Impact of Anti-Estrogen Therapy on Early Cardiovascular Referrals, Tests and Medications in Premenopausal Women with Operable Breast Cancer.

INTRODUCTION: Premenopausal women with high-risk hormone receptor (HR)-positive breast cancer often receive ovarian function suppression (OFS) and anti-estrogen therapy which induces near complete estrogen deprivation (NCED). This treatment improves recurrence-free survival but may increase cardiovascular risk. We sought to identify patterns of cardiovascular care and outcomes in premenopausal women with operable breast cancer. METHODS: Premenopausal women ≤ 50 years of age with stage I-III HR-positive or triple negative breast cancer (TNBC) were identified by retrospective review. We categorized women into 3 groups based on anti-estrogen therapy approach: NCED (HR + OFS), anti-estrogen therapy without OFS (HRnoOFS), and no anti-estrogen therapy (TNBC). Baseline characteristics, post-diagnosis cardiovascular events and cardiovascular actions (tests, referrals and medications) were recorded. Categorical variables were compared among the groups using chi-square and Fisher's exact tests; continuous outcomes were compared using ANOVA. RESULTS: 82, 83, and 52 women were identified in the HR + OFS, HRnoOFS, and TNBC groups respectively; mean follow-up was 5.0 years. Mean number of cardiovascular actions per year were highest in the HR + OFS group compared with HRnoOFS and TNBC groups (0.35 vs. 0.20 and 0.27, respectively; P = .036). The HR + OFS group had significantly more referrals and tests per year than the other groups. Cardiovascular medication initiation did not differ among groups. CONCLUSIONS: In this early follow-up period, there were meaningful numbers of cardiovascular actions, with women on NCED experiencing the most per year. Future work should seek to further understand the impact of anti-estrogen therapy on the cardiovascular health of premenopausal women and test strategies to mitigate cardiotoxicity.

Cardiovascular impact of near complete estrogen deprivation in premenopausal women with breast cancer: The CROWN study.

Survival with operable breast cancer has improved markedly in recent decades, however, treatment-related cardiovascular toxicities threaten to offset these gains. Ovarian function suppression paired with aromatase inhibition, for premenopausal women with hormone receptor (HR)-positive breast cancer, is a newer widely adopted therapy with the potential for significant long-term cardiovascular toxicity. Abrupt estrogen deprivation for non-cancer reasons is associated with accelerated coronary artery disease. Women with breast cancer treated with aromatase inhibition in addition to ovarian function suppression experience a dual hit with regards to estrogen exposure. The CaRdiac Outcomes With Near-complete estrogen deprivation (CROWN) study seeks to understand the early, subclinical natural history of cardiovascular compromise in young women undergoing near-complete estrogen deprivation (NCED) therapy. It is critical to understand the early subclinical development of cardiovascular disease to identify a window for therapeutic intervention before overt cardiovascular events occur. This three-site regional study (Atrium Health Wake Forest, Duke, and Virginia Commonwealth University) uses serial stress cardiac magnetic resonance (CMR) imaging and cardiac computed tomography angiography (CCTA) obtained during the initial two years of NCED therapy to study myocardial prefusion reserve (MPR), large cardiovascular vessel changes, left ventricular function, and other cardiovascular parameters. The CROWN cohort will consist of 90 premenopausal women with breast cancer, 67 with HR-positive disease receiving NCED and 23 comparators with HR-negative disease. Participants will undergo three annual CMR scans and 2 CCTA scans during the 2-year study period. After initial activation hurdles, accrual has been brisk, and the study is expected to complete accrual in December 2024. Efforts are in place to encourage participant retention with the study primary outcome, change in MPR between the two groups, to be reported in 2026 to 2027. The results of this study will enable premenopausal women with breast cancer to balance the health burdens of cancer at a young age and treatment-related cardiovascular morbidity. Finally, the tools developed here can be utilized to study cardiovascular risk across a range of cancer types and cancer therapies with the ultimate goals of both developing generalizable risk stratification tools as well as validating interventions which prevent overt cardiovascular compromise.

Acute cardiac tamponade during atrial flutter ablation: improved hemodynamics after positive pressure ventilation: a case report.

INTRODUCTION: Acute cardiac tamponade is a rare event during any type of interventional or surgical procedure. It can occur during electrophysiology procedures due to radiofrequency ablation, lead or catheter manipulation, transseptal puncture, laser lead extractions, or left atrial appendage occlusion device positioning. Cardiac tamponade is difficult to study in a prospective manner, and case reports and case series are important contributions to understanding the best options for patient care. An 87-year-old Caucasian male patient breathing spontaneously developed acute tamponade during an atrial flutter ablation. Pericardial drain insertion was difficult, and hypotension failed to respond to epinephrine boluses. The patient became hypoxemic and hypercarbic, requiring intubation. Unexpectedly, the blood pressure markedly increased postintubation and remained in a normal range until the pericardium was drained. CONCLUSION: Spontaneous ventilation is considered important to maintain venous return to the right heart during cardiac tamponade. However, spontaneous ventilation reduces venous return to the left heart and worsens the paradoxical pulse in tamponade. Intravenous vasopressors are thought to be ineffective during cardiac tamponade. Our patient maintained pulmonary blood flow as indicated by end-tidal carbon dioxide measurements but had no measurable systemic blood pressure during spontaneous ventilation. Our case demonstrates that tracheal intubation and positive pressure ventilation can transiently improve left heart venous return, systemic perfusion, and drug delivery to the systemic circulation.

Using Kotter's Change Management Framework to Redesign Departmental GME Recruitment.

Background: In light of the COVID-19 pandemic, dramatic change in the graduate medical education (GME) trainee recruitment process was required. Kotter's 8-Step Change Model is a change management framework that has been successfully applied to a variety of GME initiatives but not for recruitment redesign. Objective: To implement major change in program recruitment during the COVID-19 pandemic while maintaining Match outcomes and a high-quality candidate experience. Methods: In 2020, we applied Kotter's 8 steps to implement major changes to program recruitment for a department of internal medicine including 15 GME programs (1 internal medicine residency and 14 subspecialty fellowships). We collected each program's Match fill rates and used Google Analytics to collect monthly website traffic for the year prior to our change process and the subsequent 2 years. Standardized post-interview survey questions were created, and these results were reviewed for descriptive analysis. Results: We successfully used Kotter's 8 steps to change recruitment to a virtual format. Program fill rates remained high after implementation. Website engagement improved with peak monthly page rates doubling over previous values. During the highest traffic month, the average time on site increased for 7 programs, while the bounce rate decreased by more than half for 10 programs. Candidate descriptive feedback was positive. Conclusions: The application of Kotter's 8 steps guided major changes to GME recruitment for 15 programs and was associated with maintained Match fill rates and increased website engagement.

Evaluation of lead-based echodensities on transesophageal echocardiogram in patients with cardiac implantable electronic devices.

INTRODUCTION: Transesophageal echocardiography (TEE) is recommended to rule out endocarditis in patients with cardiac implantable electronic devices (CIED). A lead-based echodensity (LBE), however, is often found on TEE in patients with a CIED and may not represent an infection. We sought to evaluate the predictors, characteristics, and clinical significance of LBEs seen on TEE in patients with a CIED. METHODS: Patients with a CIED were retrospectively identified from a database using International Classification of Diseases (ICD)-9/ICD-10 codes and were cross-matched with Current Procedural Terminology codes for a TEE. Clinical and follow-up data were collected. A blinded echo board-certified cardiologist reviewed all TEEs. RESULTS: Out of the 231 patients in the cohort, 191 had TEE performed for a noninfection-related indication while 40 TEEs were part of an endocarditis workup. A total of 50 LBEs were identified, and a majority were in the noninfection cohort. Systemic anticoagulant use in the noninfection cohort was associated with a decreased odds of having LBE on TEE (odds ratio [OR] of 0.23 [95% confidence interval [CI]: 0.06-0.60, p = .003]). Lead dwell time in the noninfection cohort was associated with an increased odds of having LBE on TEE (OR 1.21 (95% CI: 1.04-1.39, p = .009]). CONCLUSION: In our cohort of patients who had TEE for noninfection indications we found that systemic anticoagulant use is associated with fewer LBEs on TEEs, suggesting possible thrombin fibrin composition of LBE.

Media Multitasking in Medical Students: A Theory-Based Approach to Understanding this Behavior.

PHENOMENON: While technology is useful and encouraged in medical school, the effect of media multitasking on academic performance remains concerning. Past research has investigated performance and cognitions associated with college students' in-class media multitasking behavior, but the extent and correlates among medical students is relatively unknown. APPROACH: We surveyed medical students at our institution to quantify media multitasking behaviors and related beliefs, and we collected corresponding course grades. Our research applies the Integrative Model of Behavioral Prediction theory to analyze course and cognitive factors influencing media multitasking behavior in medical students. Correlation of media multitasking behavior with average and block grades assessed potential academic impact of the behavior. FINDINGS: Media multitasking was common among medical students. Reported extent of media multitasking among medical students (N = 119) was not related to course grades but was driven by an interplay of beliefs about the behavior and specific course factors. Based on our hierarchical regression model, concerns about boredom appear to be the major cognitive belief underlying behavior. INSIGHTS: Our findings, in the context of the Integrative Model of Behavioral Prediction theory, show influential factors that impact medical students' behavior regarding media multitasking. A campaign targeting these factors influencing behavior may be the most effective approach to limit students' media multitasking and its potential impact on performance. Though our research did not find an association between the extent of media multitasking and course grades, our study was limited by self-report of media multitasking and relatively crude measures of academic performance. Further research is required to measure these behaviors and potential outcomes.Supplemental data for this article is available online at.

Writing Is Thinking: Implementation and Evaluation of an Internal Medicine Residency Clinical Reasoning and Documentation Curriculum.

With increasingly complicated patients and faster throughput, time for thorough critical thinking and thoughtful clinical documentation is limited, especially in the training environment. Advocating for the value of clinical documentation as a robust opportunity for critical thinking, we describe the implementation and evaluation of a clinical reasoning and documentation curriculum for internal medicine residents. Our curriculum employed facilitated discussion, practical application, and a resident-as-teacher model. Resident surveys showed improved perceptions of the clinical and educational value of clinical documentation. Residents reported increased feedback to interns about their documentation and more appreciation of documentation as a venue for critical thinking. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01570-5.

Intraoperative Transesophageal Echocardiographic Detection of a Gerbode Defect in a Patient Referred for Aortic Valve Endocarditis: A Case Report.

This clinical challenge discusses a case in which a patient was referred for aortic valve repair or replacement due to severe aortic regurgitation from infective endocarditis. In addition to discovering a previously unknown tricuspid valve vegetation, the intraoperative echocardiographic evaluation was instrumental in revealing an undiagnosed Gerbode defect. The flow through this Gerbode defect was previously mistaken for tricuspid regurgitation, and the patient was misdiagnosed as exhibiting severe pulmonary hypertension. This case highlights the importance of reviewing preoperative echocardiographic imaging, as well as diligence in completing a thorough intraoperative transesophageal echocardiographic exam prior to cardiopulmonary bypass. In addition, while flow typically occurs in Gerbode defects during systole, this case demonstrates that flow can also occur during diastole, which was most likely due to the severe aortic regurgitation. Fortunately, the patient was able to undergo successful treatment for the unexpected sequalae of the infective endocarditis, including repair of the Gerbode defect, tricuspid valve repair, and aortic valve and root replacement. Importantly, the incorrect diagnosis of severe pulmonary hypertension was removed.

Accelerated rate of progression of bioprosthetic aortic stenosis in patients with renal disease.

BACKGROUND: Renal disease can lead to more rapid progression of aortic stenosis. However, there are limited case report data investigating the impact of renal disease on the rate of prosthetic aortic valve stenosis. We sought to quantify the rate of progression of bioprosthetic aortic stenosis in patients with renal disease. METHODS: Patients with bioprosthetic aortic valves and at least two transthoracic echocardiograms six or more months apart were included. Echocardiographic data from patients with end-stage renal disease (ESRD), chronic kidney disease (CKD) stages 3-4, and normal renal function were compared using ANOVA and Kruskal-Wallis tests. RESULTS: One hundred fifteen patients (43 ESRD, 52 CKD, and 20 controls) were included in this study. Changes in dimensionless index (DI) (units/year) for patients with normal renal function, CKD, and ESRD were .025 ± .13, -.040 ± .08, -.10 ± .13, respectively, leading to calculated changes in aortic valve area (AVA) (cm2 /year) of .04 ± .28, -.13 ± .29, -.42 ± .72, respectively. Change in peak gradient (m/sec/year) was significantly lower for patients with normal renal function compared to ESRD; -.077 ± 5.98 versus 7.18 ± 17.9. In the ESRD group, a nonsignificant trend toward greater change in DI/year was seen in TAVR compared to SAVR: -.14 ± .16 versus -.08 ± .11. CONCLUSION: Our results confirm limited available data reporting an accelerated rate of bioprosthetic stenosis in patients with CKD and ESRD. These data not only quantify this progression but may also inform clinical decision-making and valve selection in patients with renal disease.

Right Internal Mammary Artery Occlusion in a Patient With Failed Left Internal Mammary Artery Coronary Artery Bypass Graft Surgery Post a Laparoscopic Appendectomy for Acute Appendicitis.

Patients who present with acute myocardial infarction are often urgently evaluated for possible revascularization via coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), or medical therapy alone. CABG has been shown to provide symptomatic relief as well as increased long-term survival for patients with multivessel coronary artery disease (CAD). Though venous grafts can be used to revascularize the ischemic territory, long-term patency is most successful when using pedicled coronary grafts such as the left internal mammary artery (LIMA) or right internal mammary artery (RIMA) graft. Only a fraction of patients who undergo a RIMA or LIMA will occlude their graft, and mid-graft lesions presumed secondary to atherosclerosis are even rare. For our case report, we evaluate a 72-year-old female who has had a very rare acute coronary occlusion of her mid-RIMA graft resulting in an acute apical left ventricular infarct. A heart catheterization confirmed a 100% thrombotic occlusion of the mid-RIMA-LAD, which was stented with a 2.5 x 20 mm drug-eluting stent.

Impact of anatomical variations of the left ventricular outflow tract on stroke volume calculation by Doppler echocardiography in aortic stenosis.

BACKGROUND: Accurate calculation of stroke volume (SV) by Doppler echocardiography is important for the assessment of aortic stenosis (AS), which may be impacted by anatomical variations of left ventricular outflow tract (LVOT). METHODS: Patients with AS (n = 64) were studied using computed tomography (CT) and transthoracic echocardiography (TTE). Anatomical variations of LVOT areas were measured at (a) the aortic annulus (Aa ); (b) 5 mm (A5 ); and (c) 10 mm below the annulus (A10 ) by CT. LVOT diameters were also measured by 2D TTE at these three levels for calculation of LVOT areas. Stroke volumes (SV) were calculated using continuity equation. The impacts of anatomical variations of LVOT on SV calculation were evaluated. RESULTS: Anatomical LVOT area increased from Aa to A10 (5.0 ± 0.9 cm2 vs 5.8 ± 1.9 cm2 , P < .01). Differences between TTE-calculated LVOT areas and anatomical areas were most significant at A10 due to elongation of mediolateral diameters with variable changes in anteroposterior diameters (5.8 ± 1.9 cm2 vs 3.4 ± 1.1 cm2 , P < .001). Although mean calculated SV by TTE was not significant at different LVOT levels (Aa 69 ± 22 mL, vs A5 66 ± 21 mL, vs A10 66 ± 28 ± 22 mL, P > .05), the most significant variations in individuals were at A10 levels (ΔSV: 8.2 ± 6.4 mL, 12 ± 9%). CONCLUSION: Variations of LVOT anatomy in individuals with AS significantly impact the SV calculated by Doppler echocardiography. These features should be taken into account for AS diagnosis and a clinical decision-making for intervention.

Prognostic Significance and Clinical Utility of Intraventricular Conduction Delays on the Preoperative Electrocardiogram.

The prognostic significance of the preoperative electrocardiogram (ECG), particularly intraventricular conduction delays (IVCDs), on postoperative outcomes among patients undergoing noncardiac surgery is uncertain. In a retrospective cohort, we evaluated the risk associated with preoperative IVCDs on in-hospital death and postoperative myocardial infarction (POMI). The 152,479 patients who underwent noncardiac surgery were categorized by preoperative electrocardiographic findings: normal (36.1%), left bundle branch block (LBBB, 1.2%), right bundle branch block (2.9%), nonspecific IVCD (3.3%), and any other ECG abnormality (56.5%). The primary and secondary outcomes were postoperative in-hospital mortality and POMI, respectively. In multivariable-adjusted models, compared with normal ECGs, each electrocardiographic abnormality category was associated with increased risk of postoperative death: LBBB odds ratio (OR) 1.89 (95% confidence interval [CI] 1.35 to 2.65), right bundle branch block OR 1.73 (95% CI 1.33 to 2.24), nonspecific IVCD OR 1.95 (95% CI 1.53 to 2.48), and other abnormal ECG OR 1.94 (95% CI 1.68 to 2.25). ECGs with conduction delays did not confer increased risk of postoperative death compared with other ECG abnormalities. Moreover, receiver operating characteristic analysis of models incorporating demographic and co-morbidity data demonstrated marginal additive benefit of any electrocardiographic data. Risk of POMI was not significantly increased among ECGs with conduction delays compared with both normal and other abnormal ECGs. In conclusion, patients with intraventricular conduction disease, including LBBB, on preoperative ECG are not at greater risk of postoperative in-hospital death or POMI compared with patients with other ECG abnormalities. Furthermore, any preoperative electrocardiographic abnormalities, including intraventricular delays, provide marginal clinical utility beyond demographic and clinical history for predicting postoperative in-hospital death or POMI.

Improving Practice Guideline Adherence Through Peer Feedback: Impact of an Ambulatory Cardiology Curriculum.

PROBLEM: Graduate medical trainees must be prepared to practice in a quality-driven system that values adherence to and documentation of evidence-based care. Few validated approaches exist to teach these skills. Our objective was to develop, implement, and evaluate an ambulatory practice improvement curriculum capitalizing on peer feedback aimed at improving cardiology fellow guideline knowledge, adherence, and chart documentation. INTERVENTION: Four outpatient topics were reviewed in dedicated 1-hour sessions: stable ischemic heart disease, heart failure, atrial fibrillation, and aortic valvular disease. Each session began with peer review, critique, and guideline adherence discussion of deidentified outpatient fellow clinic charts, followed by discussion of clinical guidelines. The open discussion of real clinic notes provided a forum for peer feedback exchange. Before each session and after the final session, participants completed a multiple-choice knowledge assessment and self-assessment of comfort with the guidelines. To evaluate the potential effect on patient care, random clinic chart audits were conducted before and after the curriculum using a chart scoring system. CONTEXT: Although the format is broadly applicable, the specific curriculum content was designed for a cardiology fellowship cohort in a large academic medical center. It was organized and implemented by 2 cardiology fellows under the direction and supervision of program directors. The curriculum was implemented during prescheduled noon conference hours. The intention was to carry forward this ambulatory curriculum in subsequent years and to use the first 4 sessions to study its potential successes and opportunities for improvement. OUTCOME: All 22 general cardiology fellows attended at least two sessions (M = 3.1). Knowledge test scores rose from 52.6% to 73.0% (20.4% increase, p < .001), 95% confidence interval (CI) [13.6%, 27.2%]. Self-reported guidelines knowledge improved by 15.1% (p = .002), 95% CI [6.2%, 24.0%], and self-reported documentation improved by 12.5% (p = .008), 95% CI [3.8%, 21.7%]. Chart audit scores improved by 17.8% (p < .001), 95% CI [10.6%, 25.0%], driven in part by 16.4% improvement in adherence to Class I therapies (p = .001). LESSONS LEARNED: A targeted curriculum combining peer chart review, feedback, and guideline discussion was associated with significant improvement in fellows' knowledge and adherence to evidence-based therapies. Peer assessment and group-based education and feedback can be leveraged to improve trainee education and impact patient care.

Statins and cognitive function: a systematic review.

BACKGROUND: Despite the U.S. Food and Drug Administration (FDA) warning regarding cognitive impairment, the relationship between statins and cognition remains unknown. PURPOSE: To examine the effect of statins on cognition. DATA SOURCES: PubMed, Embase, and Cochrane Library from inception through October 2012; FDA databases from January 1986 through March 2012. STUDY SELECTION: Randomized, controlled trials (RCTs) and cohort, case-control, and cross-sectional studies evaluating cognition in patients receiving statins. DATA EXTRACTION: Two reviewers extracted data, 1 reviewer assessed study risk of bias, and 1 reviewer checked all assessments. DATA SYNTHESIS: Among statin users, low-quality evidence suggested no increased incidence of Alzheimer disease and no difference in cognitive performance related to procedural memory, attention, or motor speed. Moderate-quality evidence suggested no increased incidence of dementia or mild cognitive impairment or any change in cognitive performance related to global cognitive performance scores, executive function, declarative memory, processing speed, or visuoperception. Examination of the FDA postmarketing surveillance databases revealed a low reporting rate for cognitive-related adverse events with statins that was similar to the rates seen with other commonly prescribed cardiovascular medications. LIMITATIONS: The absence of many well-powered RCTs for most outcomes resulted in final strengths of evidence that were low or moderate. Imprecision, inconsistency, and risk of bias also limited the strength of findings. CONCLUSION: Larger and better-designed studies are needed to draw unequivocal conclusions about the effect of statins on cognition. Published data do not suggest an adverse effect of statins on cognition; however, the strength of available evidence is limited, particularly with regard to high-dose statins.