Pragmatic Study of Clinician Use of a Personalized Patient Decision Aid Integrated into the Electronic Health Record: An 8-Year Experience.

Background: Patient decision aids (PDAs) facilitate shared decision-making (SDM) and are delivered in a variety of formats, including printed material or instructional videos, and, more recently, web-based tools. Barriers such as time constraints and disruption to clinical workflow are reported to impede usage in routine practice. Introduction: This pragmatic study examines use of PDAs integrated (iPDAs) into the electronic health record (EHR) over an 8-year period. Methods: A suite of iPDAs that personalize decision-making was integrated into an academic health system EHR. Clinician use was tracked using patient and clinician encrypted information, enabling identification of clinician types and unique uses for an 8-year period. Clinician feedback was obtained through survey. Results: Over 8 years, 1,209 identifiable clinicians used the iPDAs at least once ("aware"). Use increased over time, with 2,415 unique uses in 2010, and 23,456 in 2017. Clinicians who used an iPDA with at least 5 patients ("adopters"), increased by 82 clinicians each year (range 56-108); of clinicians who used the tool once, 54.3% became adopters. Of 261 primary care clinicians, 93.5% were aware, 86.2% were adopters, and 80.5% used the tools in the last 90 days. Clinicians perceived the iPDAs to be convenient, efficient, and encouraging of SDM. Discussion: We demonstrate that use of decision aids integrated into the EHR result in repeated use among clinicians over time and have the potential to overcome barriers to implementation. We noted a high degree of clinician satisfaction, without a sense of increase in visit time. Conclusion: Integration of PDAs into the EHR results in sustained use. Further research is needed to assess the impact of iPDAs on decisional quality.

Reduced haemodynamic coupling and exercise are associated with vascular stiffening in pulmonary arterial hypertension.

OBJECTIVE: Inadequate right ventricular (RV) and pulmonary arterial (PA) functional responses to exercise are important yet poorly understood features of pulmonary arterial hypertension (PAH). This study combined invasive catheterisation with echocardiography to assess RV afterload, RV function and ventricular-vascular coupling in subjects with PAH. METHODS: Twenty-six subjects with PAH were prospectively recruited to undergo right heart catheterisation and Doppler echocardiography at rest and during incremental exercise, and cardiac MRI at rest. Measurements at rest included basic haemodynamics, RV function and coupling efficiency (η). Measurements during incremental exercise included pulmonary vascular resistance (Z0), characteristic impedance (ZC, a measure of proximal PA stiffness) and proximal and distal PA compliance (CPA). RESULTS: In patients with PAH, the proximal PAs were significantly stiffer at maximum exercise (ZC =2.31±0.38 vs 1.33±0.15 WU×m2 at rest; p=0.003) and PA compliance was decreased (CPA=0.88±0.10 vs 1.32±0.17 mL/mm Hg/m2 at rest; p=0.0002). Z0 did not change with exercise. As a result, the resistance-compliance (RC) time decreased with exercise (0.67±0.05 vs 1.00±0.07 s at rest; p<10-6). When patients were grouped according to resting coupling efficiency, those with poorer η exhibited stiffer proximal PAs at rest, a lower maximum exercise level, and more limited CPA reduction at maximum exercise. CONCLUSIONS: In PAH, exercise causes proximal and distal PA stiffening, which combined with preserved Z0 results in decreased RC time with exercise. Stiff PAs at rest may also contribute to poor haemodynamic coupling, reflecting reduced pulmonary vascular reserve that contributes to limit the maximum exercise level tolerated.

Intracranial Arterial 4D-Flow is Associated with Metrics of Brain Health and Alzheimer's Disease.

INTRODUCTION: While cerebrovascular disease has long been known to co-occur with Alzheimer's disease (AD), recent studies suggest an etiologic contribution to AD pathogenesis. We used 4D-Flow magnetic resonance imaging (MRI) to evaluate blood flow and pulsatility indices in the Circle of Willis. We hypothesized decreased mean blood flow and increased pulsatility, metrics indicative of poor vascular health, would be associated with cerebral atrophy and an AD cerebrospinal fluid (CSF) profile. METHODS: 312 patients along the AD continuum (172 middle-aged, 60 cognitively-healthy older, 44 mild cognitive impairment (MCI), and 36 AD) underwent MRI, CSF, and medical examinations. Regression was used to predict CSF biomarkers and atrophy from 4D-Flow, and ANCOVA to compare vascular health between groups. RESULTS: Decreased mean flow in the middle cerebral (MCA) and superior portion of the internal carotid arteries (sICA) and increased pulsatility in the MCA were associated with greater brain atrophy. Decreased mean flow in the sICA was associated with lower Aß-42 in the CSF, a pathological biomarker profile associated with AD. Interestingly, although metrics of flow and pulsatility differed markedly across the AD spectrum, there were no significant differences in cardiovascular risk score, mean arterial pressure and pulse pressure across the three age-matched older cohorts. DISCUSSION: By measuring intracranial arterial health directly with 4D-Flow MRI, these data suggest that intracranial arterial health is compromised in symptomatic AD. Even after accounting for disease stage, cerebral artery health is associated with atrophy and an AD Aß-42 profile, suggesting neurovascular health may contribute to the etiopathogenesis of AD.

A case series of real-time hemodynamic assessment of high output heart failure as a complication of arteriovenous access in dialysis patients.

Congestive heart failure (CHF) is an important source of morbidity and mortality in end-stage renal disease patients. Although CHF is commonly associated with low cardiac output (CO), it may also occur in high CO states. Multiple conditions are associated with increased CO including congenital or acquired arteriovenous fistulae or arteriovenous grafts. Increased CO resulting from permanent AV access in dialysis patients has been shown to induce structural and functional cardiac changes, including the development of eccentric left ventricle hypertrophy. Often, the diagnosis of high output heart failure requires invasive right heart monitoring in the acute care setting such as a medical or cardiac intensive care unit. The diagnosis of an arteriovenous access causing high output heart failure is usually confirmed after the access is ligated surgically. We present for the first time, a case for real-time hemodynamic assessment of high output heart failure due to AV access by interventional nephrology in the cardiac catheterization suite.

Successful computed tomography angiogram through tibial intraosseous access: a case report.

BACKGROUND: Intraosseous access has been used increasingly with proven efficacy in emergent situations for adults when intravenous access could not be obtained. OBJECTIVE: Our aim was to demonstrate if tibial intraosseous (IO) is an effective route for iodinated contrast administration and pulmonary vasculature visualization. CASE REPORT: We report on an obtunded patient requiring a computed tomography angiogram to help with diagnosis and tibial IO was the only viable access appropriate to withstand the pressure of a computed tomography iodinated contrast load. Tibial IO access was used successfully for administration of iodinated contrast to evaluate for massive pulmonary embolism in an obtunded patient in extremis secondary to cardiovascular instability. CONCLUSIONS: The pulmonary arteries were opacified and demonstrated a high-quality CT angiogram can be done via tibial IO device.

Trends in low-density lipoprotein cholesterol goal achievement in high risk United States adults: longitudinal findings from the 1999-2008 National Health and Nutrition Examination Surveys.

BACKGROUND: Previous studies have demonstrated gaps in achievement of low-density lipoprotein-cholesterol (LDL-C) goals among U.S. individuals at high cardiovascular disease risk; however, recent studies in selected populations indicate improvements. OBJECTIVE: We sought to define the longitudinal trends in achieving LDL-C goals among high-risk United States adults from 1999-2008. METHODS: We analyzed five sequential population-based cross-sectional National Health and Nutrition Examination Surveys 1999-2008, which included 18,656 participants aged 20-79 years. We calculated rates of LDL-C goal achievement and treatment in the high-risk population. RESULTS: The prevalence of high-risk individuals increased from 13% to 15.5% (p = 0.046). Achievement of LDL-C <100 mg/dL increased from 24% to 50.4% (p<0.0001) in the high-risk population with similar findings in subgroups with (27% to 64.8% p<0.0001) and without (21.8% to 43.7%, p<0.0001) coronary heart disease (CHD). Achievement of LDL-C <70 mg/dL improved from 2.4% to 17% (p<0.0001) in high-risk individuals and subgroups with (3.4% to 21.4%, p<0.0001) and without (1.7% to 14.9%, p<0.0001) CHD. The proportion with LDL-C ≥130 mg/dL and not on lipid medications decreased from 29.4% to 18% (p = 0.0002), with similar findings among CHD (25% to 11.9% p = 0.0013) and non-CHD (35.8% to 20.8% p<0.0001) subgroups. CONCLUSION: The proportions of the U.S. high-risk population achieving LDL-C <100 mg/dL and <70 mg/dL increased over the last decade. With 65% of the CHD subpopulation achieving an LDL-C <100 mg/dL in the most recent survey, U.S. LDL-C goal achievement exceeds previous reports and approximates rates achieved in highly selected patient cohorts.

Women up, men down: the clinical impact of replacing the Framingham Risk Score with the Reynolds Risk Score in the United States population.

BACKGROUND: The Reynolds Risk Score (RRS) is one alternative to the Framingham Risk Score (FRS) for cardiovascular risk assessment. The Adult Treatment Panel III (ATP III) integrated the FRS a decade ago, but with the anticipated release of ATP IV, it remains uncertain how and which risk models will be integrated into the recommendations. We sought to define the effects in the United States population of a transition from the FRS to the RRS for cardiovascular risk assessment. METHODS: Using the National Health and Nutrition Examination Surveys, we assessed FRS and RRS in 2,502 subjects representing approximately 53.6 Million (M) men (ages 50-79) and women (ages 45-79), without cardiovascular disease or diabetes. We calculated the proportion reclassified by RRS and the subset whose LDL-C goal achievement changed. RESULTS: Compared to FRS, the RRS assigns a higher risk category to 13.9% of women and 9.1% of men while assigning a lower risk to 35.7% of men and 2% of women. Overall, 4.7% of women and 1.1% of men fail to meet newly intensified LDL-C goals using the RRS. Conversely, 10.5% of men and 0.6% of women now meet LDL-C goal using RRS when they had not by FRS. CONCLUSION: In the U.S. population the RRS assigns a new risk category for one in six women and four of nine men. In general, women increase while men decrease risk. In conclusion, adopting the RRS for the 53.6 million eligible U.S. adults would result in intensification of clinical management in 1.6 M additional women and 2.10 M fewer men.

The population effects of the global cardiovascular risk model in United States adults: findings from the National Health and Nutrition Surveys, 2005-2006.

BACKGROUND: The Framingham Global Cardiovascular Disease (FRS-CVD) risk assessment is a proposed alternative for the assessment of hard coronary heart disease (FRS-CHD) event risk. Beyond heart attack and death, FRS-CVD risk adds the end points of cerebrovascular disease, angina, heart failure, and peripheral vascular disease. OBJECTIVE: We sought to estimate the population impact of using FRS-CVD instead of FRS-CHD risk prediction on U.S. adults. METHODS: We analyzed FRS-CHD and FRS-CVD risk in men age 45-74 and women age 55-74 without cardiovascular disease or diabetes, using the National Health and Nutrition Examination Survey 2005-2006. We stratified the population into 10-year risk categories: low: <6%, moderate ≥ 6 to <10%, moderate high ≥ 10 to <20%, and high ≥ 20% by both risk models, and assessed change in risk category distribution and achievement of lipid goals. RESULTS: We analyzed 1020 subjects who statistically represent approximately 50 million U.S. adults. When the FRS-CVD was used, we found that 63% of men and 74% of women increase at least one risk category compared with when the FRS-CHD is used. Overall, the low-risk population decreases from 52% to 16% and the high-risk group increases from 4% to 20%. Of the subjects changing risk categories, 30% will now fail to meet their new corresponding lipid goals. CONCLUSIONS: FRS-CVD end points are more comprehensive, yet the population implications of such a change may be profound. The use of a FRS-CVD risk model significantly increases the intermediate and high-risk groups, thus increasing the number of individuals eligible for novel risk assessment tools such as high-sensitivity C-reactive protein, coronary calcium scoring, and more frequent use of pharmacotherapy.

Cardiac computed tomography and quadricuspid aortic valve: a case report.

A quadricuspid aortic valve is rare and often incidentally found by echocardiography, surgically, or on post mortem examination. Aortic regurgitation is common and if severe enough can lead to symptoms of dyspnea. We report a case of a quadricuspid aortic valve, which was found by cardiac multidetector computed tomography during a pre-operative assessment for severe aortic regurgitation.

National improvements in low-density lipoprotein cholesterol management of individuals at high coronary risk: National Health and Nutrition Examination Survey, 1999 to 2002.

BACKGROUND: This study sought to evaluate national levels of elevated low-density lipoprotein cholesterol (LDL-C) before and after publication of the Adult Treatment Panel III (ATP III). The ATP III guidelines intensified LDL-C targets and defined additional high-risk conditions. These recommendations are expected to have a noticeable impact on US cholesterol levels. METHODS: Coronary heart disease (CHD) risk was determined per ATP III guidelines for US residents aged 20 to 79 years in the 1999 to 2000 and 2001 to 2002 surveys. For those at high risk, the LDL-C mean percentage <100 mg/dL and percentage > or =130 mg/dL, although not taking lipid-lowering therapy, were compared between the 2 surveys. In addition, subsets with and without CHD were evaluated. RESULTS: Of all high-risk US residents, the mean LDL-C dropped from 129 mg/dL in 1999 to 2000 to 120 mg/dL in 2001 to 2002 (P = .003). Those <100 mg/dL increased from 23% to 32% (P = .003). Those > or =130 mg/dL and not on medication dropped from 36% to 27% (P = .001). Goal achievement and improvements were more favorable in the subset with CHD compared with those at high risk due to high-risk equivalent conditions. CONCLUSIONS: The sharp increase in high-risk US residents at the goal and the drop in the untreated percentage of those above treatment threshold illustrate national improvements in the management of LDL-C for those at high coronary risk. High-risk subjects without CHD displayed less significant improvements, suggesting an opportunity for better recognition and management of these individuals.

Rationale for targeted rather than population based screening with C-reactive protein using the National Health and Nutrition Examination Survey (1999 to 2002).

C-reactive protein (CRP) is the most well-studied inflammatory marker for the prediction of coronary artery disease. It was hypothesized that population-wide screening would have minimal impact but that a target population might be identified for whom CRP testing could be appropriate. The National Health and Nutrition Examination Survey (NHANES; 1999 to 2002) included 7,399 subjects who represented 171 million United States residents aged 20 to 79 years. Subjects were risk stratified according to National Cholesterol Education Program Adult Treatment Panel III guidelines. Subjects with CRP levels >3 mg/L then had their risk profiles adjusted by adding 1 risk factor and multiplying their Framingham risk scores by 1.5. Subjects had their low-density lipoprotein (LDL) cholesterol goals adjusted as necessary and were then recategorized as above or below their CRP-adjusted LDL cholesterol goal. LDL cholesterol goals were met initially by 67.8% (116 +/- 8 million) of United States residents, and 64.8% (111 +/- 8 million) achieved their LDL cholesterol goals after CRP adjustment. Thus, 5.3 +/- 1.1 million of the population (3.1 +/- 0.1%) had their risk modified in a clinically meaningful way by CRP adjustment. Targeting the screening to 2 groups, those with 1 risk factor and LDL cholesterol levels 130 to 159 mg/dl and those with moderately high risk and LDL cholesterol levels 100 to 129 mg/dl, we were able to identify all 5.3 million by screening only 14.8 million, achieving a screening yield of 35%. In conclusion, population-based screening with CRP provided a clinical impact for only 3.1% of United States residents. Patients with 1 risk factor and LDL cholesterol levels of 130 to 159 mg/dl and those with moderately high risk and LDL cholesterol levels of 100 to 129 mg/dl represent high-yield subgroups for routine CRP screening.

Implications of cardiac risk and low-density lipoprotein cholesterol distributions in the United States for the diagnosis and treatment of dyslipidemia: data from National Health and Nutrition Examination Survey 1999 to 2002.

BACKGROUND: Updated guidelines from the National Cholesterol Education Program Adult Treatment Panel III stratify patients into 5 groups of coronary heart disease (CHD) risk that determine intensity of lipid-lowering therapy. The present study assesses the distribution of low-density lipoprotein cholesterol (LDL-C) in the United States across the 5 groups of CHD risk as defined in the updated guidelines. METHODS AND RESULTS: Subjects included 7399 individuals 20 to 79 years of age in the 1999 to 2002 National Health and Nutrition Examination Survey representing 171 million individuals in the United States. CHD risk, LDL-C levels, and goal achievement were determined per Adult Treatment Panel III guidelines. CHD risk assessment incorporated a medical condition review, risk factor summation, and Framingham Risk Score calculation. Percentages were weighted to represent population estimates, and SEs were adjusted for the survey design. The distribution of individuals by CHD risk included 61.1% at lower risk, 10.6% at high risk, and 5.7% at very high risk. From Adult Treatment Panel III criteria, only 5.4% of the population was at "intermediate" risk. Two thirds (66.3%) met their Adult Treatment Panel III-defined LDL-C goal. Of those at high and very high risk, 23% and 26%, respectively, met the goal of LDL-C <100 mg/dL, whereas only 3.1% and 4.6% had an LDL-C <70 mg/dL (or non-high-density lipoprotein C <100 mg/dL). CONCLUSIONS: Most adult US residents are at lower 10-year CHD risk and meet risk-adjusted LDL-C goals. However, large portions of the high-risk population are undertreated. The commonly described population at intermediate risk is small. A novel method of identifying patients who might benefit from additional testing to determine their treatment strategy is provided.

Is the ankle-brachial index a useful screening test for subclinical atherosclerosis in asymptomatic, middle-aged adults?

BACKGROUND: Measurement of the ankle-brachial index (ABI) is recommended as a screening test for cardiovascular risk prediction in individuals > or = 50 years old; however, there is little data regarding the utility of the ABI as a screening test in individuals for whom physicians actually order non-invasive testing for cardiovascular risk prediction. METHODS: This study included 493 consecutive asymptomatic patients without known atherosclerotic vascular disease who were referred by their physician for measurement of the ABI and ultrasound measurement of carotid intima-media thickness (CIMT). ABI values were classified as "reduced" (<0.9), "normal" (0.9-1.3), and "increased" (>1.3). RESULTS: The mean age of the patients was 55.3 (standard deviation 7.5) years. Only 1 patient had a reduced ABI (0.2%). ABI values tended to be higher in those with increased CIMT (P=0.051); however, CIMT was not significantly different between those with normal and increased ABI values (P=0.802). There were no significant differences in the prevalence of traditional cardiovascular risk factors or carotid plaque presence among the ABI groups. CONCLUSIONS: Despite recommendations, the ABI is not sensitive as a screening tool for detecting subclinical atherosclerosis in asymptomatic middle-aged individuals.

Use of carotid intima-media thickness and vascular age to modify cardiovascular risk prediction.

BACKGROUND: This study identified predictors of patients for whom carotid artery intima-media thickness (CIMT) measurement and determination of vascular age could change cardiovascular disease (CVD) risk assessment. METHODS: We studied consecutive patients who were asymptomatic and nondiabetic, referred for ultrasound measurement of CIMT. Individuals with CIMT 75th percentile or greater for age, sex, and race were defined as having advanced subclinical atherosclerosis. CIMT values were converted to vascular age estimates and were used to modify Framingham 10-year CVD risk estimates. RESULTS: Of 506 patients, 261 (51.6%) were not taking lipid-lowering therapy. Advanced subclinical atherosclerosis was present in 77 (30%). There were 62 patients (23.8%) with a change in CVD risk of 5% or more. Predictors of 5% or more change in CVD risk were systolic blood pressure (P < .001), total/high-density lipoprotein cholesterol ratio (P < .001), and male sex (P < .001). Of the 97 patients at moderate or moderately high risk, 56.7% changed risk classification. CONCLUSIONS: Measurement of CIMT and determination of vascular age can identify individuals with advanced subclinical atherosclerosis, resulting in clinically meaningful alterations in CVD risk estimates.

Transient left ventricular apical ballooning: a review of the literature.

Transient left ventricular apical ballooning is a newly defined syndrome characterized by sudden onset of chest symptoms, electrocardiographic changes characteristic of myocardial ischemia, transient left ventricular dysfunction-particularly in the apical region, low-grade troponin elevation, and no significant coronary stenosis by angiogram. This syndrome is also referred to as Takotsubo cardiomyopathy, "Ampulla" cardiomyopathy, Human Stress cardiomyopathy, and Broken Heart Syndrome. Emergency physicians, family physicians, general internists, and cardiologists may all encounter this syndrome at the point of contact. The similarity to acute coronary syndrome requires all clinicians who may potentially care for these patients to familiarize themselves with this newly recognized disease. We provide a recent case and review the current literature surrounding this syndrome.

Ultrasound-detected carotid plaque as a screening tool for advanced subclinical atherosclerosis.

BACKGROUND: There is great need for a simple, noninvasive tool that can be used in an office setting to screen for subclinical atherosclerosis. In patients referred for cardiovascular (CV) risk assessment, we evaluated the ability of ultrasound screening for carotid plaque to identify patients with advanced subclinical atherosclerosis. METHODS: Consecutive asymptomatic patients without vascular disease referred by their physician for measurement of the ankle-brachial pressure index and carotid intima-media thickness (CIMT) were included. Carotid intima-media thickness was measured using the standardized ultrasound protocol from the Atherosclerosis Risk in Communities (ARIC) study. Advanced atherosclerosis was defined as CIMT > or = 75th percentile for age, sex, and race in ARIC. RESULTS: The mean age of the 327 subjects was 55.4 years (SD 7.7 years). The 10-year Framingham CV risk was 5.1% (4.8%). In a multiple logistic regression model that included Framingham CV risk, ankle-brachial pressure index, and use of lipid-lowering medications, plaque presence significantly predicted advanced atherosclerosis (odds ratio 3.08, 95% CI 1.91-4.96, P < .001). In stepwise regression models that included age, body mass index, current tobacco use, family history of premature CV disease, fasting glucose, sex, systolic blood pressure, total/high-density lipoprotein cholesterol ratio, and use of antihypertensive and lipid-lowering medications, plaque presence independently predicted advanced atherosclerosis (P < .001). CONCLUSION: Ultrasound detection of carotid plaque helped identify asymptomatic patients with advanced subclinical atherosclerosis. Screening for carotid plaque is easier than determination of CIMT and may help detect asymptomatic patients at increased CV risk.

The association of homocysteine and coronary artery disease.

Hyperhomocysteinemia has been associated with increased risk of atherosclerosis and myocardial infarction by a number of prospective case-control studies. A variety of genetic mutations, nutritional deficiencies, disease states, and drugs can elevate homocysteine concentrations. Treatment with folic acid with or without B-complex vitamins effectively lowers homocysteine levels. Whether therapy corresponds with decreased risk of coronary events is unknown, but may be promising. This article reviews the biochemistry of homocysteine metabolism, pathogeneisis, and etiology of hyperhomocysteinemia, along with its association with coronary artery disease, screening, and treatment.

Cardiovascular disease prevention.

In this chapter, we have reviewed many of the steps necessary for effective CHD risk reduction. The first step in the office setting is to assess the individual CHD risk. This combines the evaluation of current CHD or a "secondary risk equivalent" with the counting of risk factors and in many cases, the absolute risk calculation. The next steps are to consider each of the major modifiable risk factors (hypertension, dyslipidemia, diabetes mellitus, smoking status) to set goals for each and then work to achieve those goals through lifestyle changes and medication therapy. We reviewed each of these risk factors in detail and then turned to a discussion of emerging risk factors that may help "fine-tune" the risk assessment in some borderline cases. We also discussed additional non-invasive testing that is available to the clinician to help refine the assessment of current burden of disease. Finally, we discuss some of the barriers that exist on both a global and local level to effective treatment of CHD risk factors.