Chest Pain Evaluation: Diagnostic Testing.

Chest pain/discomfort (CP) is a common symptom and can be a diagnostic dilemma for many clinicians. The misdiagnosis of an acute or progressive chronic cardiac etiology may carry a significant risk of morbidity and mortality. This review summarizes the different options and modalities for establishing the diagnosis and severity of coronary artery disease. An effective test selection algorithm should be individually tailored to each patient to maximize diagnostic accuracy in a timely fashion, determine short- and long-term prognosis, and permit implementation of evidence-based treatments in a cost-effective manner. Through collaboration, a decision algorithm was developed (www.chowmd.ca/cadtesting) that could be adopted widely into clinical practice.

La douleur ou la gêne thoracique sont des symptômes fréquents qui peuvent poser un dilemme diagnostique pour de nombreux médecins. Les erreurs de diagnostic d'une cause aiguë ou chronique progressive d'origine cardiaque peuvent d'ailleurs entraîner un risque considérable de morbidité et de mortalité. La présente synthèse porte sur les différentes options et modalités d'établissement du diagnostic et de la gravité d'une coronaropathie. Un algorithme efficace pour le choix des tests doit être adapté à chaque patient afin de maximiser l'exactitude diagnostique dans les plus brefs délais, de déterminer le pronostic à court et à long terme, et de permettre une mise en œuvre de traitements fondés sur des données probantes tout en tenant compte des coûts. Un algorithme décisionnel a donc été conjointement mis au point (www.chowmd.ca/cadtesting) et pourrait être largement adopté dans la pratique clinique.

Comparison of Apple Watch vs KardiaMobile: A Tale of Two Devices.

Background: The Apple Watch Series 4 (AW4) and the KardiaMobile single bipolar lead model (KM) are 2 of the most popular US Food & Drug Administration (FDA)-approved commercial heart trackers. However, a lack of knowledge remains regarding their rhythm-detection accuracy in real-life clinical situations. This paper aims to determine the practicality of using an AW4 or a KM in modern medical practice, by assessing the accuracy of each in identifying heart rhythms and heart rate. Methods: Participants from the Toronto Heart Centre clinic were enrolled from January 2019 to December 2019. They had a 12-lead electrocardiogram (ECG), followed by wearing the AW4 watch (OS 5.3), and pressing on the KM electrode plates, within the span of 5 minutes of one another. Each session involved a 12-lead ECG, an ECG from each device, and AW4's photoplethysmography function (APPG). Results: Of 200 participants, 162 (81%) were in sinus rhythm, and 38 (19%) had atrial fibrillation. The rhythm-detection accuracy for sinus rhythm was 100% for the AW4, and 99.03% for the KM. For atrial fibrillation, accuracy was 90.48% for the AW4, and 100% for the KM. The heart rate accuracy for sinus rhythm was 94.39% for the KM, 90.65% for the APPG, and 96.26% for the Apple ECG function. The heart rate accuracy for atrial fibrillation was 91.30% for the KM, 82.61% for the APPG, and 86.96% for the Apple ECG function. Conclusions: Both the AW4 and the KM could reliably detect rhythm and heart rate in real-life clinical situations. However, a nonsignificant trend occurred toward better rhythm detection and accuracy with KM, compared with AW4. The difference is mainly due to artifacts (eg, tremors) and the fit of the strap for AW4. The findings have important implications for how these consumer devices can be used in real-life clinical settings.

Contexte: La Apple Watch Series 4 (AW4) et le dispositif KardiaMobile à trois électrodes (KM) sont deux des capteurs cardiaques commerciaux les plus populaires approuvés par la Food & Drug Administration (FDA) des États-Unis. Cependant, les connaissances sont encore insuffisantes en ce qui concerne leur précision à détecter le rythme cardiaque dans des situations cliniques réelles. Cet article vise à déterminer l'utilité de l'AW4 ou du KM dans la pratique médicale moderne, en évaluant la précision de chaque appareil dans la perception des rythmes cardiaques et de la fréquence cardiaque. Méthodologie: Des patients du Toronto Heart Centre ont participé à l'étude de janvier à décembre 2019. Ils ont subi un électrocardiogramme (ECG) à 12 dérivations, puis ont porté la montre AW4 (OS 5.3) et utilisé les électrodes du KM, à intervalles de 5 minutes. Chaque séance comprenait un ECG à 12 dérivations, un ECG réalisé avec chacun des dispositifs et l'utilisation de la fonction de photopléthysmographie de l'AW4. Résultats: Sur les 200 participants, 162 (81 %) étaient en rythme sinusal et 38 (19 %) présentaient une fibrillation auriculaire. Pour ce qui est du rythme cardiaque, la précision de détection chez les patients en rythme sinusal était de 100 % pour l'AW4 et de 99,03 % pour le KM. Pour ceux présentant une fibrillation auriculaire, la précision était de 90,48 % pour l'AW4 et de 100 % pour le KM. En ce qui concerne la fréquence cardiaque, la précision de détection pour le rythme sinusal était de 94,39 % pour le KM, de 90,65 % pour la fonction de photopléthysmographie de l'AW4 et de 96,26 % pour la fonction ECG d'Apple. Chez les patients atteints de fibrillation auriculaire, la précision à détecter la fréquence cardiaque était de 91,30 % pour le KM, de 82,61 % pour la fonction de photopléthysmographie de l'AW4 et de 86,96 % pour la fonction ECG d'Apple. Conclusions: L'AW4 et le KM ont tous deux permis de détecter de manière fiable le rythme cardiaque et la fréquence cardiaque dans des situations cliniques réelles. Soulignons toutefois qu'une tendance non significative s'est dégagée en faveur du KM pour ce qui est de la détection du rythme et de la précision par rapport à l'AW4. La différence s'explique principalement par des interférences (secousses) et par l'ajustement du bracelet avec l'AW4. Ces résultats ont une incidence importante quant à l'utilisation de ces appareils destinés aux consommateurs dans un contexte clinique réel.

Epidemiology of COVID-19 and Its Cardiac and Neurologic Complications Among Chinese and South Asians in Ontario: Waves 1, 2, and 3.

Background: Although we had previously reported the cardiac and neurologic outcomes of Chinese and South Asian Ontarians in wave 1 of COVID-19, data on subsequent waves of COVID-19 remain unexamined. This is an extension study of this cohort in waves 2 and 3. Methods: We identified adult Ontarians with a positive COVID-19 polymerase chain reaction test from January 1, 2020 to June 30, 2021, and they were classified as being Chinese or South Asian using a validated surname algorithm; we compared their outcomes of mortality, and cardiac and neurologic complications with those of the general population using multivariable logistic regression models. Results: Compared to the general population (n = 439,977), the Chinese population (n = 15,208) was older (mean age 44.2 vs 40.6 years, P < 0.001) and the South Asian population (n = 46,333) was younger (39.2 years, P < 0.001). The Chinese population had a higher 30-day mortality (odds ratio [OR] 1.44; 95% confidence interval [CI] 1.28-1.61) and more hospitalization or emergency department visits (OR, 1.14; 95% CI, 1.09-1.28), with a trend toward a higher incidence of cardiac complications (OR, 1.03; 95% CI, 0.87-1.12) and neurologic complications (OR, 1.23; 95% CI, 0.96-1.58). South Asians had a lower 30-day mortality (OR, 0.88; 95% CI, 0.78-0.98) but a higher incidence of hospitalization or emergency department visits (OR, 1.17; 95% CI, 1.14-1.20) with a trend toward a lower incidence of cardiac complications (OR, 0.76; 95% CI, 0.67-0.87) and neurologic complications (OR, 0.89; 95% CI, 0.73-1.09). There was also a significant difference in these outcomes between wave 1, 2 and 3, with a greater mortality in all groups in waves 2 and 3. Conclusions: Ethnicity continues to be an important determinant of mortality, cardiac and neurologic outcomes, and healthcare use among patients with COVID-19, requiring further studies to understand factors driving these differences.

Contexte: Nous avons déjà présenté les issues cliniques cardiaques et neurologiques chez les Ontariens de descendance chinoise ou sud-asiatique pour la première vague de la pandémie de COVID-19, mais les données au sujet des vagues ultérieures n'avaient pas encore été analysées. Nous présentons ici une prolongation de cette étude de cohortes pour la seconde et la troisième vague de COVID-19. Méthodologie: Notre analyse porte sur des adultes ontariens ayant obtenu un résultat positif à un test de COVID-19 par réaction en chaîne de la polymérase entre le 1er janvier 2020 et le 30 juin 2021. Un algorithme validé pour l'analyse des noms de famille a été utilisé pour isoler les sujets de descendance chinoise ou sud-asiatique, et leur taux de mortalité de même que les complications cardiaques et neurologiques ont été comparés à ceux de la population générale à l'aide de modèles de régression logistique multivariée. Résultats: En comparaison de la population générale (n = 439 977), les personnes de descendance chinoise (n = 15 208) se sont révélées plus âgées (âge moyen de 44,2 ans contre 40,6 ans, P < 0,001), tandis que les personnes de descendance sud-asiatique (n = 46 333) étaient plus jeunes (39,2 ans, P < 0,001). Dans la population de descendance chinoise, le taux de mortalité après 30 jours était plus élevé (rapport de cotes [RC] de 1,44; intervalle de confiance [IC] à 95 % de 1,28 à 1,61), et davantage d'hospitalisations ou de consultations aux urgences sont survenues (RC de 1,14; IC à 95 % de 1,09 à 1,28). L'incidence de complications cardiaques (RC de 1,03; IC à 95 % de 0,87 à 1,12) et de complications neurologiques (RC de 1,23; IC à 95 % de 0,96 à 1,58) avait également tendance à être plus élevée. Chez les personnes de descendance sud-asiatique, le taux de mortalité après 30 jours était plus faible (RC de 0,88; IC à 95 % de 0,78 à 0,98), mais l'incidence d'hospitalisations ou de consultations aux urgences était plus élevée (RC de 1,17; IC à 95 % de 1,14 à 1,20). Elles présentaient également une tendance vers une plus faible incidence de complications cardiaques (RC de 0,76; IC à 95 % de 0,67 à 0,87) et de complications neurologiques (RC de 0,89; IC à 95 % de 0,73 à 1,09). Des différences significatives ont également été observées pour ces paramètres entre les vagues 1, 2 et 3 de la maladie, et le taux de mortalité était plus élevé pour tous les groupes des vagues 2 et 3. Conclusions: L'origine ethnique demeure un déterminant important de la mortalité, des issues cliniques cardiaques et neurologiques ainsi que de l'utilisation des ressources en santé chez les patients atteints de la COVID-19. D'autres études sont toutefois nécessaires pour mieux comprendre les facteurs qui expliquent ces différences.

A Web-Based Health Application to Translate Nutrition Therapy for Cardiovascular Risk Reduction in Primary Care (PortfolioDiet.app): Quality Improvement and Usability Testing Study.

BACKGROUND: The Portfolio Diet, or Dietary Portfolio, is a therapeutic dietary pattern that combines cholesterol-lowering foods to manage dyslipidemia for the prevention of cardiovascular disease. To translate the Portfolio Diet for primary care, we developed the PortfolioDiet.app as a patient and physician educational and engagement tool for PCs and smartphones. The PortfolioDiet.app is currently being used as an add-on therapy to the standard of care (usual care) for the prevention of cardiovascular disease in primary care. To enhance the adoption of this tool, it is important to ensure that the PortfolioDiet.app meets the needs of its target end users. OBJECTIVE: The main objective of this project is to undertake user testing to inform modifications to the PortfolioDiet.app as part of ongoing engagement in quality improvement (QI). METHODS: We undertook a 2-phase QI project from February 2021 to September 2021. We recruited users by convenience sampling. Users included patients, family physicians, and dietitians, as well as nutrition and medical students. For both phases, users were asked to use the PortfolioDiet.app daily for 7 days. In phase 1, a mixed-form questionnaire was administered to evaluate the users' perceived acceptability, knowledge acquisition, and engagement with the PortfolioDiet.app. The questionnaire collected both quantitative and qualitative data, including 2 open-ended questions. The responses were used to inform modifications to the PortfolioDiet.app. In phase 2, the System Usability Scale was used to assess the usability of the updated PortfolioDiet.app, with a score higher than 70 being considered acceptable. RESULTS: A total of 30 and 19 users were recruited for phase 1 and phase 2, respectively. In phase 1, the PortfolioDiet.app increased users' perceived knowledge of the Portfolio Diet and influenced their perceived food choices. Limitations identified by users included challenges navigating to resources and profile settings, limited information on plant sterols, inaccuracies in points, timed-logout frustration, request for step-by-step pop-up windows, and request for a mobile app version; when looking at positive feedback, the recipe section was the most commonly praised feature. Between the project phases, 6 modifications were made to the PortfolioDiet.app to incorporate and address user feedback. At phase 2, the average System Usability Scale score was 85.39 (SD 11.47), with 100 being the best possible. CONCLUSIONS: By undertaking user testing of the PortfolioDiet.app, its limitations and strengths were able to be identified, informing modifications to the application, which resulted in a clinical tool that better meets users' needs. The PortfolioDiet.app educates users on the Portfolio Diet and is considered acceptable by users. Although further refinements to the PortfolioDiet.app will continue to be made before its evaluation in a clinical trial, the result of this QI project is an improved clinical tool.

COVID-19 and its Cardiac and Neurological Complications among Ontario Visible Minorities.

BACKGROUND: Due to lack of data on the epidemiology, cardiac, and neurological complications among Ontario visible minorities (Chinese and South Asians) affected by coronavirus disease (COVID-19), this population-based retrospective study was undertaken to study them systematically. METHODS: From January 1, 2020 to September 30, 2020 using the last name algorithm to identify Ontario Chinese and South Asians who were tested positive by PCR for COVID-19, their demographics, cardiac, and neurological complications including hospitalization and emergency visit rates were analyzed compared to the general population. RESULTS: Chinese (N = 1,186) with COVID-19 were found to be older (mean age 50.7 years) compared to the general population (N = 42,547) (mean age 47.6 years) (p < 0.001), while South Asians (N = 3,459) were younger (age of 42.1 years) (p < 0.001). The 30-day crude rate for cardiac complications among Chinese was 169/10,000 (p = 0.069), while for South Asians, it was 64/10,000 (p = 0.008) and, for the general population, it was 112/10,000. For neurological complications, the 30-day crude rate for Chinese was 160/10,000 (p < 0.001); South Asians was 40/10,000 (p = 0.526), and general population was 48/10,000. The 30-day all-cause mortality rate was significantly higher for Chinese at 8.1% vs 5.0% for the general population (p < 0.001), while it was lower in South Asians at 2.1% (p < 0.001). CONCLUSIONS: Chinese and South Asians in Ontario affected by COVID-19 during the first wave of the pandemic were found to have a significant difference in their demographics, cardiac, and neurological outcomes.

Deliver Cardiac Virtual Care: A Primer for Cardiovascular Professionals in Canada.

The COVID-19 pandemic, with its need for distancing, has necessitated the use of virtual care in never-before-seen volumes. This review article aims to provide a primer on virtual care for cardiovascular professionals in Canada. The technology to facilitate remote patient interactions is already available, but barriers exist. Adequate and effective cardiac virtual care must be further developed given the need for rapid evaluation and close ongoing follow-up of patients, as seen in the areas of management of heart failure, cardiac rehabilitation, electrophysiology, and hypertension. Many Canadian organizations have published resources to assist health care providers and patients navigate the unfamiliar virtual care landscape. Although there are concerns surrounding issues such as patient privacy, access to technology, language discrepancies, and billing, these deficits provide opportunities for growth by health care organizations and technology companies. The integration of virtual care, home-based devices, and disruptive technologies emphasize the trend toward virtualization of health care, with the potential for greater personalization of health care interactions and continuity of care. Funding models were rapidly developed at the beginning of the COVID-19 pandemic, and although some provinces have deemed these changes as permanent, the status from other provinces remains unknown. The foundations to support virtual care as a key modality for health care delivery in Canada have been built, and further developments may strengthen its viability as a long-term option.

Dans le contexte de la pandémie de COVID-19 et de la distanciation sociale qu'elle impose, le recours aux soins de santé virtuels a atteint des sommets historiques. Le présent article de synthèse est une introduction aux soins de santé virtuels destinée aux professionnels de la santé cardiovasculaire du Canada. La technologie permettant de faciliter les interactions à distance avec les patients existe déjà, mais il y a des obstacles à sa mise en œuvre. Des soins de santé virtuels adéquats et efficaces doivent être développés davantage en cardiologie compte tenu de la nécessité d'une évaluation rapide et d'un suivi étroit et continu des patients, notamment quand il est question de prise en charge de l'insuffisance cardiaque, de réadaptation cardiaque, d'électrophysiologie ou d'hypertension. De nombreux organismes canadiens ont publié des ressources pour aider les fournisseurs de soins et les patients à trouver leurs repères dans l'univers peu connu des soins de santé virtuels. Les questions telles que la protection des renseignements personnels des patients, l'accès à la technologie, les différences linguistiques et la facturation soulèvent des préoccupations. Néanmoins, les lacunes constituent des possibilités de croissance pour les organismes de soins de santé et les entreprises technologiques. L'intégration des soins de santé virtuels, des dispositifs à domicile et des technologies perturbatrices met en lumière la tendance à la virtualisation des soins de santé, allant de pair avec la possibilité d'accroître la personnalisation des interactions et la continuité des soins. Des modèles de financement ont été rapidement élaborés au début de la pandémie de COVID-19. Bien que certaines provinces aient reconnu le caractère permanent des changements; la position des autres provinces demeure inconnue. Les conditions de base sont réunies pour que les soins de santé virtuels soient reconnus en tant que modalités clés de la prestation des soins de santé au Canada, et d'autres développements pourraient en renforcer la viabilité en tant qu'option à long terme.

Long COVID-19: A Primer for Cardiovascular Health Professionals, on Behalf of the CCS Rapid Response Team.

It is now widely recognized that COVID-19 illness can be associated with significant intermediate and potentially longer-term physical limitations. The term, "long COVID-19" is used to define any patient with persistent symptoms after acute COVID-19 infection (ie, after 4 weeks). It is postulated that cardiac injury might be linked to symptoms that persist after resolution of acute infection, as part of this syndrome. The Canadian Cardiovascular Society Rapid Response Team has generated this document to provide guidance to health care providers on the optimal management of patients with suspected cardiac complications of long COVID-19.

Awareness of Warning Symptoms of Heart Disease and Stroke: Results of a Follow-up Study of the Chinese Canadian Cardiovascular Health Project.

BACKGROUND: Our original pilot study in 2008 demonstrated a poor degree of awareness of heart disease and stroke among Chinese Canadians, warranting an updated survey of their knowledge. We sought to determine the current degree of knowledge of cardiovascular disease, including stroke, among ethnic Chinese residents of Canada. METHODS: A 35-question online survey was conducted in the fall of 2017 among 1001 Chinese Canadians (aged ≥ 18 years) in the greater Toronto area (n = 501) and Vancouver (n = 500). Knowledge of heart disease and stroke, such as signs and symptoms of stroke and heart attack, health habits, and initial response to a cardiovascular emergency were assessed. RESULTS: A total of 52.0% of the respondents were female, and 46.3% were aged <45 years. A total of 40.1% spoke Cantonese, and 23.7% spoke Mandarin; 79.5% were immigrants, and 31% had lived in Canada < 10 years. A total of 85% identified at least one heart attack symptom, and 80% identified at least one stroke symptom; 86.2% indicated that they would call 911 if experiencing a heart attack or stroke. Internet use was positively associated with the ability to identify a greater number of heart attack and stroke symptoms, compared to the number among non-Internet users (P < 0.001). Women were 14% more likely to overlook gender as a risk factor for cardiovascular disease (CVD). CONCLUSIONS: This study found that in 2017, compared to 2008, awareness of symptoms of heart disease and stroke improved among Chinese Canadians residing in Toronto and Vancouver.

CONTEXTE: Dans le cadre d'une première étude pilote menée en 2008, nous avions montré que les Canadiens d'origine chinoise connaissaient si mal les maladies cœur et l'accident vasculaire cérébral (AVC) qu'une enquête de suivi de leurs connaissances s'imposait. Nous avons donc entrepris d'évaluer les connaissances actuelles des maladies cardiovasculaires, y compris l'AVC, chez les résidents canadiens d'origine chinoise. MÉTHODOLOGIE: Un sondage en ligne comprenant 35 questions a été effectué à l'automne 2017 auprès de 1 001 Canadiens d'origine chinoise (âgés de 18 ans ou plus) de la région du Grand Toronto (n = 501) et de Vancouver (n = 500). Les connaissances relatives aux maladies cœur et à l'AVC, notamment les signes et symptômes d'AVC et de crise cardiaque, les saines habitudes de vie et la première chose à faire en cas d'urgence cardiovasculaire, ont été évaluées. RÉSULTATS: Au total, 52,0 % des répondants étaient des femmes, et 46,3 % étaient âgés de moins de 45 ans; 40,1 % parlaient cantonnais et 23,7 %, mandarin; 79,5 % étaient des immigrants, et 31 % vivaient au Canada depuis moins de 10 ans. Au total, 85 % des répondants connaissaient au moins un symptôme de crise cardiaque et 80 %, au moins un symptôme d'AVC; 86,2 % ont indiqué qu'ils composeraient le 9-1-1 s'ils subissaient une crise cardiaque ou un AVC. Les répondants qui utilisaient l'Internet étaient capables de reconnaître un plus grand nombre de symptômes de crise cardiaque et d'AVC que les répondants qui n'utilisaient pas l'Internet (p < 0,001). Les femmes avaient 14 % plus de chances de ne pas tenir compte du sexe comme facteur de risque de maladie cardiovasculaire. CONCLUSIONS: L'étude a révélé qu'en 2017, comparativement à 2008, la connaissance des symptômes de maladie cœur et d'AVC s'est améliorée chez les Canadiens d'origine chinoise vivant à Toronto et à Vancouver.

Cardiovascular Care Delivery During the Second Wave of COVID-19 in Canada.

Hospitals and ambulatory facilities significantly reduced cardiac care delivery in response to the first wave of the COVID-19 pandemic. The deferral of elective cardiovascular procedures led to a marked reduction in health care delivery with a significant impact on optimal cardiovascular care. International and Canadian data have reported dramatically increased wait times for diagnostic tests and cardiovascular procedures, as well as associated increased cardiovascular morbidity and mortality. In the wake of the demonstrated ability to rapidly create critical care and hospital ward capacity, we advocate a different approach during the second and possible subsequent COVID-19 pandemic waves. We suggest an approach, informed by local data and experience, that balances the need for an expected rise in demand for health care resources to ensure appropriate COVID-19 surge capacity with continued delivery of essential cardiovascular care. Incorporating cardiovascular care leaders into pandemic planning and operations will help health care systems minimise cardiac care delivery disruptions while maintaining critical care and hospital ward surge capacity and continuing measures to reduce transmission risk in health care settings. Specific recommendations targeting the main pillars of cardiovascular care are presented: ambulatory, inpatient, procedural, diagnostic, surgical, and rehabilitation.

Guiding Cardiac Care During the COVID-19 Pandemic: How Ethics Shapes Our Health System Response.

The COVID-19 pandemic has raised ethical questions for the cardiovascular leader and practitioner. Attention has been redirected from a system that focuses on individual patient benefit toward one that focuses on protecting society as a whole. Challenging resource allocation questions highlight the need for a clearly articulated ethics framework that integrates principled decision making into how different cardiovascular care services are prioritized. A practical application of the principles of harm minimisation, fairness, proportionality, respect, reciprocity, flexibility, and procedural justice is provided, and a model for prioritisation of the restoration of cardiovascular services is outlined. The prioritisation model may be used to determine how and when cardiovascular services should be continued or restored. There should be a focus on an iterative and responsive approach to broader health care system needs, such as other disease groups and local outbreaks.

Cardiac Rehabilitation During the COVID-19 Era: Guidance on Implementing Virtual Care.

Cardiac rehabilitation programs across Canada have suspended in-person services as a result of large-scale physical distancing recommendations designed to flatten the COVID-19 pandemic curve. Virtual cardiac rehabilitation (VCR) offers an alternate mechanism of care delivery, capable of providing similar patient outcomes and safety profiles compared with centre-based programs. To minimize care gaps, all centres should consider developing and implementing a VCR program. The process of this rapid implementation, however, can be daunting. Centres should initially focus on the collation, utilization, and repurposing of existing resources, equipment, and technology. Once established, programs should then focus on ensuring that quality indicators are met and care processes are protocolized. This should be followed by the development of sustainable VCR solutions to account for care gaps that existed before COVID-19, and to improve cardiac rehabilitation delivery, moving forward. This article reviews the potential challenges and obstacles of this process and aims to provide pragmatic guidance to aid clinicians and administrators during this challenging time.

Use of the Valve Visualization on Echocardiography Grade Tool Improves Sensitivity and Negative Predictive Value of Transthoracic Echocardiogram for Exclusion of Native Valvular Vegetation.

BACKGROUND: Transesophageal echocardiography (TEE) remains the preferred test to rule out infective endocarditis (IE) but is resource intensive and carries risk. Multiple studies report low sensitivity of transthoracic echocardiography (TTE) for detection of IE; however, these studies did not account for TTE quality. We test the validity of a simple valve visualization grading tool to stratify TTEs by quality and determine whether a high-quality TTE may be used to exclude valvular vegetation and forgo the need for TEE. METHODS: The Valve Visualization on Echocardiography Grade (VEG) tool scores the TTE from 0 to 10 based on leaflet visualization and valve leaflet clarity. The tool was retrospectively applied to 309 sequential patients who underwent both TTE and TEE at an academic teaching hospital between 2011 and 2015. The TEE report was the gold standard for presence or absence of vegetation. Patients with prosthetic valves and pacemaker wires were excluded. Sensitivity of TTE for detecting vegetation was calculated at each VEG score, and the optimal cutoff was identified. RESULTS: A total of 309 patients were included in the analysis. Among the 216 negative TTEs, 19 (9%) had a positive TEE. The median VEG score was 4. A VEG score cutoff >6 provided optimal sensitivity and was used as the cutoff. Overall, 75 (25%) patients had a VEG score >6, and 234 (75%) had a score ≤6. Sensitivity and negative predictive value for IE were higher in the VEG >6 versus VEG ≤6 group (sensitivity 96% vs 66%, negative predictive value 97.5% vs 90%; P < .05). The false-negative rate was lower (2.5% vs 10%; P = .04) in VEG > 6 versus VEG ≤ 6 groups, respectively. CONCLUSIONS: Leaflet visualization and valve leaflet clarity are important components in the TTE evaluation of patients with suspected IE. This study demonstrates that the better the valve leaflets are visualized on TTE (as represented in this population by a score >6), the higher the confidence one can have that the TTE will not be falsely negative for vegetation(s) when vegetation(s) are not noted on these TTEs. If validated in future prospective studies, this may reduce the need to perform an invasive TEE in selected patients undergoing evaluation for native valve IE.

Association Between Transthoracic Echocardiography Appropriateness and Echocardiographic Findings.

BACKGROUND: The association between appropriate use criteria and echocardiographic findings in patients with chronic cardiovascular diseases is unknown. METHODS: As a substudy of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial, 9,230 transthoracic echocardiographic (TTE) examinations from six Ontario academic hospitals were linked to a registry of echocardiographic findings. The TTE studies were rated appropriate), rarely appropriate, or may be appropriate according to the 2011 appropriate use criteria. TTE findings of appropriately ordered examinations were compared with those of rarely appropriate examinations for specific disease subsets, including heart failure and valvular heart disease. RESULTS: There were 7,574, 1,087, and 569 TTE examinations ordered for appropriate, rarely appropriate, and may be appropriate indications, and of the 7,574 appropriate studies, 6,399 were ordered for specific indications and 1,175 for general indications. TTE examinations ordered for general indications had lower rates of left ventricular dysfunction (19.6% vs 9.1%, P < .001) and moderate to severe aortic stenosis (15.5% vs 2.6%, P < .001). Of the 2,395 TTE examinations ordered for patients with heart failure, appropriately ordered studies were more likely to result in left ventricular segmental abnormality (37.0% vs 24.9%, P = .012) but similar rates of right ventricular dilatation (15.4% vs 14.7%, P = .79), right ventricular dysfunction (14.8% vs 11.3%, P = .22), and moderate to severe mitral regurgitation (12.1% vs 9.2%, P = .35). Of the 2,859 studies ordered to assess valvular heart disease, appropriately ordered studies were significantly more likely to find moderate to severe valvular pathology, including aortic stenosis (30.4% vs 24.6%, P = .008), aortic regurgitation (8.9% vs 1.6%, P < .001), mitral stenosis (6.7% vs 3.1%, P = .002), and mitral regurgitation (16.1% vs 6.1%, P < .001), but similar rates of tricuspid regurgitation (11.2% vs 13.0%, P = .60). CONCLUSIONS: Overall, appropriately ordered TTE examinations for heart failure and valvular heart disease were significantly more likely to have abnormal findings than rarely appropriate examinations. TTE studies ordered for general indications had fewer, although still a significant proportion, of abnormalities compared with studies ordered for specific indications.

Early diastolic strain rate measurements by cardiac MRI in breast cancer patients treated with trastuzumab: a longitudinal study.

We evaluated temporal changes in early diastolic strain rates by cardiovascular magnetic resonance (CMR) as an early detector of trastuzumab-induced ventricular dysfunction. We conducted a prospective, multi-centre, longitudinal observational study of 41 trastuzumab-treated breast cancer women who underwent serial CMR (baseline, 6, 12, and 18 months). Two blinded readers independently measured left ventricular ejection fraction (LVEF), peak systolic strain parameters (global longitudinal strain [GLS] and global circumferential strain [GCS]), and early diastolic strain rate parameters (global longitudinal diastolic strain rate [GLSR-E], global circumferential diastolic strain rate [GCSR-E], and global radial diastolic strain rate [GRSR-E]), by feature tracking (FT-CMR) using CMR42. There was a significant decline in peak systolic strain GLS and GCS at 6 months (p = 0.024 and p < 0.001, respectively) and 12 months (p = 0.002 and p < 0.001, respectively), followed by recovery at 18 months, which paralleled decline in LVEF at 6 months (p = 0.034) and 12 months (p = 0.012). Conversely, early diastolic strain rates GLSR-E and GCSR-E did not significantly change over 18 months (p > 0.10), while GRSR-E was marginally significant at 12 months (p = 0.021). There was no significant correlation between changes at 6 months in LVEF and GLSR-E or GRSR-E (p > 0.10), and a marginally significant weak correlation between LVEF and GCSR-E (p = 0.046). Among trastuzumab-treated patients without overt cardiotoxicity, there was no consistent temporal change in FT-CMR-derived diastolic strain rate parameters up to 18 months, in contrast to decline in systolic strain and LVEF. Systolic strains by FT-CMR are likely more useful than diastolic strain rates for monitoring subclinical trastuzumab-related myocardial dysfunction.ClinicalTrials.gov identifier NCT01022086.

Automation, machine learning, and artificial intelligence in echocardiography: A brave new world.

Automation, machine learning, and artificial intelligence (AI) are changing the landscape of echocardiography providing complimentary tools to physicians to enhance patient care. Multiple vendor software programs have incorporated automation to improve accuracy and efficiency of manual tracings. Automation with longitudinal strain and 3D echocardiography has shown great accuracy and reproducibility allowing the incorporation of these techniques into daily workflow. This will give further experience to nonexpert readers and allow the integration of these essential tools into more echocardiography laboratories. The potential for machine learning in cardiovascular imaging is still being discovered as algorithms are being created, with training on large data sets beyond what traditional statistical reasoning can handle. Deep learning when applied to large image repositories will recognize complex relationships and patterns integrating all properties of the image, which will unlock further connections about the natural history and prognosis of cardiac disease states. The purpose of this review article was to describe the role and current use of automation, machine learning, and AI in echocardiography and discuss potential limitations and challenges of in the future.