in diagnostics, medications, and trained healthcare workers. The Package of Essential NCD Interventions - Plus (PEN-Plus) is an integrated care model for severe chronic noncommunicable diseases (NCDs) that aims to decentralize services and increase access. PEN-Plus strategies are being initiated by a growing number of LLMICs. We describe how PEN-Plus addresses the need for advanced cardiac care and discuss how a global group of cardiac organizations are working through the PEN-Plus Cardiac expert group to promote a shared operational strategy for management of severe cardiac disease in high-poverty settings.


Asunto(s)
Hipertensión , Enfermedades no Transmisibles , Humanos , Enfermedades no Transmisibles/epidemiología , Enfermedades no Transmisibles/terapia , Política
7.
Glob Heart ; 18(1): 22, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-37125388

RESUMEN

Guyana is one of the poorest countries in South America, with the highest rate of cardiovascular mortality on the continent. As is the case in many low- and middle-income countries, cardiovascular care is available through the private sector but is not accessible to much of the urban and rural poor. We present the 10-year experience of the Guyana Program to Advance Cardiac Care (GPACC), an academic partnership aiming to provide high-quality, equitable cardiovascular care in Georgetown's only public hospital. We discuss the implementation of a cardiac care program using the World Health Organization Framework for Action, outlining vital components for care delivery in resource-limited settings. GPACC was able to demonstrate that targeted investment, education of clinicians, and cohesive healthcare delivery strategies can contribute to sustainable service delivery for Guyana's largest burden of disease. This structured approach may provide lessons for implementation of similar programs in other resource-limited settings. Highlights: In many LMICs, specialized cardiovascular care is available in the private, but not public, sector.The WHO Framework for Action can guide development of sustainable programs in low-resource settings.GPACC can serve as a successful and innovative model for delivery of sustainable cardiovascular care.


Asunto(s)
Atención a la Salud , Países en Desarrollo , Humanos , Guyana , América del Sur , Calidad de la Atención de Salud
8.
Glob Heart ; 18(1): 35, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-37334396

RESUMEN

Background: Cardiovascular disease (CVD) is a major cause of death in Malawi. In rural districts, heart failure (HF) care is limited and provided by non-physicians. The causes and patient outcomes of HF in rural Africa are largely unknown. In our study, non-physician providers performed focused cardiac ultrasound (FOCUS) for HF diagnosis and longitudinal clinical follow-up in Neno, Malawi. Objectives: We described the clinical characteristics, HF categories, and outcomes of patients presenting with HF in chronic care clinics in Neno, Malawi. Methods: Between November 2018 and March 2021, non-physician providers performed FOCUS for diagnosis and longitudinal follow-up in an outpatient chronic disease clinic in rural Malawi. A retrospective chart review was performed for HF diagnostic categories, change in clinical status between enrollment and follow-up, and clinical outcomes. For study purposes, cardiologists reviewed all available ultrasound images. Results: There were 178 patients with HF, a median age of 67 years (IQR 44 - 75), and 103 (58%) women. During the study period, patients were enrolled for a mean of 11.5 months (IQR 5.1-16.5), after which 139 (78%) were alive and in care. The most common diagnostic categories by cardiac ultrasound were hypertensive heart disease (36%), cardiomyopathy (26%), and rheumatic, valvular or congenital heart disease (12.3%).At follow-up, the proportion of New York Heart Association (NYHA) class I patients increased from 24% to 50% (p < 0.001; 95% CI: 31.5 - 16.4), and symptoms of orthopnea, edema, fatigue, hypervolemia, and bibasilar crackles all decreased (p < 0.05). Conclusion: Hypertensive heart disease and cardiomyopathy are the predominant causes of HF in this elderly cohort in rural Malawi. Trained non-physician providers can successfully manage HF to improve symptoms and clinical outcomes in limited resource areas. Similar care models could improve healthcare access in other rural African settings.


Asunto(s)
Cardiomiopatías , Insuficiencia Cardíaca , Humanos , Femenino , Anciano , Adulto , Persona de Mediana Edad , Masculino , Estudios Retrospectivos , Malaui/epidemiología , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/terapia , Accesibilidad a los Servicios de Salud
9.
Lancet Glob Health ; 9(7): e957-e966, 2021 07.
Artículo en Inglés | MEDLINE | ID: mdl-33984296

RESUMEN

BACKGROUND: Despite declines in deaths from rheumatic heart disease (RHD) in Africa over the past 30 years, it remains a major cause of cardiovascular morbidity and mortality on the continent. We present an investment case for interventions to prevent and manage RHD in the African Union (AU). METHODS: We created a cohort state-transition model to estimate key outcomes in the disease process, including cases of pharyngitis from group A streptococcus, episodes of acute rheumatic fever (ARF), cases of RHD, heart failure, and deaths. With this model, we estimated the impact of scaling up interventions using estimates of effect sizes from published studies. We estimated the cost to scale up coverage of interventions and summarised the benefits by monetising health gains estimated in the model using a full income approach. Costs and benefits were compared using the benefit-cost ratio and the net benefits with discounted costs and benefits. FINDINGS: Operationally achievable levels of scale-up of interventions along the disease spectrum, including primary prevention, secondary prevention, platforms for management of heart failure, and heart valve surgery could avert 74 000 (UI 50 000-104 000) deaths from RHD and ARF from 2021 to 2030 in the AU, reaching a 30·7% (21·6-39·0) reduction in the age-standardised death rate from RHD in 2030, compared with no increase in coverage of interventions. The estimated benefit-cost ratio for plausible scale-up of secondary prevention and secondary and tertiary care interventions was 4·7 (2·9-6·3) with a net benefit of $2·8 billion (1·6-3·9; 2019 US$) through 2030. The estimated benefit-cost ratio for primary prevention scale-up was low to 2030 (0·2, <0·1-0·4), increasing with delayed benefits accrued to 2090. The benefit-cost dynamics of primary prevention were sensitive to the costs of different delivery approaches, uncertain epidemiological parameters regarding group A streptococcal pharyngitis and ARF, assumptions about long-term demographic and economic trends, and discounting. INTERPRETATION: Increased coverage of interventions to control and manage RHD could accelerate progress towards eradication in AU member states. Gaps in local epidemiological data and particular components of the disease process create uncertainty around the level of benefits. In the short term, costs of secondary prevention and secondary and tertiary care for RHD are lower than for primary prevention, and benefits accrue earlier. FUNDING: World Heart Federation, Leona M and Harry B Helmsley Charitable Trust, and American Heart Association.


Asunto(s)
Unión Africana/economía , Inversiones en Salud , Cardiopatía Reumática/prevención & control , África/epidemiología , Análisis Costo-Beneficio , Humanos , Modelos Teóricos , Prevención Primaria , Cardiopatía Reumática/mortalidad , Prevención Secundaria
10.
Aorta (Stamford) ; 7(3): 93-95, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31618780

RESUMEN

This case report describes a 55-year-old male who presented with acute Type A aortic dissection. He underwent emergent surgical repair, and his intraoperative transesophageal echocardiography revealed a quadricuspid aortic valve. His aortic root measured 45 mm. Quadricuspid aortic valves have previously been associated with aortic root dilation. This case illustrates the possible association of quadricuspid aortic valves with aortic dissection, similar to what is described with bicuspid valves.

12.
Curr Treat Options Cardiovasc Med ; 20(7): 52, 2018 Jun 19.
Artículo en Inglés | MEDLINE | ID: mdl-29923126

RESUMEN

Aortic stenosis (AS) is the most common valvular disease in the elderly and is associated with poor outcomes. Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) in high-risk patients. Herein, we describe the gender-related differences in baseline characteristics and pathophysiologic response to severe AS, imaging considerations unique to females, and short- and long-term outcomes after TAVR. Women undergoing TAVR are older and frailer, have less cardiovascular comorbidities, smaller femoral artery size, better left ventricular systolic function, hypertrophied and small left ventricles leading to a higher incidence of paradoxical low-flow low-gradient AS, and a greater prevalence of porcelain aorta, smaller aortic annulus size, and lower coronary ostia heights. Imaging and histopathological data also suggests a sex-related myocardial response to pressure overload from AS. Women experience more vascular complications and blood transfusion requirements, serious procedural complications, and a greater incidence of stroke, but have better long-term outcomes than men. Patient-prosthesis mismatch, which is a concern in patients with a small aortic annulus size undergoing SAVR, has not been problematic with TAVR. The aforementioned findings suggest that TAVR may be preferable for women with severe AS. Further studies are warranted to directly compare TAVR with SAVR in women.

13.
Heart ; 104(16): 1317-1322, 2018 08.
Artículo en Inglés | MEDLINE | ID: mdl-29572249

RESUMEN

Echocardiography plays an important role in the assessment of valvular aortic stenosis. Updated recommendations focusing on a stepwise approach to evaluating aortic stenosis have recently been published by the European Association of Cardiovascular Imaging and the American Society of Echocardiography. This review uses illustrative cases to demonstrate technical aspects of aortic stenosis assessment and use of the new proposed classification scheme for aortic stenosis. Key points from the updated recommendations reviewed in this paper are: (1) technical considerations and sources of error in measurement of peak velocity, mean aortic valve gradient and aortic valve area by continuity equation. (2) Application of flow status using indexed left ventricular stroke volume to distinguish patients with low gradients and a low calculated aortic valve area. (3) Use of low-dose dobutamine stress echocardiography in patients with low ejection fraction. (4) Application of the new classification scheme and review of algorithm use for echocardiographic evaluation of severe aortic stenosis. Improved understanding of how to handle unmatched variables and adopting an integrated approach to determine severity is central to guiding the clinician's management of aortic stenosis.


Asunto(s)
Estenosis de la Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/diagnóstico por imagen , Ecocardiografía , Anciano , Anciano de 80 o más Años , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/clasificación , Estenosis de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/terapia , Femenino , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Reproducibilidad de los Resultados , Índice de Severidad de la Enfermedad
14.
Can J Cardiol ; 34(6): 804-807, 2018 06.
Artículo en Inglés | MEDLINE | ID: mdl-29801744

RESUMEN

Atrial fibrillation and atrial flutter (AF/AFL) are associated with an increased risk of stroke and systemic embolism. However, many patients are not started on guideline-recommended oral anticoagulation (OAC). We determined factors associated with initiation of OAC in eligible patients presenting to emergency departments. This retrospective cohort included patients with electrocardiogram (ECG)-documented AF/AFL presenting to 4 urban emergency departments in 2015. Presenting diagnoses, admission status, and comorbidities were determined by chart review. The primary outcome was OAC prescription within 90 days of ED presentation in guideline-eligible patients not previously on OAC. Of 4948 patients presenting to emergency departments with ECG-documented AF/AFL, we identified 2059 patients with Congestive Heart failure, Age (≥65),Diabetes, and Stroke (CHADS-65) score ≥1 not previously on OAC. Of those patients, 1287 (62.5%) were admitted, and 772 (37.5%) were discharged from the emergency department. Within 90 days of discharge, 663 (32.2%) patients were initiated on OAC. On multivariable analysis, hospitalization (odds ratio [OR] 1.31; 95% confidence interval [CI] 1.05-1.63, P = 0.02), presenting diagnosis of AF/AFL (OR 4.56, 95% CI 3.60-5.79, P < 0.01), and higher CHADS-65 score (OR 1.14 per point, 95% CI 1.04-1.25, P < 0.01) were associated with increased rates of OAC initiation. However, there was no association with individual components of the CHADS-65 score. Guideline-directed OAC is infrequently initiated in eligible patients within 90 days of presenting to emergency departments. The strongest factors associated with OAC initiation rates were hospitalization or having primary presenting diagnoses in emergency departments of AF/AFL after adjusting for other important characteristics. New interventions are required to improve appropriate OAC initiation in patients with AF/AFL.


Asunto(s)
Anticoagulantes , Fibrilación Atrial , Aleteo Atrial , Pautas de la Práctica en Medicina/normas , Medición de Riesgo/métodos , Accidente Cerebrovascular , Administración Oral , Anciano , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/epidemiología , Aleteo Atrial/complicaciones , Aleteo Atrial/diagnóstico , Aleteo Atrial/tratamiento farmacológico , Aleteo Atrial/epidemiología , Canadá/epidemiología , Electrocardiografía/métodos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Adhesión a Directriz/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control
15.
CJEM ; 20(6): 841-849, 2018 11.
Artículo en Inglés | MEDLINE | ID: mdl-30295590

RESUMEN

OBJECTIVE: Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF) or atrial flutter (AFL). However, OAC initiation rates in patients discharged directly from the emergency department (ED) are low. We aimed to address this care gap by implementing a quality improvement intervention. METHODS: The study was performed in four Canadian urban EDs between 2015 and 2016. Patients were included if they had an electrocardiogram (ECG) documenting AF/AFL in the ED, were directly discharged from the ED, and were alive after 90 days. Baseline rates of OAC initiation were determined prior to the intervention. Between June and December 2016, we implemented our intervention in two EDs (ED-intervention), with the remaining sites acting as controls (ED-control). The intervention included a reminder statement prompting OAC initiation according to guideline recommendations, manually added to ECGs with a preliminary interpretation of AF/AFL, along with a decision-support algorithm that included a referral sheet. The primary outcome was the rate of OAC initiation within 90 days of the ED visit. RESULTS: Prior to the intervention, 37.2% OAC-naïve patients with ECG-documented AF/AFL were initiated on OAC. Following implementation of the intervention, the rate of OAC initiation increased from 38.6% to 47.5% (absolute increase of 8.5%; 95% CI, 0.3% to 16.7%, p=0.04) among the ED-intervention sites, whereas the rate remained unchanged in ED-control sites (35.3% to 35.9%, p=0.9). CONCLUSIONS: Implementation of a quality improvement intervention consisting of a reminder and decision-support tool increased initiation of OAC in high-risk patients. This support package can be readily implemented in other jurisdictions to improve OAC rates for AF/AFL.


Asunto(s)
Fibrilación Atrial/tratamiento farmacológico , Aleteo Atrial/tratamiento farmacológico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Pacientes Ambulatorios , Alta del Paciente , Accidente Cerebrovascular/prevención & control , Terapia Trombolítica/métodos , Administración Oral , Anciano , Anciano de 80 o más Años , Alberta/epidemiología , Anticoagulantes/administración & dosificación , Fibrilación Atrial/complicaciones , Aleteo Atrial/complicaciones , Electrocardiografía , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Resultado del Tratamiento
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