Late Presentation of Pulmonary Artery-Left Atrial Appendage Fistula Formation After Left Atrial Appendage Device Closure.

Atrial fibrillation is the most common arrhythmia in clinical practice with indication for anticoagulation in those patients whose annual risk for thromboembolism is >2%. Left atrial appendage closure is growing as an alternative to anticoagulation. We present a case of pulmonary artery-left atrial appendage fistula seen after left atrial appendage closure. (Level of Difficulty: Intermediate.).

Angina Severity, Mortality, and Healthcare Utilization Among Veterans With Stable Angina.

Background Canadian Cardiovascular Society (CCS) angina severity classification is associated with mortality, myocardial infarction, and coronary revascularization in clinical trial and registry data. The objective of this study was to determine associations between CCS class and all-cause mortality and healthcare utilization, using natural language processing to extract CCS classifications from clinical notes. Methods and Results In this retrospective cohort study of veterans in the United States with stable angina from January 1, 2006, to December 31, 2013, natural language processing extracted CCS classifications. Veterans with a prior diagnosis of coronary artery disease were excluded. Outcomes included all-cause mortality (primary), all-cause and cardiovascular-specific hospitalizations, coronary revascularization, and 1-year healthcare costs. Of 299 577 veterans identified, 14 216 (4.7%) had ≥1 CCS classification extracted by natural language processing. The mean age was 66.6±9.8 years, 99% of participants were male, and 81% were white. During a median follow-up of 3.4 years, all-cause mortality rates were 4.58, 4.60, 6.22, and 6.83 per 100 person-years for CCS classes I, II, III, and IV, respectively. Multivariable adjusted hazard ratios for all-cause mortality comparing CCS II, III, and IV with those in class I were 1.05 (95% CI, 0.95-1.15), 1.33 (95% CI, 1.20-1.47), and 1.48 (95% CI, 1.25-1.76), respectively. The multivariable hazard ratio comparing CCS IV with CCS I was 1.20 (95% CI, 1.09-1.33) for all-cause hospitalization, 1.25 (95% CI, 0.96-1.64) for acute coronary syndrome hospitalizations, 1.00 (95% CI, 0.80-1.26) for heart failure hospitalizations, 1.05 (95% CI, 0.88-1.25) for atrial fibrillation hospitalizations, 1.92 (95% CI, 1.40-2.64) for percutaneous coronary intervention, and 2.51 (95% CI, 1.99-3.16) for coronary artery bypass grafting surgery. Conclusions Natural language processing-extracted CCS classification was positively associated with all-cause mortality and healthcare utilization, demonstrating the prognostic importance of anginal symptom assessment and documentation.

Head CT scan overuse in frequently admitted medical patients.

BACKGROUND: Patients frequently admitted to medical services undergo extensive computed tomography (CT) imaging. Some of this imaging may be unnecessary, and in particular, head CT scans may be over-used in this patient population. We describe the frequency of abnormal head CT scans in patients with multiple medical hospitalizations. METHODS: We retrospectively reviewed all CT scans done in 130 patients with 7 or more admissions to medical services between January 1 and December 31, 2011 within an integrated health care system. We calculated the number of CT scans, anatomic site of imaging, and source of ordering (emergency department, inpatient floor). We scored all head CT scans on a 0-4 scale based on the severity of radiographic findings. Higher scores signified more clinically important findings. RESULTS: There were 795 CT scans performed in total, with a mean of 6.7 (± SD 5.8) CT scans per patient. Abdominal/pelvis (39%), chest (30%), and head (22%) CT scans were the most frequently obtained. The mean number of head CT scans performed was 2.9 (SD ± 4.2). Inpatient floors were the major site of CT scan ordering (53.7%). Of 172 head CT scans, only 4% had clinically significant findings (scores of 3 or 4). CONCLUSIONS: Patients with frequent medical admissions are medically complex and undergo multiple CT scans in a year. The vast majority of head CT scans lack clinically significant findings and should be ordered less frequently. Interdisciplinary measures should be advocated by hospitalists, emergency departments, and radiologists to decrease unnecessary imaging in this population.

Effect of electronic prescription on attainment of cholesterol goals.

BACKGROUND: Although recent federal mandate provides incentives for physicians to use electronic prescribing (e-prescribing), clinical end points to support its use are lacking. HYPOTHESIS: E-prescribing should improve low-density lipoprotein (LDL) goal attainment. METHODS: In this retrospective cohort study, we queried the electronic medical records (Allscripts Electronic Health Record [EHR]) of a multispecialty outpatient academic medical practice to identify patient encounters during which consecutive lipid panels were drawn in 2007 (n = 2218). The EHR did not include a clinical decision tool for guideline adherence but did include formulary decision support (FDS), which informs physicians about drug costs specific to each patient. Logistic regression was used to examine whether the odds of reaching LDL goal were influenced by e-prescribing and adjusted for characteristics known to affect prescribing patterns and goal attainment. RESULTS: Of 796 patients not at LDL goal at baseline, 49% (n = 393) were at goal at follow-up. Patients receiving an e-prescription with FDS were 59% more likely to achieve LDL goal than those with a manual prescription (95% confidence interval [CI]: 1.12-2.25). Superior LDL goal attainment may be from lower cost of medications; patients with an e-prescription were significantly more likely to receive a generic statin than patients with a manual prescription (38% vs 22.9%; P = 0.0004), and for each $10 increase in prescription price, the likelihood of being at goal decreased by 5% (odds ratio = 0.95; 95% CI: 0.93-0.98). CONCLUSIONS: Our study is the first to demonstrate that e-prescribing with FDS is associated with improved LDL goal attainment. Therefore, e-prescribing can deliver tangible clinical gains to patients, likely from improved adherence to more affordable treatment.