Universal electronic consultation (e-consultation) program of a cardiology service. Long-term results.

INTRODUCTION AND OBJECTIVES: Many health systems have initiated electronic consultation (e-consultation) programs, although little is known about their impact on accessibility, safety, and satisfaction. The aim of this study was to assess the clinical impact of the implementation of an outpatient care model that includes an initial e-consultation and to compare it with a one-time face-to-face consultation model. METHODS: We selected patients who visited the cardiology service at least once between 2010 and 2019. Using an interrupted time series regression model, we analyzed the impact of incorporating e-consultation into the health care model (started in 2013), and evaluated waiting times, emergency services, hospital admissions, and mortality. RESULTS: We analyzed 47 377 patients: 61.9% were attended in e-consultation and 38.1% in one-time face-to-face consultations. The waiting time for care was shorter in the e-consultation model (median [IQR]: 7 [5-13] days) than in the face-to-face model (median [IQR]: 33 [14-81] days), P<.001. The interrupted time series regression model showed that the introduction of e-consultation substantially decreased waiting times, which held steady at around 9 days, although with slight oscillations. Patients evaluated via e-consultation had fewer hospital admissions (0.9% vs 1.2%, P=.0017) and lower mortality (2.5% vs 3.9%, P<.001). CONCLUSIONS: An outpatient care program that includes an e-consultation reduced waiting times significantly and was safe, with a lower rate of hospital admissions and mortality in the first year.

Nutritional status is related to heart failure severity and hospital readmissions in acute heart failure.

BACKGROUND: Malnutrition is common in hospitalized heart failure (HF) patients and predicts adverse outcomes. The relationship between nutritional status and outcomes in HF has been partially studied. Our aim was to determine the relationship between the nutritional status and the long-term prognosis in patients hospitalized for acute HF. METHODS: We analyzed 145 patients admitted consecutively to a cardiology department for acute HF. Nutritional status was measured with the CONUT method, a validated scale based on laboratory testing (albumin; cholesterol; lymphocytes) during hospitalization. Patients were classified as normal, mildly, moderately or severely malnourished, and followed in a HF clinic. RESULTS: The mean aged of the population was 69.6years and 61% of patients were men, 54 had previous HF hospitalization (37%), 112 had hypertension (77%), 67 were diabetic (46%) and 135 had class III or IV NYHA (93%). Forty eight patients (33%) had normal nutritional status, 75 were mildly malnourished (52%), and 22 were moderately or severely malnourished (15%). Age, sex, hypertension, diabetes mellitus, or NYHA class among the three groups were not statistically different. ProBNP was directly correlated with the nutritional status. After a mean follow-up of 326days, 27 had a HF hospitalization (19%) and 61 (42,1%) had a hospitalization not related to HF. The analysis by Kaplan-Meier curves and log rank test showed that these differences were statistically significant. CONCLUSION: Malnutrition is common in patients hospitalized for HF. It seems to be a mediator of disease progression and determines a poor prognosis especially in advanced stages.

Usefulness of the QRS-T angle to improve long-term risk stratification of patients with acute myocardial infarction and depressed left ventricular ejection fraction.

In light of the low cost, the widespread availability of the electrocardiogram, and the increasing economic burden of the health-related problems, we aimed to analyze the prognostic value of automatic frontal QRS-T angle to predict mortality in patients with left ventricular (LV) systolic dysfunction after acute myocardial infarction (AMI). About 467 consecutive patients discharged with diagnosis of AMI and with LV ejection fraction ≤40% were followed during 3.9 years (2.1 to 5.9). From them, 217 patients (47.5%) died. The frontal QRS-T angle was higher in patients who died (116.6±52.8 vs 77.9±55.1, respectively, p<0.001). The QRS-T angle value of 90° was the most accurate to predict all-cause cardiac death. After multivariate analysis, frontal QRS-T angle remained as an excellent predictor of all-cause and cardiac deaths, increasing the mortality 6% per each 10°. For the global mortality, the hazard ratio for a QRS-T angle>90° was 2.180 (1.558 to 3.050), and for the combined end point of cardiac death and appropriate implantable cardioverter defribrillator therapy, it was 2.385 (1.570 to 3.623). This independent predictive value was maintained even after adjusting by bundle brunch block, ST-elevation AMI, and its localization. In conclusion, a wide automatic frontal QRS-T angle (>90°) is a good discriminator of long-term mortality in patients with LV systolic dysfunction after an AMI. The ability to easily measure it from a standard 12-lead electrocardiogram together with its prognostic value makes the frontal QRS-T angle an attractive tool to help clinicians to improve risk stratification of those patients.

Dosing of iodinated contrast volume: a new simple algorithm to stratify the risk of contrast-induced nephropathy in patients with acute coronary syndrome.

OBJECTIVES AND BACKGROUND: Previous studies on contrast-induced nephropathy (CIN) have identified contrast volume (CV) as a risk factor. The aim of our research was to define the safe dose of contrast media based on absolute CV, maximum allowable contrast dose (MACD) and estimated glomerular filtrate rate (eGFR). METHODS AND RESULTS: A total of 940 consecutive patients with acute coronary syndrome (ACS) were enrolled. Fifty-four patients developed CIN. MACD was defined as 5*body weight/serum creatinine. When using a CV higher than MACD, CIN-risk was increased 19-fold (OR 9.810-39.307, P < 0.001). For the CV/eGFR ratio, we found that for every increase of one-tenth, CIN-risk increased by 4.9% (OR 1.037-1.061, P < 0.001). The discriminative ability of CV (C statistic = 0.626 ± 0.038) was significantly lower than for the CV/MACD (C statistic = 0.782 ± 0.036, P = 0.003) and CV/eGFR (C statistics: 0.796 ± 0.033 for MDRD-4, 0.796 ± 0.034 for Cockcroft-Gault, and 0.803 ± 0.033 for CKD-EPI; P < 0.001). There were no differences in the discriminative ability to predict CIN between the three eGFR equations. The combination of CV/MACD and CV/eGFR in a single protocol increases the positive predictive value of the Mehran risk score (40.7% vs. 8.8%) with the same sensitivity (90.7% vs. 83.3%). High doses of relative CV (CV/MACD and CV/eGFR) were also significantly associated with higher in-hospital mortality, reinfarction, and heart failure. CONCLUSIONS: A sequential protocol based on CV/MACD and CV/eGFR appropriately identified those ACS patients who developed CIN, with predictive values similar to a Mehran score, reducing the false positive rate. It is also useful to predict risk of in-hospital cardiac events regardless of GRACE score.

Prognostic impact of atrial fibrillation progression in a community study: AFBAR Study (Atrial Fibrillation in the Barbanza Area Study).

INTRODUCTION: The aim of the study is to describe the natural history of an unselected population of patients with atrial fibrillation (AF) currently attending primary care services in a single health-service area in Galicia, north-western Spain. METHODS: AFBAR is a transverse prospective study in which 35 general practitioners within one health-service area have enrolled patients diagnosed with AF who presented at their clinics during a three-month recruiting period. Primary endpoints are mortality or hospital admission. Here we report the results of the first 7-month follow-up period. RESULTS: 798 patients (421 male) were recruited; mean age of cohort was 75 years old. Hypertension was the most prevalent risk factor (77%). 87% of the patients were both overweight and obese. Permanent AF was diagnosed in 549 patients (69%). In the follow-up period, 16.4% of the patients underwent a primary endpoint and the overall survival was 98%. The following independent determinants of primary endpoint were identified: change in AF status (Hazard Ratio (HR) 2.89 (95% confidence interval (CI) 1.28-6.55); p=0.011); ischemic heart disease (IHD) (HR 2.78 (95% CI 1.51-5.13); p=0.001); pre-recruitment hospital admission (HR 2.22 (95% CI 1.18-4.19); p=0.013); left ventricular systolic dysfunction (HR 2.19 (95% CI 1.11-4.32); p=0.023); or AF-related complications (HR 1.98 (95% CI 1.10-3.56); p=0.022). CONCLUSIONS: In the first 7-month follow-up period of patients with AF in a primary care setting the study identified several independent risk factors for mortality or hospital admission, i.e. change in AF status, ischemic heart disease, left ventricular systolic dysfunction, previous AF-related complications and hospital admission.

Persistent left superior vena cava draining into the coronary sinus: report of 10 cases and literature review.

BACKGROUND: Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly. HYPOTHESIS: This study examines the epidemiologic, clinical, and morphologic characteristics of a cohort of patients with PLSVC draining into the coronary sinus. METHODS: We examined the clinical and morphologic characteristics of patients with PLSVC draining into the coronary sinus diagnosed at a single referral hospital for a defined population in northwestern Spain. We designed a prospective study of the case records of all patients diagnosed with PLSVC draining into the coronary sinus at the echocardiography laboratory of the Hospital Xeral-Calde from January 2001 through December 2002. Patients were included if they had a PLSVC diagnosed by transthoracic echocardiogram (TTE) using an echo-contrast enhancement and confirmed by a magnetic resonance (MR) imaging. Ten patients (6 women) fulfilled the inclusion criteria described above. All patients were adults and had associated heart disease, including a congenital heart disease in three cases. RESULTS: Magnetic resonance imaging examination confirmed the presence of PLSVC and the site of drainage into the coronary sinus. Absence of the right superior vena cava was observed only in three patients, in whom the main coronary sinus size was significantly increased. Absence of the left brachiocephalic vein was diagnosed in five patients. CONCLUSION: This study describes 10 new cases of PLSVC and supports the necessity of considering PLSVC draining into the coronary sinus in the diagnosis of patients presenting with dilated coronary sinus diagnosed by TTE. It also underlines the important role of MR imaging in the evaluation of these abnormalities. An associated heart disease must always be excluded in these patients.

Active but transient improvement of endothelial function in rheumatoid arthritis patients undergoing long-term treatment with anti-tumor necrosis factor alpha antibody.

OBJECTIVE: Cardiovascular disease is the major cause of excessive mortality in rheumatoid arthritis (RA). Atherosclerosis and RA share similar inflammatory mechanisms that include involvement of tumor necrosis factor alpha (TNF alpha). Anti-TNF alpha antibody improved endothelial function in RA patients after a 12-week treatment. The aim of the present study was to assess whether improvement of endothelial function is still effective in long-term infliximab-treated RA patients. METHODS: Seven RA patients (5 women; age range 25-73 years) were studied. They had been treated with infliximab for at least 1 year and were currently being treated with this drug every 8 weeks. Endothelial-dependent and independent vasodilatation were measured by brachial ultrasonography. RESULTS: Following infliximab infusion, a rapid increase in the percentage of endothelial-dependent vasodilatation was found in all patients (mean +/- SD 9.4 +/- 5.5% 2 days postinfusion compared with 2.8 +/- 2.5% 2 days before infusion). However, values returned to baseline by 4 weeks after infusion. There were no differences in the percentage of endothelial-independent vasodilatation prior to and after infusion. A decrease in the individual disease activity score for each patient was observed at day 7 postinfusion (P = 0.02). CONCLUSION: Our study confirms an active but transient effect of infliximab on endothelial function in RA patients treated periodically with this drug. It may support long-term use of drugs that block TNF alpha function to reduce the high incidence of cardiovascular complications in RA.

Echocardiographic and Doppler findings in long-term treated rheumatoid arthritis patients without clinically evident cardiovascular disease.

OBJECTIVE: To assess the frequency of echocardiographic and Doppler abnormalities in long-term treated rheumatoid arthritis (RA) patients without clinically evident cardiovascular manifestations. METHODS: Forty-seven patients with RA were recruited from Hospital Xeral-Calde, Lugo, Spain. Patients were required to have been treated for at least 5 years and to be on treatment with 1 or more disease-modifying antirheumatic drugs. Patients seen during the period of recruitment who had cardiovascular risk factors or had suffered cardiovascular or cerebrovascular events were excluded. Forty-seven healthy matched controls were also studied. Echocardiographic and Doppler studies were performed in all cases and controls. Patients were HLA-DRB1 genotyped by using molecular-based methods. RESULTS: In patients with RA, the prevalence of aortic regurgitation (17%) and tricuspid regurgitation (17%) was not higher than that seen in controls (15% and 6%). The pulmonary artery systolic pressure was higher in patients with RA (30.3 +/- 8.0 mm Hg) than in controls (26.2 +/- 4.8) (P =.004). Incidence of pulmonary artery systolic pressure >35 mm Hg was significantly higher in patients with RA (21% versus 4% in controls; P =.03). Diastolic dysfunction caused by impaired relaxation was also more common in patients with RA (66%) than in controls (43%) (P =.02). It was more frequent in the older patients. Extra-articular manifestations were more common in patients with RA with diastolic dysfunction (P =.05). The HLA-DRB1 genotype was not implicated in the risk of developing diastolic dysfunction. CONCLUSIONS: The present study confirms a high frequency of left ventricular diastolic dysfunction and pulmonary hypertension in patients with RA without evident cardiovascular disease.

[Use of anticoagulation at the time of discharge in patients with heart failure and atrial fibrillation]. / Uso de anticoagulación al alta hospitalaria en pacientes con insuficiencia cardíaca y fibrilación auticular.

INTRODUCTION AND OBJECTIVES: To assess the degree of compliance with current guidelines for chronic anticoagulation in patients with heart failure and atrial fibrillation. PATIENTS AND METHOD: From the INCARGAL Study database, we analyzed data from 195 consecutive patients (88 men; mean age 76 10 years) with both conditions, admitted to three Galician hospitals between January and March 1999. It was assumed that these patients should have received anticoagulant therapy at discharge, unless contraindicated. We studied the association of treatment at discharge (anticoagulation or not) with the presence or absence of contraindications. RESULTS: 152 patients (78%) had no contraindication for anticoagulation and 43 had at least one (absolute: 11, relative: 32). Only 50% of patients without contraindications received anticoagulation at the time of discharge. No patient with an absolute contraindication and 3 with a relative one received anticoagulation. Factors related with the less frequent prescription of anticoagulation therapy in patients without a formal contraindication were: age, a previous history of coronary heart disease, absence of valvular heart disease, prior myocardial infarction, treatment with beta-blocking agents, non performance of an echocardiogram, and admission to a department other than cardiology. On multivariate analysis, age, prior myocardial infarction, and non-valvular disease were found to be independent predictors of less use of anticoagulation. CONCLUSIONS: Anticoagulant therapy is used less often than recommended at discharge in patients with heart failure and atrial fibrillation for whom there were no contraindications. Advanced age reduces its use. The presence of other indications for antiplatelet or anticoagulation therapy appears to determine the choice of one or the other. Noncompliance with the guidelines due to overprescription was not found.

Uso de anticoagulación al alta hospitalaria en pacientes con insuficiencia cardíaca y fibrilación auricular / Use of anticoagulation at the time of discharge in patients with heart failure and atrial fibrillation

Introducción y objetivos. Evaluar el grado de cumplimiento de las guías sobre uso de anticoagulación crónica en pacientes con insuficiencia cardíaca y fibrilación auricular. Pacientes y método. Se usó la base de datos del estudio INCARGAL, analizando datos de 195 pacientes consecutivos (88 varones, edad 76 ñ 10 años) admitidos con ambos diagnósticos en tres hospitales gallegos entre enero y junio de 1999. Se asumió que todos deberían de haber recibido anticoagulación al alta hospitalaria en ausencia de contraindicaciones. Se comparó el tratamiento al alta (anticoagulación o no) con la presencia o ausencia de contraindicaciones. Resultados. Un total de 152 pacientes (78 por ciento) no tenían contraindicaciones para la anticoagulación y 43 presentaban alguna (absoluta, 11; relativa, 32). De los pacientes sin contraindicación, sólo recibieron anticoagulación al alta el 50 por ciento. Ningún paciente con contraindicación absoluta y tres con contraindicación relativa recibieron anticoagulación. La prescripción de anticoagulación en los pacientes sin contraindicaciones fue menor en los que tenían una mayor edad, antecedente de cardiopatía isquémica, ausencia de valvulopatía, uso de bloqueadores beta, no realización de ecocardiograma e ingreso en un servicio diferente del de cardiología (p < 0,05). En el análisis multivariante, la edad, el infarto de miocardio previo y la ausencia de valvulopatía significativa permanecieron como predictores independientes de menor uso de anticoagulación. Conclusiones. El empleo de anticoagulación al alta hospitalaria en pacientes sin contraindicación para su uso, con fibrilación auricular e insuficiencia cardíaca, es menor del recomendado. La edad avanzada disminuye su empleo. La presencia de otras indicaciones para la antiagregación o la anticoagulación parecen determinar la elección de una u otra terapia. No hubo mala adecuación por exceso de prescripción (AU)

HLA-DRB1 status affects endothelial function in treated patients with rheumatoid arthritis.

PURPOSE: To examine endothelial function in rheumatoid arthritis patients and to assess whether clinical or genetic factors affect the development of endothelial dysfunction. METHODS: Fifty-five patients fulfilling the 1987 American College of Rheumatology classification criteria for rheumatoid arthritis were recruited from Hospital Xeral-Calde, Lugo, Spain. Patients were required to have been treated for at least 5 years, including current treatment with one or more disease-modifying antirheumatic drugs. Patients with diabetes mellitus, renal insufficiency, or cardiovascular disease were excluded. Thirty-one age-, sex-, and ethnically matched controls were also studied. Endothelium-dependent (postischemia) and -independent (postnitroglycerin) vasodilatation were measured by brachial ultrasonography. Patients were genotyped for human leukocyte antigen (HLA)-DRB1. RESULTS: Patients had decreased endothelium-dependent vasodilatation (mean [+/- SD], 3.8% +/- 4.9%) compared with controls (8.0% +/- 4.5%; P <0.001). There were no differences in endothelium-independent vasodilatation. Clinical features were not associated with endothelial dysfunction. Endothelium-dependent vasodilatation was lower in the 30 rheumatoid arthritis patients with the HLA-DRB1*04 shared epitope alleles (2.4% +/- 4.1%) than in the remaining patients (5.5% +/- 5.3%; P = 0.01). Similar results were seen for patients with the HLA-DRB1*0404 shared epitope allele (-0.4% +/- 2.5%) compared with other patients (4.4% +/- 4.9%; P = 0.01). CONCLUSION: Patients with chronically treated rheumatoid arthritis had evidence of endothelial dysfunction, especially those with certain HLA-DRB1 genotypes. If confirmed, our results suggest that HLA-DRB1 status may be a predictor of cardiovascular risk in these patients.

[Use of diagnostic and therapeutic resources in patients hospitalized for heart failure: influence of admission ward type (INCARGAL Study)]. / Utilización de recursos diagnósticos y terapéuticos en pacientes ingresados por insuficiencia cardíaca: influencia del servicio de ingreso (estudio INCARGAL).

BACKGROUND: Heart failure (HF) is the most rapidly growing cardiac pathology in industrialized countries, and already the primary cause of hospital admissions of elderly people. Outside the field of clinical trials, there have not been many studies in Spain of the influence of the admission department on diagnostic and therapeutic management, whether this affects short-term and long-term prognosis, and the factors that determine the department the patient is admitted to. OBJECTIVE: . To analyze whether management and prognosis of patients admitted with heart failure differ depending on the admission ward (cardiology versus internal medicine-geriatrics). PATIENTS AND METHODS: Cross-sectional study of 951 patients (505 men and 446 women) consecutively hospitalized for HF in the cardiology (n = 363) and internal medicine-geriatrics (n = 588) wards of 12 hospitals of Galicia and recruited over a maximum period of 6 months. The main epidemiological and clinical variables were recorded at admission, and the complications, treatments, and clinical status were recorded at release.Results. HF patients had a mean age of 75.5 12 years (women 78.5 years and men 72.6 years). The average hospitalization time was 11 8 days and 50.8% were first admissions. Total hospital mortality was 6.8%. Fifty-nine percent (58.9%) of patients had arterial hypertension, 31.9% ischemic heart disease, 27.6% cardiac valve disease, 28.5% diabetes mellitus, and 32.5% chronic obstructive pulmonary disease (COPD). The patients admitted to cardiology ward were younger (72.5 13 vs 77.4 11 years; p < 0.005), more frequently men (51.9 vs 43.7%; p < 0.005), more often first hospitalizations (54.8 vs 48.4%; p < 0.005), and acute pulmonary edema was more common (22.8 vs 9.2%; p < 0.005). The odds ratio (and 95% CI) for therapeutic and diagnostic procedures in relation to admission ward (reference group internal medicine-geriatrics), adjusted for age, sex, systolic function, number of hospitalizations, and history of dementia, hypertension, COPD, AMI, valve disease and ischemic heart disease, are: echocardiogram, 3.49 (2.58-4.73); catheterization, 6.42 (3.29-12.55), admission to intensive care, 3.94 (2.15-7.25), revascularization, 2.15 (0.57-8.08), and beta-blocker treatment, 3.39 (1.93-5.97). No differences in hospital mortality (6.6% in cardiology vs 7% in internal medicine-geriatrics) or average hospitalization time were found between departments. CONCLUSIONS: The admission ward was related with a clear difference in HF management, with better adherence to guidelines and more use of resources by cardiologists. This was unrelated with differences in hospital mortality so a longer follow-up of these patients is required to evaluate the impact of these therapeutic measures on the prognosis and evolution of HF, as well as the cost-benefit relation in an elderly patient population.