RESUMO
BACKGROUND: Atrial fibrillation (AF) and mitral regurgitation (MR) are closely interrelated in the setting of heart failure (HF). Here we investigate the prevalence and prognostic significance of AF in patients with acute decompensated HF (ADHF) stratified by MR severity. METHODS AND RESULTS: The Atherosclerosis Risk in Communities Study investigated ADHF hospitalizations in residents greater than or equal to 55 years of age in 4 US communities. ADHF cases were stratified by MR severity (none/mild or moderate/severe) and HF subtype (HF with reduced [HFrEF] or preserved [HFpEF] ejection fraction). The odds of AF in patients with increasing MR severity was estimated using multivariable logistic regression, adjusting for age, race, sex, diabetes, hypertension, coronary artery disease, hemodialysis, stroke, and anemia. Cox regression models were used to assess the association of AF with 1-year mortality in patients with HFpEF and HFrEF, stratified by MR severity and adjusted as described, also adjusting for the year of hospitalization. From 2005 to 2014, there were 3,878 ADHF hospitalizations (17,931 weighted). AF was more likely in those with higher MR severity regardless of HF subtype; more so in HFpEF (odds ratio [OR] 1.38, 95% confidence interval [CI], 1.31-1.45) than in HFrEF (OR, 1.19, 95% CI, 1.13-1.25) (interaction P [by HF subtype] < .01). When stratified by HF type, association between AF and 1-year mortality was noted in patients with HFpEF (OR, 1.28, 95% CI 1.04-1.56) but not HFrEF (OR 0.96, 95% CI 0.79-1.16) (interaction by EF subtype, Pâ¯=â¯.02). CONCLUSIONS: In patients with ADHF, AF prevalence increased with MR severity and this effect was more pronounced in HFpEF compared with HFrEF. AF was associated with an increased 1-year mortality only in patients with HFpEF and concomitant moderate/severe MR. REGISTRATION: NCT00005131, https://clinicaltrials.gov/ct2/show/NCT00005131.
Assuntos
Fibrilação Atrial , Insuficiência Cardíaca , Insuficiência da Valva Mitral , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Humanos , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/epidemiologia , Prognóstico , Fatores de Risco , Volume SistólicoRESUMO
AIM: This retrospective case series study sought to describe the safety and clinical effectiveness of propafenone for the control of arrhythmias in children with and without CHD or cardiomyopathy. METHODS: We reviewed baseline characteristics and subsequent outcomes in a group of 63 children treated with propafenone at 2 sites over a 15-year period Therapy was considered effective if no clinically apparent breakthrough episodes of arrhythmias were noted on the medication. RESULTS: Sixty-three patients (29 males) were initiated on propafenone at a median age of 2.3 years. CHD or cardiomyopathy was noted in 21/63 (33%). There were no significant differences between demographics, clinical backgrounds, antiarrhythmic details, side effect profiles, and outcomes between children with normal hearts and children with CHD or cardiomyopathy. Cardiac depression at the initiation of propafenone was more common amongst children with CHD or cardiomyopathy compared to children with normal hearts. Systemic ventricular function was diminished in 15/63 patients (24%) prior to starting propafenone and improved in 8/15 (53%) of patients once better rhythm control was achieved. Other than one child in whom medication was stopped due to gastroesophageal reflux, no other child experienced significant systemic or cardiac side effects during treatment with propafenone. Propafenone achieved nearly equal success in controlling arrhythmias in both children with normal hearts and children with congenital heart disease or cardiomyopathy (90% versus 86%, p = 0.88). CONCLUSION: Propafenone is a safe and effective antiarrhythmic medication in children.
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Arritmias Cardíacas , Propafenona , Antiarrítmicos/efeitos adversos , Arritmias Cardíacas/prevenção & controle , Cardiomiopatias/epidemiologia , Pré-Escolar , Doença das Coronárias/epidemiologia , Feminino , Humanos , Masculino , Propafenona/efeitos adversos , Estudos RetrospectivosRESUMO
BACKGROUND: The patient experience of atrial fibrillation (AF) involves several daily self-care behaviors and ongoing confidence to manage their condition. Currently, no standardized self-report measure of AF patient confidence exists. The purpose of this study is to provide preliminary support for the reliability and validity of a newly developed confidence in AF management measure. METHODS: This study provides preliminary analysis of the Confidence in Atrial FibriLlation Management (CALM) scale, which was rationally developed to measure patient confidence related to self-management of AF. The scale was provided to a sample of AF patients N = 120, (59% male) electronically through a patient education platform. Principal component analysis (PCA) and Cronbach's α were employed to provide preliminary assessment of the validity and reliability of the measure. RESULTS: PCA identified a four-factor solution. Internal consistency of the CALM was considered excellent with Cronbach's α = .910. Additional PCA confirmed the value of a single factor solution to produce a total confidence score for improved utility and ease of clinical interpretation. CONCLUSIONS: Initial assessment of a novel scale measuring patient confidence in managing AF provided promising reliability and validity. Patient confidence in self-management of AF may prove useful as a key marker and endpoint of the patient experience beyond QOL.
Assuntos
Fibrilação Atrial , Autogestão , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Feminino , Humanos , Masculino , Psicometria , Qualidade de Vida , Reprodutibilidade dos Testes , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Insertable cardiac monitors (ICMs) are often used for long-term monitoring of cardiac rhythm. The Medtronic's LINQ Reveal ™ is a new generation wireless, automated, and patient responsive subcutaneous ECG monitoring device. Despite several advantages to its small size we have noted an unusually high incidence of extrusion at our center. METHODS: & Results: We conducted a retrospective case analysis to review Reveal LINQs implanted at our center. All devices were inserted using the provided insertion tools. Patients with extruded devices were identified and details regarding the site and technique of insertion, incision closure, use of peri-operative antibiotics, and follow-up details were collected. 81 patients underwent 85 Reveal LINQ implants at a tertiary care University Hospital referral center. The most common reason for implant was suspected arrhythmia with or without structural heart disease or unexplained syncope. There were 4 spontaneous extrusions occurring within 7-24 days after insertion with an incidence rate of 4.7%. One extruded device was anchored to subcutaneous tissue, and no pocket/device infections or hematomas were noted. CONCLUSIONS: Device migration and erosion through skin are important potential adverse events for the Reveal LINQ implantable loop recorder. This study reports an unexpectedly high rate of extrusion without infection. The authors suggest that the depth of the incision is the main factor impacting extrusions. Larger studies are recommended, however, and a proposed measure to avoid spontaneous extrusion is the design of a longer manufacturer's blade in order to increase the depth of the incision and insertion.
Assuntos
Desfibriladores Implantáveis , Taquicardia Sinusal , Fibrilação Ventricular , Humanos , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/fisiopatologia , Fibrilação Ventricular/classificação , Fibrilação Ventricular/etiologia , Taquicardia Sinusal/diagnóstico , Taquicardia Sinusal/fisiopatologia , Taquicardia Sinusal/classificação , Taquicardia Sinusal/etiologia , Masculino , Eletrocardiografia , Pessoa de Meia-Idade , Erros de DiagnósticoRESUMO
BACKGROUND: Catheter ablation improves symptoms and quality of life in patients with atrial fibrillation (AF); however, despite its benefit, women are less likely than men to undergo catheter ablation. Women with AF have been described to have more frequent and severe symptoms with a lower quality of life than men, and it is therefore unclear why women are less likely to undergo catheter ablation. We prospectively characterized gender differences in AF symptoms among men and women undergoing ablation at UNC using questionnaire data. METHODS: Functional capacity was assessed with the Duke Activity Status Index (DASI) and quality of life was assessed with the Canadian Cardiovascular Society Symptoms of AF score (CCS-SAF) and the AF Effect on Quality-of-Life Questionnaire Tool (AFEQT). RESULTS: Among 191 patients in the study, women were less likely to undergo catheter ablation and had higher rates of paroxysmal AF and higher CHADS2 -VASc scores than men. Women had a worse functional capacity with significantly lower DASI scores than men; quality of life was also worse among women, with higher CCS-SAF scores and lower AFEQT scores than men. After adjustment for AF type, there was a persistent gender difference for functional capacity and symptom measures. CONCLUSIONS: At the time of catheter ablation, women with AF had a significantly lower functional status with worse symptoms and a lower quality of life than men. The role of this symptom difference on the gender gap in enrollment for catheter ablation is unclear and likely due to multiple patient and provider factors.
Assuntos
Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Ablação por Cateter , Fibrilação Atrial/fisiopatologia , Autoavaliação Diagnóstica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida , Fatores Sexuais , Inquéritos e Questionários , Avaliação de SintomasRESUMO
BACKGROUND: Many patients with atrial fibrillation (AF) and elevated stroke risk are not prescribed oral anticoagulation (OAC) despite evidence of benefit. Identification of factors associated with OAC non-prescription could lead to improvements in care. METHODS AND RESULTS: Using NCDR PINNACLE, a United States-based ambulatory cardiology registry, we examined factors associated with OAC non-prescription in patients with non-valvular AF at elevated stroke risk (CHA2DS2-VASc ≥2) between January 5, 2008 and December 31, 2014. Among 674,841 patients, 57% were treated with OAC (67% of whom were treated with warfarin). OAC prescription varied widely (28%-75%) across preselected strata of age, stroke risk (CHA2DS2-VASc), and bleeding risk (HAS-BLED), generally indicating that older patients at high stroke and low bleeding risk are commonly treated with OAC. Other factors associated with OAC non-prescription included reversible AF etiology; female sex; liver, renal, or vascular disease; and physician versus non-physician provider. Antiplatelet use was common (57%) and associated with the greatest risk of OAC non-prescription (odds ratio [OR] 4.44, 95% confidence interval [CI] 4.39-4.49). CONCLUSIONS: In this registry of AF patients, older patients at elevated stroke and low bleeding risk were commonly treated with OAC. However, a variety of factors were associated with OAC non-prescription. Specifically, antiplatelet use was prevalent and associated with the highest likelihood of OAC non-prescription. Future studies are warranted to understand provider and patient rationale that may underlie observed associations with OAC non-prescription.
Assuntos
Anticoagulantes , Fibrilação Atrial , Mau Uso de Serviços de Saúde , Hemorragia , Acidente Vascular Cerebral , Idoso , Anticoagulantes/classificação , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Feminino , Mau Uso de Serviços de Saúde/prevenção & controle , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/uso terapêutico , Padrões de Prática Médica/normas , Melhoria de Qualidade , Sistema de Registros/estatística & dados numéricos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Decisions to use rhythm control in atrial fibrillation (AF) should generally be dictated by patient factors, such as quality of life, heart failure, and other comorbidities. Whether or not other factors affect decisions about the use of rhythm control, and catheter ablation in particular, is unknown. METHODS: A cohort of all patients diagnosed with nonvalvular AF were identified from the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence (PINNACLE) AF registry of US outpatient cardiology practices during the study period from May 1, 2008, to December 31, 2014. Overall and practice-specific rates of rhythm control (cardioversion, antiarrhythmic drug therapy, or catheter ablation) were assessed. We assessed patient and practice factors associated with rhythm control and determined the relative contribution of patient, practice, and unmeasured practice factors with its use. RESULTS: Among 511,958 PINNACLE AF patients, 22.3% were treated with rhythm control and 2.9% underwent catheter ablation. Significant practice variation in rhythm control was present (median rate of rhythm control across practices 22.8%, range 0.2%-62.9%). Significant patient factors associated with rhythm control therapy included white (vs nonwhite) race (odds ratio [OR] 2.43, P<.001), private (vs nonprivate) insurance (OR 1.04, P<.001), and whether a patient was seen by an electrophysiologist (OR 1.77, P<.001). In an analysis of the relative contribution of patient, practice, and unmeasured practice factors with rhythm control, the contribution of unmeasured practice factors (95% range OR 0.29-3.44) exceeded that of either patient (95% range OR 0.46-2.30) or practice (95% range OR 0.15-2.77) factors. CONCLUSIONS: One in 5 AF patients in the PINNACLE registry received rhythm control, and 1 in 50 received catheter ablation, suggesting that rhythm control may be underused. A variety of measured and unmeasured practice factors unrelated to patient characteristics play a disproportionate role in the use of rhythm control treatment decisions. Understanding the drivers of these decisions may identify inappropriate treatment variation and better inform optimal use of these therapies.
Assuntos
Fibrilação Atrial/terapia , Tomada de Decisão Clínica , Padrões de Prática Médica , Idoso , Antiarrítmicos/uso terapêutico , Ablação por Cateter , Cardioversão Elétrica , Feminino , Humanos , Masculino , Qualidade de Vida , Sistema de Registros , Fatores de Risco , Fatores SocioeconômicosRESUMO
OBJECTIVES: To determine the relationship between severity of stenosis and hemodynamic significance in calcified coronary arteries. BACKGROUND: Severity of stenosis is widely used to determine the need for revascularization but the effect of lesion calcification on hemodynamic significance is not well understood. METHODS: Two hundred consecutive patients undergoing fractional flow reserve (FFR) testing of an intermediate coronary lesion with a pressure wire and intravenous infusion of adenosine were studied. Coronary calcium was quantified based upon radiopacities at the site of the stenosis on cineangiography using the method of Mintz et al. (0 = none or mild calcium, 1 = moderate calcium, 2 = severe calcium). RESULTS: Mean age was 61 ± 11 years, 66% were males, 87.5% had hypertension, 44.5% had diabetes, and 20.5% were current smokers. The mean coronary stenosis by quantitative coronary angiography was 60 ± 12% and the mean FFR was 0.83 ± 0.08. There were 109, 45, and 46 patients classified as Calcium Score of 0, 1, or 2, respectively. Compared to those with no/mild or moderate calcification, patients with severe coronary calcium were older and more likely to have chronic kidney disease and pulmonary disease. The correlation between angiographic severity and FFR decreased as lesion calcification increased [calcium score = 0 (R2 = 0.25, P < 0.005); calcium score = 1 (R2 = 0.11, P < 0.005); calcium score = 2 (R2 = 0.02, P = 0.35)]. CONCLUSIONS: In patients with heavily calcified coronary lesions, there was no association between angiographic stenosis and hemodynamic significance and FFR is needed to determine hemodynamic significance of intermediate lesions. © 2016 Wiley Periodicals, Inc.
Assuntos
Cateterismo Cardíaco , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Vasos Coronários/diagnóstico por imagem , Reserva Fracionada de Fluxo Miocárdico , Hemodinâmica , Calcificação Vascular/diagnóstico , Adenosina/administração & dosagem , Idoso , Distribuição de Qui-Quadrado , Cineangiografia , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/fisiopatologia , Vasos Coronários/fisiopatologia , Feminino , Humanos , Infusões Intravenosas , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , North Carolina , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Índice de Gravidade de Doença , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/fisiopatologia , Vasodilatadores/administração & dosagemRESUMO
BACKGROUND: Emerging evidence indicates that the association between depression and subsequent cardiovascular events is largely mediated by health behaviors. However, it is unclear whether depression is the cause or the consequence of poor health behaviors. PURPOSE: The purpose of the present study is to examine prospective, bidirectional relationships of depressive symptoms with behavioral and lifestyle factors among patients with coronary heart disease. METHODS: Depressive symptoms and lifestyle behaviors (physical activity, medication adherence, body mass index, waist to hip ratio, sleep quality, and smoking status) were assessed at baseline and 5 years later among a prospective cohort of 667 patients with stable coronary heart disease. RESULTS: Greater depressive symptoms at baseline predicted poorer lifestyle behaviors 5 years later (less physical activity, lower medication adherence, higher body mass index, higher waist to hip ratio, worse sleep quality, and smoking). After adjustment for demographics, cardiac disease severity, comorbidity, and baseline lifestyle behaviors, depressive symptom severity remained predictive of subsequent worsening of physical activity (beta = -0.08; 95 % confidence interval (CI) = -0.16, -0.01; p = 0.03), medication adherence (beta = -0.16; 95 % CI = -0.24, -0.08; p < 0.001), and sleep quality (beta = -0.19; 95 % CI = -0.27, -0.11; p < 0.001). Baseline lifestyle behaviors also predicted 5-year change in depressive symptoms, although the associations were attenuated after adjustment for baseline depressive symptoms and covariates. CONCLUSIONS: Among patients with coronary heart disease, depressive symptoms were linked to a range of lifestyle risk factors and predicted further declines in physical activity, medication adherence, and sleep quality.
Assuntos
Doença das Coronárias/psicologia , Depressão/psicologia , Comportamentos Relacionados com a Saúde , Estilo de Vida , Idoso , Estudos de Casos e Controles , Doença das Coronárias/complicações , Depressão/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de RiscoRESUMO
BACKGROUND: Symptoms attributed to atrial fibrillation (AF) are nonspecific, and it remains unclear what influences perception of symptoms. Anxiety or depression may be important in modulating perception of AF symptoms. However, few longitudinal studies have addressed this effect. METHODS: A total of 378 patients with AF completed anxiety and depression severity questionnaires as well as AF symptom and frequency severity questionnaires. Patients were offered treatment strategies including catheter ablation or antiarrhythmic or rate-controlling medications. Patients were followed at 3-month intervals and completed follow-up questionnaires including repeat assessment of anxiety, depression, and AF symptoms. A method of generalized estimating equations was used for longitudinal analyses. RESULTS: Analysis revealed that increased anxiety or depression was associated with increased AF symptom severity (AFSS), after adjusting for potential confounders. In both unadjusted and adjusted follow-up analyses, antiarrhythmic drug therapy or catheter ablation reduced AFSS (P < 0.001). However, none of anxiety severity, depression severity, or the perception of AF frequency severity improved significantly with AF treatment. CONCLUSIONS: Our results extend previous studies demonstrating that anxiety and depression are associated with worsened AFSS. Antiarrhythmic drug therapy or catheter ablation reduces AFSS but does not affect depression and anxiety symptoms. To achieve more comprehensive AF symptom relief, treatment of both AF and psychological comorbidities may be beneficial.
Assuntos
Ansiedade/epidemiologia , Ansiedade/psicologia , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/psicologia , Fibrilação Atrial/terapia , Depressão/epidemiologia , Depressão/psicologia , Distribuição por Idade , Antiarrítmicos/uso terapêutico , Ablação por Cateter/psicologia , Ablação por Cateter/estatística & dados numéricos , Causalidade , Comorbidade , Feminino , Humanos , Incidência , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , North Carolina/epidemiologia , Fatores de Risco , Distribuição por Sexo , Resultado do TratamentoRESUMO
BACKGROUND: Displacement of ECG leads can result in unwarranted findings. We assessed the frequency of Brugada-type patterns in athletes when precordial leads were purposely placed upward. METHODS: Four hundred ninety-one collegiate athletes underwent two ECGs: one with standard leads, one with V1 and V2 along the 2nd intercostal space. A positive Brugada-type pattern was defined as ST elevation in V1 or V2 consistent with a Type 1, 2, or 3 pattern in the high-lead ECG. A control group was comprised of 181 outpatients. RESULTS: No Type 1 patterns were seen. In 58 athletes (11.8%), a Brugada-type 2 or 3 pattern was observed. Those with Brugada-type 2 or 3 patterns were more likely male, taller, and heavier. In the control group, 18 (9.9%) had Brugada-type 2 or 3 patterns and were more likely male. CONCLUSIONS: Proper lead positioning is essential to avoid unwarranted diagnosis of a Brugada-type ECG, especially in taller, heavier male athletes.
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Síndrome de Brugada/diagnóstico , Eletrocardiografia/instrumentação , Eletrocardiografia/estatística & dados numéricos , Eletrodos/estatística & dados numéricos , Esportes/estatística & dados numéricos , Adulto , Artefatos , Reações Falso-Positivas , Feminino , Humanos , Masculino , North Carolina , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Fatores Sexuais , Universidades/estatística & dados numéricosRESUMO
Atrial fibrillation (AF) is exceedingly common in patients with heart failure (HF), as they share common risk factors. Rate control is the cornerstone of treatment for AF; however, restoration of sinus rhythm should be considered when more than minimal symptoms are present. Life-threatening ventricular arrhythmias are responsible for the primary mode of death in patients with NYHA I, II, or III HF. Although implantable cardioverter defibrillators protect against sudden cardiac arrest, many patients will present with VT or ICD shocks. Antiarrhythmic drug therapy beyond beta-blocker therapy remains fundamental to the termination of acute VT and the prevention of ICD shocks.
Assuntos
Antiarrítmicos/uso terapêutico , Arritmias Cardíacas/tratamento farmacológico , Arritmias Cardíacas/etiologia , Insuficiência Cardíaca/complicações , HumanosRESUMO
There is an association between emotional eating and cardiovascular disease (CVD) risk factors; however, little is known about this association in the police force. This study explores the associations between emotional eating and CVD risk factors in law enforcement officers in North Carolina. Four hundred and five officers completed The Emotional Eating Scale, and 221 of them completed the assessment for CVD-related markers. Descriptive statistics, Pearson's correlation, and multiple linear regression analyses were performed. Emotional eating in response to anger was significantly positively associated with body weight (ß = 1.51, t = 2.07, p = 0.04), diastolic blood pressure (ß = 0.83, t = 2.18, p = 0.03), and mean arterial pressure (ß = 0.84, t = 2.19, p = 0.03) after adjusting for age and use of blood pressure medicine. Emotional eating in response to depression was significantly positively associated with triglycerides (ß = 5.28, t = 2.49, p = 0.02), while the emotional eating in response to anxiety was significantly negatively associated with triglycerides (ß = -11.42, t = -2.64, p = 0.01), after adjusting for age and use of cholesterol medicine. Our findings offer new insights to address emotional eating and lower CVD risk in law enforcement officers.
Assuntos
Doenças Cardiovasculares , Polícia , Humanos , Doenças Cardiovasculares/epidemiologia , Fatores de Risco , Fatores de Risco de Doenças Cardíacas , Triglicerídeos , Aplicação da LeiRESUMO
Background: Guidelines and risk scores have sought to standardize the management of syncope in the emergency department (ED), but variation in practice remains. Objective: The purpose of this study was to explore factors associated with admission for patients presenting to the ED with low-risk syncope. Methods: Our study population included adult patients in the Nationwide Emergency Department Sample between 2006 and 2019 who presented to an ED with a primary diagnosis of syncope. Multivariable hierarchical logistic regression analyses determined the association of patient or hospital factors with admission. Reference effect measures methodology assessed the relative contributions of patient, hospital, and unmeasured hospital factors. Results: Of the 3,206,739 qualifying encounters during the study period, 804,398 (25.1%) met low-risk criteria. Of these patients, 20,260 were admitted to the hospital (2.5%). Factors associated with increased odds of admission included increasing age and weekend presentation to the hospital, while female sex, lack of medical insurance, hospital region, teaching status, and higher ED volume decile were associated with lower odds of admission. Reference effect measures methodology demonstrated that unmeasured site variability contributed the widest range of odds for admission (odds ratio [OR] 5th percentile vs 95th percentile 0.23-4.38) compared with the composite patient (OR 0.33-3.68) or hospital (OR 0.65-1.30) factors. Conclusion: Admission patterns for low-risk syncope varies widely across institutions. Unmeasured site variation contributes significantly to the variability in admission rates, suggesting which hospital a patient presents to plays a disproportionate role in admission decisions. Further guidance to reduce practice variation in syncope care in the ED is needed.
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OBJECTIVE: Physical activity (PA) is an important clinical and quality of life outcome after transcatheter aortic valve replacement (TAVR). We examined the effect of TAVR on objectively measured PA in patients with cardiac implanted electronic devices (CIEDs). METHODS: Daily accelerometer data was obtained from CIEDs. Patients in the University of North Carolina Health System with continuous PA data at least 6 months before TAVR and 12 months after TAVR were included. Changes in activity pre- and post-TAVR were analyzed with linear mixed-effects models using a random intercept for each patient. An interaction term was included to determine differences in PA between men and women pre- and post-TAVR. RESULTS: Of the 306 patients with CIEDs who underwent TAVR, 24,655 patient-days of data from 46 patients, mean age of 82 years old, 44% of whom were female met inclusion criteria. A significant and sustained increase of 14.7% in daily PA was seen after TAVR [10.15 minutes per day, 95% confidence interval (CI) 8.75 to 11.56 P < .001] after adjusting for sex, obesity, race, history of depression, and Charlson Comorbidity Index. Effects were more prominent in women (18.57 [95% CI 16.36 to 20.79, P < .001] minute increase post-TAVR) compared to men (4.51 [95% CI 3.87 to 5.16] minute increase post-TAVR, P < .001). CONCLUSIONS: This study demonstrates PA increases after TAVR with effects more pronounced in women than men. Further, this study highlights the potential use of remote monitoring data for monitoring functional outcomes in device patients after a procedure.
Assuntos
Estenose da Valva Aórtica , Substituição da Valva Aórtica Transcateter , Humanos , Feminino , Masculino , Idoso de 80 Anos ou mais , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/etiologia , Qualidade de Vida , Caracteres Sexuais , Resultado do Tratamento , Exercício Físico , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Fatores de RiscoRESUMO
The role for direct current cardioversion (DCCV) in the management of atrial fibrillation (AF) in the emergency department (ED) is unclear. Factors associated with DCCV in current practice are not well described, nor is the variation across patients and institutions. All ED encounters with a primary diagnosis of AF were identified from the Nationwide Emergency Department Sample from 2006 to 2017. The independent association of patient and hospital factors with use of DCCV was assessed using multivariable hierarchical logistic regression. The relative contributions of patient, hospital, and unmeasured hospital factors were assessed using reference effect measures methods. Among 1,280,914 visits to 3,264 EDs with primary diagnosis of AF, 31,422 patients (2.4%) underwent DCCV in the ED. History of stroke (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.09 to 0.22, p <0.001) and dementia (OR 0.14, 95% CI 0.10 to 0.19, p <0.001) was associated with lowest odds of DCCV. Comparing patients more likely to receive DCCV (ninety-fifth percentile) with patients with median risk, the influence of unmeasured hospital factors (OR 14.13, 95% CI 12.55 to 16.09) exceeded the contributions of patient (OR 5.66, 95% CI 5.28 to 6.15) and measured hospital factors (OR 3.89, 95% CI 2.87 to 5.60). In conclusion, DCCV use in the ED varied widely across institutions. Disproportionately large unmeasured hospital variation suggests that presenting hospital is the most determinative factor in the use of DCCV for ED management of AF. Clarification is needed on best practices for management of AF in the ED, including the use of DCCV.
Assuntos
Fibrilação Atrial , Humanos , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/terapia , Fibrilação Atrial/complicações , Cardioversão Elétrica/métodos , Serviço Hospitalar de EmergênciaRESUMO
BACKGROUND: A straightforward decision aid to guide disposition of atrial fibrillation (AF) patients in the emergency department (ED) was developed for use by ED providers. The implementation of this decision aid in the ED has not been studied. METHODS: A pragmatic stepped-wedge cluster approach for analysis of retrospectively collected electronic health record data was used in which 5 hospitals were selected to commence the intervention at periodic intervals following an initial 1-year baseline assessment with 5 additional hospitals included in the comparison group (all in North Carolina). The primary end point of analysis was hospitalization rate. Hierarchical multivariable logistic regression analyses for admission as a function of the intervention while controlling for prespecified patient and hospital predictors were performed with clustering done at the hospital level. RESULTS: Between October 2017 and May 2020, a total of 11 458 patients (mean age, 71.4; 50.5% female) presented to 1 of the 10 hospitals with a primary diagnosis of AF. Absolute admission rate was reduced from 60.5% to 48.3% following the intervention (odds ratio, 0.83 [95% CI, 0.71-0.97]; P=0.016). After adjusting for covariates, the intervention was associated with a small increased rate of return to the ED for AF within 30 days of the initial presentation (1.6% to 2.7%; hazard ratio, 1.70 [95% CI, 1.26-2.31]; P<0.001). CONCLUSIONS: We demonstrate that implementation of a novel decision aid to guide disposition of patients primary diagnosis of AF presenting to the ED was associated with a reduced admission rate independent of patient and hospital factors. Use of the protocol was associated with a small but significant increase in rate of repeat presentations for AF at 30-day follow-up. Use of a decision aid such as the one described here represents an important tool to reduce unnecessary AF hospitalizations.
Assuntos
Fibrilação Atrial , Humanos , Feminino , Idoso , Masculino , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/terapia , Procedimentos Clínicos , Estudos Retrospectivos , Hospitalização , Serviço Hospitalar de Emergência , Técnicas de Apoio para a DecisãoRESUMO
Background: Disparities in atrial fibrillation (AF) care are partially attributed to inadequate access to providers with specialized training in AF. Primary care providers (PCPs) are often the sole providers of AF care in under-resourced regions. Objective: To create a virtual education intervention for PCPs and evaluate its impact on use of stroke risk reduction strategies in AF patients. Methods: A multi-disciplinary team mentored PCPs on AF management over 6 months using a virtual case-based training format. Surveys of participant knowledge and confidence in AF care were compared pre- and post-intervention. Hierarchical logistic regression modeling was used to evaluate change in stroke risk reduction therapies among patients seen by participants before or after training. Results: Of 41 participants trained, 49% worked in family medicine, 41% internal medicine, and 10% general cardiology. Participants attended a mean of 14 one-hour sessions. Overall, appropriate use of oral anticoagulation (OAC) therapy (CHA 2 DS 2 -VASc score ≥1 men, ≥2 women) increased from 37% to 46% (p<.001) comparing patients seen pre- (n=1739) to post- (n=610) intervention. Factors independently associated with appropriate OAC use included participant training (OR 1.4, p=.002) and participant competence in AF management (by survey). Factors associated with decreased OAC use included patient age (OR 0.8 per 10 years, p=.008), nonwhite race (OR 0.7, p=.028). Provider knowledge and confidence in AF care both improved (p<.001). Conclusions: A virtual case-based PCP training intervention improved use of stroke risk reduction therapy in outpatients with AF. This widely scalable intervention could improve AF care in under-resourced communities. CONDENSED ABSTRACT: A virtual educational model was developed for primary care providers to improve competency in AF care in their community. Following a 6-month training intervention, the rate of appropriate oral anticoagulation (OAC) therapy among patients cared for by participating providers increased from 37% to 46% (p<.001). Among participants, knowledge and confidence in AF care improved. These findings suggest a virtual AF training intervention can improve PCP competency in AF care. This widely scalable intervention could help improve AF care in under-resourced communities.
RESUMO
The disparities in atrial fibrillation (AF) care are partially attributed to inadequate access to providers with specialized training in AF. Primary care providers (PCPs) are often the sole providers of AF care in under-resourced regions. As such, we sought to create a virtual education intervention for PCPs and to evaluate its impact on the use of stroke risk reduction strategies in patients with AF. A multidisciplinary team mentored PCPs on AF management over 6 months using a virtual case-based training format. Surveys of participant knowledge and confidence in AF care were compared before and after the intervention. Hierarchical logistic regression modeling was used to evaluate change in oral anticoagulation (OAC) therapy in the patients seen by participants before or after training. Of 41 participants trained, 49% worked in family medicine, 41% internal medicine, and 10% general cardiology. Participants attended a mean of 14 1-hour sessions. Overall, the appropriate use of OAC (for CHA2DS2-VASc score ≥1 man, ≥2 women) increased from 37% to 46% (p <0.001) comparing the patients seen before (n = 1,739) versus after (n = 610) intervention. The factors independently associated with appropriate OAC use included participant training (odds ratio [OR] 1.4, p = 0.002) and participant competence in AF management. The factors associated with decreased OAC use included patient age (OR 0.8 per 10 year, p = 0.008) and nonwhite race (OR 0.7, p = 0.028). Provider knowledge and confidence in AF care improved (p <0.001). In conclusion, we show that a virtual PCP training intervention improves the use of stroke risk reduction therapy in outpatients with AF and could be a widely scalable intervention to improve AF care in under-resourced communities.