Physician perceptions of medication prescribing in heart failure: a scoping review.

INTRODUCTION: The swift uptake of new medications into clinical practice has many benefits, however slow uptake has been seen previously with other guideline-directed medical therapies (GDMT) in heart failure (HF). Sodium glucose co-transporter 2 inhibitors are a novel therapy in HF proven to be efficacious and will have beneficial clinical outcomes if prescribed. Understanding physician perspectives on prescribing GDMT in HF can help target strategies to bridge the gap between guidelines and practice. METHODS: The study followed the PRISMA guide for scoping reviews and the JBI Manual for scoping reviews. A search was conducted using EMBASE, Medline and PubMed databases in April 2024. Studies included were those using qualitative methods to assess physician perspectives towards prescribing any HF medication. Common themes were identified through thematic synthesis following the methods from Cochrane Training and using software MAXQDA Analysis Pro. RESULTS: 708 studies were found in the search, with 23 full studies included. The most pertinent barriers identified were concern for medication adverse effects, unclear role responsibilities between physicians of different specialties, patient comorbidities and unwillingness to alter therapies of stable patients. The most identified enablers included awareness of efficacy, influence from colleagues and the use of multi-media approaches for information dissemination. Perceptions were also found to change over time and vary among prescriber groups. CONCLUSIONS: Physicians perceive common barriers and enablers of prescribing GDMT in HF, despite differences in prescriber groups and time periods. The identified barriers and enablers may be targeted to improve implementation of GDMT into clinical practice.

A cohort study comparing pharmacist activities during participation in general medical ward rounds: telehealth versus in-person during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic created systemic challenges in patient care delivery. AIM: To evaluate the impact on pharmacist activities during pharmacist participation in ward rounds via telehealth, compared to physical attendance. METHOD: A single-centre, retrospective cohort study conducted from 18th Aug through 26th Oct 2020. Patients admitted to COVID and non-COVID general medical teams were included. Pharmacists attended ward rounds via telehealth for COVID teams; physical attendance continued for non-COVID teams. Telehealth involved pharmacists interacting with clinicians and patients virtually via videoconferencing whilst stationed remotely on the ward. Routine clinical pharmacy activities during telehealth ward rounds were compared to those during face-to-face ward rounds using comparative statistics. RESULTS: Among the 1230 patients included (762 COVID, 468 non-COVID), pharmacist participation in telehealth ward rounds demonstrated significantly more documented activities compared with face-to-face rounds (mean 6.7 vs 4.9 per patient per day, p < 0.001). The telehealth cohort exhibited a higher number of orders placed via pharmacy-partnered medication charting (3.0 vs 2.4 per patient per day, p < 0.001), medication orders verified (2.3 vs 1.1, p < 0.001), and documented pharmacy notes (0.6 vs 0.2, p < 0.001). No significant difference was observed in medication requests processed (0.4 vs 0.4, p = 738), whilst non-COVID patients had more discharge prescription items generated (0.3 vs 0.7, p < 0.001). CONCLUSION: Pharmacist involvement in medical ward rounds via telehealth enabled the ongoing provision of advanced clinical pharmacy services to inpatients in isolation rooms during the COVID-19 pandemic. This approach resulted in a greater number of pharmacy activities during telehealth ward rounds compared to standard in-person attendance.

Incidence and predictors of post-thrombotic syndrome in patients with proximal DVT in a real-world setting: findings from the GARFIELD-VTE registry.

Although substantial progress has been made in the pathophysiology and management of the post-thrombotic syndrome (PTS), several aspects still need clarification. Among them, the incidence and severity of PTS in the real world, the risk factors for its development, the value of patient's self-evaluation, and the ability to identify patients at risk for severe PTS. Eligible participants (n = 1107) with proximal deep-vein thrombosis (DVT) from the global GARFIELD-VTE registry underwent conventional physician's evaluation for PTS 36 months after diagnosis of their DVT using the Villalta score. In addition, 856 patients completed a Villalta questionnaire at 24 months. Variable selection was performed using stepwise algorithm, and predictors of severe PTS were incorporated into a multivariable risk model. The optimistic adjusted c-index was calculated using bootstrapping techniques. Over 36-months, 27.8% of patients developed incident PTS (mild in 18.7%, moderate in 5.7%, severe in 3.4%). Patients with incident PTS were older, had a lower prevalence of transient risk factors of DVT and a higher prevalence of persistent risk factors of DVT. Self-assessment of overall PTS at 24 months showed an agreement of 63.4% with respect to physician's evaluations at 36 months. The severe PTS multivariable model provided an optimistic adjusted c-index of 0.68 (95% CI 0.59-0.77). Approximately a quarter of DVT patients experienced PTS over 36 months after VTE diagnosis. Patient's self-assessment after 24 months provided added value for estimating incident PTS over 36 months. Multivariable risk analysis allowed good discrimination for severe PTS.

Contribution of general medicine to perioperative and consultative care: an Australian metropolitan teaching hospital experience.

Little is known about the contribution of general medicine to perioperative and consultative care in Australia. A descriptive observational study was undertaken at a quaternary institution to evaluate the characteristics of perioperative and nonoperative consultations undertaken by general medicine. Results demonstrated patterns of engagement within a 'traditional' model of perioperative care and highlighted several opportunities for a redesign to a more proactive and collaborative cross-disciplinary model.

Enoxaparin for symptomatic COVID-19 managed in the ambulatory setting: An individual patient level analysis of the OVID and ETHIC trials.

BACKGROUND: Antithrombotic treatment may improve the disease course in non-critically ill, symptomatic COVID-19 outpatients. METHODS: We performed an individual patient-level analysis of the OVID and ETHIC randomized controlled trials, which compared enoxaparin thromboprophylaxis for either 14 (OVID) or 21 days (ETHIC) vs. no thromboprophylaxis for outpatients with symptomatic COVID-19 and at least one additional risk factor. The primary efficacy outcome included all-cause hospitalization and all-cause death within 30 days from randomization. Both studies were prematurely stopped for futility. Secondary efficacy outcomes were major symptomatic venous thromboembolic events, arterial cardiovascular events, or their composite occurring within 30 days from randomization. The same outcomes were assessed over a 90-day follow-up. The primary safety outcome was major bleeding (ISTH criteria). RESULTS: A total of 691 patients were randomized: 339 to receive enoxaparin and 352 to the control group. Over 30-day follow-up, the primary efficacy outcome occurred in 6.0 % of patients in the enoxaparin group vs. 5.8 % of controls for a risk ratio (RR) of 1.05 (95%CI 0.57-1.92). The incidence of major symptomatic venous thromboembolic events and arterial cardiovascular events was 0.9 % vs. 1.8 %, respectively (RR 0.52; 95%CI 0.13-2.06). Most cardiovascular thromboembolic events were represented by symptomatic venous thromboembolic events, occurring in 0.6 % vs. 1.5 % of patients, respectively. A similar distribution of outcomes between the treatment groups was observed over 90 days. No major bleeding occurred in the enoxaparin group vs. one (0.3 %) in the control group. CONCLUSIONS: We found no evidence for the clinical benefit of early administration of enoxaparin thromboprophylaxis in outpatients with symptomatic COVID-19. These results should be interpreted taking into consideration the relatively low occurrence of events.

Understanding the workflow of nurses in acute and subacute medical wards: A time and motion study.

AIMS AND OBJECTIVES: The aim of this study was to determine how much time nurses spend on direct and indirect patient care in acute and subacute hospital settings. BACKGROUND: Quantifying direct and indirect nursing care provided during inpatient stay is vital to optimise the quality of care and manage resources. DESIGN: Time and motion cross-sectional observational study and reported the study according to the STROBE guideline. METHODS: Nurses working in an acute or subacute medical wards of a single health service participated. Nurses were observed twice for 2 h on the same day with an observer break in between sessions. Real-time task-related data were digitally recorded using the Work Observation Method By Activity Timing (WOMBAT) tool by a single research assistant. Frequency and time spent on pre-determined tasks were recorded and included direct care, indirect care, documentation, medication-related tasks, communication (professional) and other tasks. Task interruptions and multitasking were also recorded. RESULTS: Twenty-one nurses (acute n = 12, subacute n = 9) were observed during shifts between 7 AM and 9 PM in May-July 2021. A total of 7240 tasks were recorded. Nurses spent a third of their time on direct patient care (27% direct care and 3% medication administration). A total of 556 task interruptions occurred, mostly during documentation, and medication-related tasks. A further 1385 tasks were performed in parallel with other tasks, that is multitasking. CONCLUSIONS: Time spent on tasks was similar regardless of the setting and was consistent with previous research. We found differences in the distribution of tasks throughout the day between settings, which could have implications for workforce planning and needs to be investigated further. Interruptions occurred during documentation, direct care and medication-related tasks. Local-level strategies should be in place and regularly revised to reduce interruptions and prevent errors. Relevance to clinical practice The association between interruption and increased risk of error is well-established and should be an ongoing area of attention including observations and education provided in local settings.

Venous anomalies and thromboembolism.

Patients with venous anomalies are at increased risk of developing venous thromboembolism (VTE) and subsequent complications, but they are often under-recognised. While unprovoked VTE may trigger testing for inherited thrombophilias and malignancy screening, anatomic variants are considered less often. Venous anomalies increase the risk due to venous flow disturbance, resulting in hypertension, reduced flow velocity and turbulence. Recognition is important as endovascular or surgical intervention may be appropriate, these patients have a high rate of VTE recurrence if anticoagulation is ceased, and the anomalies can predispose to extensive VTE and severe post-thrombotic syndrome (PTS). In this case series, we present representative cases and radiological images of May-Thurner syndrome (MTS), inferior vena cava (IVC) variants and venous aneurysms, and review the available literature regarding optimal diagnosis and management in each condition.

Risk factors and management outcomes in epistaxis: a tertiary centre experience.

BACKGROUND: Risk factors and outcomes associated with severe epistaxis are not well understood. This study explores the associations between epistaxis severity, comorbidities, use of antiplatelets or anticoagulants and management outcomes. METHODS: This is a retrospective cross-sectional study of all epistaxis cases presenting to the emergency department at a tertiary academic hospital from January 2016 to December 2019. Epistaxis severity was defined as mild (no intervention), moderate (required cautery and/or packing) and severe (clinical instability with reversal products, surgical or radiological intervention). Univariable and multivariable regression analyses were undertaken, with risk factors and management outcomes analysed according to severity. RESULTS: A total of 543 patients with epistaxis (54.2% male, mean age 74.4 ± 15.7 years) were included in this study, with 14.7% (80) having severe epistaxis. Of these presentations 216 (39.8%) were on antiplatelets, while 207 (38.1%) were on anticoagulants. In univariate analyses, clopidogrel use, hereditary haemorrhagic telangiectasia (HHT), haematological malignancy, bleeding disorders and chronic liver disease (CLD) were associated with moderate to severe epistaxis (P < 0.05), while the use of rivaroxaban was inversely associated severity (P = 0.002). Only HHT, haematological malignancy and CLD remained significant in multivariate models. Cautery as first-line management was infrequently utilized while anticoagulation was frequently withheld. A longer length of stay (1.1 days vs. 4.3 days; P < 0.001) and higher 2-week readmission rates (2.2% vs. 12.5%; P < 0.001) were noted with severe epistaxis compared with mild presentations. CONCLUSION: Epistaxis severity is associated with certain clinical conditions and poor outcomes. Despite recommended guidelines, variations in first-line management were evident.

36-month clinical outcomes of patients with venous thromboembolism: GARFIELD-VTE.

BACKGROUND: Venous thromboembolism (VTE), encompassing both deep vein thrombosis (DVT) and pulmonary embolism (PE), is a leading cause of morbidity and mortality worldwide. METHODS: GARFIELD-VTE is a prospective, non-interventional observational study of real-world treatment practices. We aimed to capture the 36-month clinical outcomes of 10,679 patients with objectively confirmed VTE enrolled between May 2014 and January 2017 from 415 sites in 28 countries. FINDINGS: A total of 6582 (61.6 %) patients had DVT alone, 4097 (38.4 %) had PE ± DVT. At baseline, 98.1 % of patients received anticoagulation (AC) with or without other modalities of therapy. The proportion of patients on AC therapy decreased over time: 87.6 % at 3 months, 73.0 % at 6 months, 54.2 % at 12 months and 42.0 % at 36 months. At 12-months follow-up, the incidences (95 % confidence interval [CI]) of all-cause mortality, recurrent VTE and major bleeding were 6.5 (7.0-8.1), 5.4 (4.9-5.9) and 2.7 (2.4-3.0) per 100 person-years, respectively. At 36-months, these decreased to 4.4 (4.2-4.7), 3.5 (3.2-2.7) and 1.4 (1.3-1.6) per 100 person-years, respectively. Over 36-months, the rate of all-cause mortality and major bleeds were highest in patients treated with parenteral therapy (PAR) versus oral anti-coagulants (OAC) and no OAC, and the rate of recurrent VTE was highest in patients on no OAC versus those on PAR and OAC. The most frequent cause of death after 36-month follow-up was cancer (n = 565, 48.6 %), followed by cardiac (n = 94, 8.1 %), and VTE (n = 38, 3.2 %). Most recurrent VTE events were DVT alone (n = 564, 63.3 %), with the remainder PE, (n = 236, 27.3 %), or PE in combination with DVT (n = 63, 7.3 %). INTERPRETATION: GARFIELD-VTE provides a global perspective of anticoagulation patterns and highlights the accumulation of events within the first 12 months after diagnosis. These findings may help identify treatment gaps for subsequent interventions to improve patient outcomes in this patient population.

On-treatment Comparative Effectiveness of Vitamin K Antagonists and Direct Oral Anticoagulants in GARFIELD-VTE, and Focus on Cancer and Renal Disease.

Background Direct oral anticoagulants (DOACs) provide a safe, effective alternative to vitamin K antagonists (VKAs) for venous thromboembolism (VTE) treatment, as shown via intention-to-treat comparative effectiveness analysis. However, on-treatment analysis is imperative in observational studies because anticoagulation choice and duration are at investigators' discretion. Objectives The aim of the study is to compare the effectiveness of DOACs and VKAs on 12-month outcomes in VTE patients using on-treatment analysis. Methods The Global Anticoagulant Registry in the FIELD - VTE (GARFIELD-VTE) is a world-wide, prospective, non-interventional study observing treatment of VTE in routine clinical practice. Results In total, 8,034 patients received VKAs ( n = 3,043, 37.9%) or DOACs ( n = 4,991, 62.1%). After adjustment for baseline characteristics and follow-up bleeding events, and accounting for possible time-varying confounding, all-cause mortality was significantly lower with DOACs than VKAs (hazard ratio: 0.58 [95% confidence interval 0.42-0.79]). Furthermore, patients receiving VKAs were more likely to die of VTE complications (4.9 vs. 2.2%) or bleeding (4.9 vs. 0.0%). There was no significant difference in rates of recurrent VTE (hazard ratio: 0.74 [0.55-1.01]), major bleeding (hazard ratio: 0.76 [0.47-1.24]), or overall bleeding (hazard ratio: 0.87 [0.72-1.05]) with DOACs or VKAs. Unadjusted analyses suggested that VKA patients with active cancer or renal insufficiency were more likely to die than patients treated with DOAC (52.51 [37.33-73.86] vs. 26.52 [19.37-36.29] and 9.97 [7.51-13.23] vs. 4.70 [3.25-6.81] per 100 person-years, respectively). Conclusion DOACs and VKAs had similar rates of recurrent VTE and major bleeding. However, DOACs were associated with reduced all-cause mortality and a lower likelihood of death from VTE or bleeding compared with VKAs.

Thromboprophylactic low-molecular-weight heparin versus standard of care in unvaccinated, at-risk outpatients with COVID-19 (ETHIC): an open-label, multicentre, randomised, controlled, phase 3b trial.

BACKGROUND: COVID-19 is associated with inflammation and an increased risk of thromboembolic complications. Prophylactic doses of low-molecular-weight heparin have been used in hospitalised and non-critically ill patients with COVID-19. We aimed to evaluate the efficacy and safety of prophylactic low-molecular-weight heparin (enoxaparin) versus standard of care (no enoxaparin) in at-risk outpatients with COVID-19. METHODS: This open-label, multicentre, randomised, controlled, phase 3b trial (ETHIC) was done at 15 centres in six countries (Belgium, Brazil, India, South Africa, Spain, and the UK). We consecutively enrolled participants aged at least 30 years who had not received a COVID-19 vaccine and had symptomatic, confirmed COVID-19 in the outpatient setting plus at least one risk factor for severe disease. Within 9 days of symptom onset and by use of a web-based random block design (block size either 2 or 4), eligible participants were randomly assigned (1:1) to receive either subcutaneous enoxaparin for 21 days (40 mg once daily if they weighed <100 kg and 40 mg twice daily if they weighed ≥100 kg) or standard of care (without enoxaparin). The primary efficacy endpoint was the composite of all-cause hospitalisation and all-cause mortality at 21 days after randomisation and, in our main analysis, was analysed in the intention-to-treat population, which comprised all patients who were randomly assigned. Safety was also analysed in the intention-to-treat population for our main analysis. This trial is registered with ClinicalTrials.gov, NCT04492254, and is complete. FINDINGS: Following the advice of the Data and Safety Monitoring Board, this study was terminated early due to slow enrolment and a lower-than-expected event rate. Between Oct 27, 2020, and Nov 8, 2021, 230 patients with COVID-19 were assessed for eligibility, of whom 219 were enrolled and randomly assigned to receive standard of care (n=114) or enoxaparin (n=105). 96 (44%) patients were women, 122 (56%) were men, and one patient had missing sex data. 141 (65%) of 218 participants with data on race and ethnicity were White, 60 (28%) were Asian, and 16 (7%) were Black, mixed race, or Arab or Middle Eastern. Median follow-up in both groups was 21 days (IQR 21-21). There was no difference in the composite of all-cause mortality and hospitalisation at 21 days between the enoxaparin group (12 [11%] of 105 patients) and the standard-of-care group (12 [11%] of 114 patients; unadjusted hazard ratio 1·09 [95% CI 0·49-2·43]; log-rank p=0·83). At 21 days, two (2%) of 105 patients in the enoxaparin group (one minor bleed and one bleed of unknown severity) and one (1%) of 114 patients in the standard-of-care group (major abnormal uterine bleeding) had a bleeding event. 22 (21%) patients in the enoxaparin group and 13 (11%) patients in the standard-of-care group had adverse events. The most common adverse event in both groups was COVID-19-related pneumonia (six [6%] patients in the enoxaparin group and five [4%] patients in the standard-of-care group). One patient in the enoxaparin group died and their cause of death was unknown. INTERPRETATION: The ETHIC trial results suggest that prophylaxis with low-molecular-weight heparin had no benefit for at-risk outpatients with COVID-19. Although the trial was terminated early, our data, combined with data from similar studies, provide further insights to inform international guidelines and influence clinical practice. FUNDING: The Thrombosis Research Institute and Sanofi UK.

Collective pause: improving staff performance in acute medicine through a brief mindfulness-based group programme.

BACKGROUND: Hospital wards are a complex and dynamic environment that rely on optimal staff performance. However, there is little research evaluating group interventions to improve staff attention and teamwork. AIMS: To evaluate whether a regular, short and guided group mindfulness practice for staff in an acute general medicine team improves attention and teamwork. METHODS: A 10-min programme comprising mindfulness exercises and techniques was delivered daily to a multidisciplinary general medicine team based in a tertiary hospital for 4 weeks. This was undertaken immediately prior to the team's interdisciplinary ward round. We used a mixed-method design, with self-rated surveys to measure mindfulness and staff perception of hospital safety culture, and a focus group to understand participants' experiences. We estimated mean differences using Kruskal-Wallis tests across 10 time-points and thematically analysed recorded transcripts. RESULTS: There was an increase in staff attention to the team meeting as measured by the decentering domain across time (P < 0.001). There was a trend to greater staff openness with a non-significant increase in curiosity (P = 0.14). We identified two overarching qualitative themes: feasibility of the programme and impact on staff and workplace. The programme was a calming circuit breaker to staff's day, which aided in feeling more connected to the group and subjectively better ward round experience. The logistics of the programme, including timing, and the facilitator developing trust with the participants, appear important in implementation. CONCLUSION: A brief mindfulness-based intervention delivered to a general medical team improves staff attention at a multidisciplinary team meeting and team functioning.

Management strategies and clinical outcomes in patients with inferior vena cava thrombosis: Data from GARFIELD-VTE.

BACKGROUND: Inferior vena cava (IVC) thrombosis is a rare form of venous thromboembolism (VTE). The optimal treatment strategies and outcomes are unclear in patients with this presentation. OBJECTIVE: We aimed to compare baseline characteristics, treatment patterns and 24-month outcomes in IVC thrombosis patients (n = 100) with lower extremity deep vein thrombosis (LEDVT) patients (n = 7629). METHODS: GARFIELD-VTE is a prospective, observational registry of 10 868 patients with objectively diagnosed VTE from 415 sites in 28 countries. RESULTS: IVC thrombosis patients were younger (51.9 vs. 59.8 years), more frequently had active cancer (26.0% vs. 8.9%) or history of cancer (21.0% vs. 12.2%), and less frequently had recent trauma or surgery than LEDVT patients. IVC thrombosis was more frequently treated with parenteral anticoagulants alone (35.1% vs. 15.9%), whereas patients with LEDVT more commonly received vitamin K antagonists (32.0% vs. 25.8%) or direct oral anticoagulants (49.0% vs. 35.1%). Thrombolysis (11.0% vs. 3.6%) and surgical/mechanical interventions (4.0% vs. 1.4%) were more frequent in IVC thrombosis. At 24-months, the rate per 100 person-years (95% confidence interval) of all-cause mortality was higher in patients with IVC thrombosis than LEDVT (13.28 [8.57-20.58] vs. 4.91 [4.55-5.3]); the incidence of cancer-associated mortality was comparable as was the incidence of VTE recurrence (4.11 [1.85-9.15] vs. 4.18 [3.84-4.55]). Major bleeding was slightly higher in IVC thrombosis (2.03 [0.66-6.31] vs. 1.66 [1.45-1.89]). CONCLUSION: In summary, IVC thrombosis patients have higher all-cause mortality rates than those with LEDVT, a finding only partly attributable to malignancy.

Influence of body mass index on clinical outcomes in venous thromboembolism: Insights from GARFIELD-VTE.

BACKGROUND: There is limited information on the influence of body mass index (BMI) on clinical outcomes in patients with venous thromboembolism (VTE). OBJECTIVES: Investigate the influence of BMI on baseline characteristics, treatment patterns, and 24-month outcomes in VTE patients. METHODS: GARFIELD-VTE is a prospective, non-interventional study of 10 869 patients with objectively confirmed VTE. Patients were grouped according to BMI: <18.5 (underweight; n = 214); 18.5-24.9 (normal; n = 2866); 25.0-29.9 (overweight; n = 3326); ≥30 (obese; n = 3073). RESULTS: Compared with patients with a normal BMI, obese patients were more frequently Caucasian (77.4% vs. 57.9%), treated in the outpatient setting (30.4% vs. 23.1%), and had previous VTE (17.5% vs. 11.7%). Active cancer was associated with lower BMI (underweight: 30.4%, normal: 13.5%, overweight: 9.4%, obese: 7.0%). At baseline, overweight and obese patients less often received parenteral therapy alone (16.7% and 14.4%) compared with those with an underweight or normal BMI (30.8% and 21.6%). Obese patients more commonly remained on anticoagulants for ≥2-years compared to those with a normal BMI (52.3% vs. 37.7%). After 24-months, the risk of all-cause mortality was lower in overweight and obese patients than in those with normal BMI (adjusted hazard ratio [95% CI]; 0.75 [0.63-0.89] and 0.59 [0.49-0.72], respectively). Underweight patients more often experienced major bleeding (2.45 [1.41-4.26]) and all-cause mortality (1.90 [1.43-2.53]) than patients with a normal BMI. Recurrent VTE was comparable among groups. CONCLUSION: Underweight VTE patients have the highest risk of mortality and major bleeding. The risk of mortality in obese VTE patients is lower than that in VTE patients with a normal BMI.

Clinical Outcomes in Asymptomatic and Symptomatic Atrial Fibrillation Presentations in GARFIELD-AF: Implications for AF Screening.

BACKGROUND: Asymptomatic atrial fibrillation is often detected incidentally. Prognosis and optimal therapy for asymptomatic compared with symptomatic atrial fibrillation is uncertain. This study compares clinical characteristics, treatment, and 2-year outcomes of asymptomatic and symptomatic atrial fibrillation presentations. METHODS: Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) is a global, prospective, observational study of newly diagnosed atrial fibrillation with ≥1 stroke risk factors (http://www.clinicaltrials.gov, unique identifier: NCT01090362). Patients were characterized by atrial fibrillation-related symptoms at presentation and the CHA2DS2-VASc score. Two-year follow-up recorded anticoagulation patterns (vitamin K antagonist, direct oral anticoagulants, parenteral therapy) and outcomes (stroke/systemic embolism, all-cause mortality, and bleeding). RESULTS: At presentation, of 52,032 eligible patients, 25.4% were asymptomatic and 74.6% symptomatic. Asymptomatic patients were slightly older (72 vs 70 years), more often male (64.2% vs 52.9%), and more frequently initiated on anticoagulation ± antiplatelets (69.4% vs 66.0%). No difference in events (adjusted hazard ratios, 95% confidence interval) for nonhemorrhagic stroke/systemic embolism (1.19, 0.97-1.45), all-cause mortality (1.06, 0.94-1.20), or bleeding (1.02, 0.87-1.19) was observed. Anticoagulation was associated with comparable reduction in nonhemorrhagic stroke/systemic embolism (0.59, 0.43-0.82 vs 0.78, 0.65-0.93) and all-cause mortality (0.69, 0.59-0.81 vs 0.77, 0.71-0.85) in asymptomatic versus symptomatic, respectively. CONCLUSIONS: Major outcomes do not differ between asymptomatic and symptomatic atrial fibrillation presentations and are comparably reduced by anticoagulation. Opportunistic screening-detected asymptomatic atrial fibrillation likely has the same prognosis as asymptomatic atrial fibrillation at presentation and likely responds similarly to anticoagulation thromboprophylaxis.

A preliminary study of intensivist-performed DVT ultrasound screening in trauma ICU patients (APSIT Study).

BACKGROUND: Multiple screening Duplex ultrasound scans (DUS) are performed in trauma patients at high risk of deep vein thrombosis (DVT) in the intensive care unit (ICU). Intensive care physician performed compression ultrasound (IP-CUS) has shown promise as a diagnostic test for DVT in a non-trauma setting. Whether IP-CUS can be used as a screening test in trauma patients is unknown. Our study aimed to assess the agreement between IP-CUS and vascular sonographer performed DUS for proximal lower extremity deep vein thrombosis (PLEDVT) screening in high-risk trauma patients in ICU. METHODS: A prospective observational study was conducted at the ICU of Alfred Hospital, a major trauma center in Melbourne, Australia, between Feb and Nov 2015. All adult major trauma patients admitted with high risk for DVT were eligible for inclusion. IP-CUS was performed immediately before or after DUS for PLEDVT screening. The paired studies were repeated twice weekly until the DVT diagnosis, death or ICU discharge. Written informed consent from the patient, or person responsible, or procedural authorisation, was obtained. The individuals performing the scans were blinded to the others' results. The agreement analysis was performed using Cohen's Kappa statistics and intraclass correlation coefficient for repeated binary measurements. RESULTS: During the study period, 117 patients had 193 pairs of scans, and 45 (39%) patients had more than one pair of scans. The median age (IQR) was 47 (28-68) years with 77% males, mean (SD) injury severity score 27.5 (9.53), and a median (IQR) ICU length of stay 7 (3.2-11.6) days. There were 16 cases (13.6%) of PLEDVT with an incidence rate of 2.6 (1.6-4.2) cases per 100 patient-days in ICU. The overall agreement was 96.7% (95% CI 94.15-99.33). The Cohen's Kappa between the IP-CUS and DUS was 0.77 (95% CI 0.59-0.95), and the intraclass correlation coefficient for repeated binary measures was 0.75 (95% CI 0.67-0.81). CONCLUSIONS: There is a substantial agreement between IP-CUS and DUS for PLEDVT screening in trauma patients in ICU with high risk for DVT. Large multicentre studies are needed to confirm this finding.

Management of heart failure with preserved ejection fraction.

Heart failure with preserved ejection fraction is a highly heterogenous disease. There is emerging evidence that treatment should be tailored to the individual's associated comorbidities No current algorithms exist for the management of heart failure with preserved ejection fraction. Conventional therapies used in heart failure with reduced ejection fraction are yet to show a mortality benefit Key treatment objectives include control of hypertension and fluid balance Common comorbidities include coronary artery disease, atrial fibrillation, obesity, diabetes, renal impairment and pulmonary hypertension. These comorbidities should be considered in all patients and treatment optimised