Trends in High- and Low-Value Cardiovascular Diagnostic Testing in Fee-for-Service Medicare, 2000-2016.

Importance: Owing to a rapid increase in rates of diagnostic cardiovascular testing in the 1990s and early 2000s, the Centers for Medicare & Medicaid Services implemented a series of payment changes intended to reduce overall spending on fee-for-service testing. Whether guideline-concordant testing has been subsequently affected is unknown to date. Objective: To determine whether changes in overall rates of use of diagnostic cardiovascular tests were associated with changes in high-value testing recommended by guidelines and low-value testing that is expected to provide minimal benefits. Design, Setting, and Participants: This retrospective cohort study assessed a national 5% random sample of Medicare fee-for-service beneficiaries aged 65 to 95 years from January 1, 1999, through December 31, 2016. Data were analyzed from February 15, 2018, through August 15, 2019. Exposures: Eligibility to receive high-value testing (assessment of left ventricular systolic function among patients hospitalized with acute myocardial infarction or heart failure) and low-value testing (stress testing before low-risk noncardiac surgery and routine stress testing within 2 years of coronary revascularization not associated with acute care visits). Main Outcomes and Measures: Age- and sex-adjusted annual rates of overall, high-value, and low-value diagnostic cardiovascular testing. Results: Mean (SD) age was similar over time (75.57 [7.32] years in 2000-2003; 74.82 [7.79] years in 2012-2016); the proportion of women slightly declined over time (63.23% in 2000 to 2003; 57.27% in 2012 to 2016). The rate of overall diagnostic cardiovascular testing per 1000 patient-years among the 5% sample of Medicare beneficiaries increased from 275 in 2000 to 359 in 2008 (P < .001) and then declined to 316 in 2016 (P < .001). High-value testing increased steadily over the entire study period for patients with acute myocardial infarction (85.7% to 89.5%; P < .001) and heart failure (72.6% to 80.1%; P < .001). Low-value testing among patients undergoing low-risk surgery increased from 2.4% in 2000 to 3.8% in 2008 (P < .001) but then declined to 2.5% in 2016 (P < .001). Low-value testing within 2 years of coronary revascularization slightly increased from 47.4% in 2000 to 49.2% in 2003 (P = .03) but then declined to 30.8% in 2014 (P < .001). Conclusions and Relevance: Rates of overall and low-value diagnostic cardiovascular testing appear to have declined considerably and rates of high-value testing have increased slightly. Payment changes intended to reduce spending on overall testing may not have adversely affected testing recommended by guidelines.

Surveillance and screening practices of New England congenital cardiologists for patients after the Fontan operation.

INTRODUCTION: Surveillance and management guidelines for Fontan patients are lacking due to the paucity of evidence in the literature of screening efficacy on outcome measures. METHODS: The Fontan Working Group within the New England Congenital Cardiology Association designed an electronic survey to assess surveillance practices for patients with Fontan procedures among New England congenital cardiologists and to explore variability in screening low-risk vs high-risk Fontan patients across regional programs. RESULTS: Fifty-six cardiologists representing 12 regional programs responded to the survey, comprising ~40% of the total New England congenital cardiac physicians. The majority of desired testing and consultation was available within 50 miles of the patient's home institution with some limitations of cardiac catheterization and cardiac magnetic resonance imaging availability. Surveillance and screening were less frequent in low-risk Fontan patients compared to high-risk Fontan patients. Counseling practices were similar for both low-risk and high-risk Fontan patients. Aspirin monotherapy was recommended by 82% of providers for low-risk Fontan patients, while anticoagulation regimens were more varied for the high-risk population. Practitioners with ≤15 years of experience were more likely to provide quality of life testing in both low-risk and high-risk Fontan patients. There were no other major differences in testing frequencies by years of practice, quaternary vs nonquaternary care facility, or the number of Fontan patients in a practice. CONCLUSION: This survey provides insight into regional practices of screening and surveillance of Fontan patients. These data may be used to design future research studies and evidence-based guidelines to streamline the approach to manage these complex patients.

Pathophysiology, echocardiographic evaluation, biomarker findings, and prognostic implications of septic cardiomyopathy: a review of the literature.

BACKGROUND: Sepsis is a common condition encountered by emergency and critical care physicians, with significant costs, both economic and human. Myocardial dysfunction in sepsis is a well-recognized but poorly understood phenomenon. There is an extensive body of literature on this subject, yet results are conflicting and no objective definition of septic cardiomyopathy exists, representing a critical knowledge gap. OBJECTIVES: In this article, we review the pathophysiology of septic cardiomyopathy, covering the effects of key inflammatory mediators on both the heart and the peripheral vasculature, highlighting the interconnectedness of these two systems. We focus on the extant literature on echocardiographic and laboratory assessment of the heart in sepsis, highlighting gaps therein and suggesting avenues for future research. Implications for treatment are briefly discussed. CONCLUSIONS: As a result of conflicting data, echocardiographic measures of left ventricular (systolic or diastolic) or right ventricular function cannot currently provide reliable prognostic information in patients with sepsis. Natriuretic peptides and cardiac troponins are of similarly unclear utility. Heterogeneous classification of illness, treatment variability, and lack of formal diagnostic criteria for septic cardiomyopathy contribute to the conflicting results. Development of formal diagnostic criteria, and use thereof in future studies, may help elucidate the link between cardiac performance and outcomes in patients with sepsis.

Why should we continue measuring central venous pressure? / ¿Por qué deberíamos seguir midiendo la presión venosa central?

No disponible

Trends in Use of Biomarker Protocols for the Evaluation of Possible Myocardial Infarction.

BACKGROUND: Various combinations of creatine kinase-MB, myoglobin, and cardiac troponin I or T (cTnI/cTnT) have been used to evaluate patients with suspected acute coronary syndromes. The current recommendation is to use the 99th percentile of cTnI/cTnT as the sole marker for diagnosis of acute myocardial infarction. METHODS AND RESULTS: We retrospectively analyzed cardiac marker protocols collected from 824 US hospitals undergoing Chest Pain Center Accreditation through the Society of Cardiovascular Patient Care from 2009 to 2014. Data were obtained by a self-reported survey that addressed cardiac marker(s), sampling time periods, and cut points used for evaluation of suspected acute myocardial infarction. The combination of cTnI or cTnT with creatine kinase-MB was the most commonly used biomarker strategy. Use of cTnI or cTnT as the sole marker increased over time (14-37%; P<0.0001), as did use of the 99th percentile cut point for cTnI/cTnT (30-60%; P<0.0001). CONCLUSION: There is considerable variation in cardiac marker testing strategies used in US hospitals for evaluation of suspected acute myocardial infarction. Although increasing, 24% of hospitals used a cTn alone strategy, and only 49% used cTn at the recommended 99th percentile cut point. This has important implications for the diagnosis and treatment of patients with acute myocardial infarction.

Technological advances shed light on left ventricular cardiac disturbances in cystic fibrosis.

Cystic fibrosis (CF), the most common autosomal recessive lethal disease in Caucasians, causes chronic pulmonary disease and can lead to cor pulmonale with right ventricular dysfunction. The presence of the cystic fibrosis transmembrane conductance regulator (CFTR) in cardiac myocardia has prompted debate regarding possible defective ion channel-induced cardiomyopathy. Clinical heart disease in CF is considered rare and is restricted to case reports. It has been unclear if this is due to the lack of physiological importance of CFTR in the heart, the relatively short lifespan of those with CF, or a technical inability to detect subclinical disease. Extensive echocardiographic investigations have yielded contradictory results, leading to the dogma that left ventricular defects in CF occur secondary to lung disease. In this review, we consider why studies examining heart function in CF have not provided clarity on this topic. We then focus on data from new echocardiographic and magnetic resonance imaging technology, which are providing greater insight into cardiac function in CF and demonstrating that, in addition to secondary effects from pulmonary disease, there may be an intrinsic primary defect in the CF heart. With advancing lifespans and activity levels, understanding the risk of cardiac disease is vital to minimizing morbidity in adults with CF.

Cardiovascular PET-CT imaging: a new frontier?

Cardiovascular positron-emission tomography combined with computed tomography (PET-CT) has recently emerged as an imaging technology with the potential to simultaneously describe both anatomical structures and physiological processes in vivo. The scope for clinical application of this technique is vast, but to date this promise has not been realised. Nonetheless, significant research activity is underway to explore these possibilities and it is likely that the knowledge gained will have important diagnostic and therapeutic implications in due course. This review provides a brief overview of the current state of cardiovascular PET-CT and the likely direction of future developments.

Left ventricular function assessment in cirrhosis: Current methods and future directions.

Cirrhotic cardiomyopathy has been defined as a chronic cardiac dysfunction in patients with cirrhosis characterized by impaired contractile responsiveness to stress and/or altered diastolic relaxation with electrophysiological abnormalities in the absence of other known cardiac disease. Non-invasive cardiovascular imaging modalities play a major role in unmasking systolic and diastolic dysfunction in patients with cirrhosis. Echocardiography has been the most commonly used modality for assessing myocardial function in these patients. Conventional echocardiographic indices rely on several assumptions that may limit their applicability in patients with a hyperdynamic circulation. Newer imaging modalities may contribute to a more accurate diagnosis of cardiovascular abnormalities in cirrhotic patients, thereby influencing clinical management. We aimed to review the different non-invasive imaging technologies currently used for assessing left ventricular systolic and diastolic function in cirrhosis, as well as to describe new imaging modalities with potential clinical applicability in the near future.

Cuantificación de la circulación pulmonar y sistémica: Qp/Qs. Qué es, cómo se calcula y para qué sirve. Lo que el radiólogo debe saber / What radiologists need to know about the pulmonary-systemic flow ratio (Qp/Qs): what it is, how to calculate it, and what it is for

La resonancia magnética cardiaca aporta abundante información morfológica y funcional al estudio de las cardiopatías congénitas. Entre los datos funcionales se encuentran el gasto pulmonar y el gasto sistémico; el cociente entre ambos es el cociente Qp/Qs. Después del nacimiento, en condiciones normales el gasto pulmonar y el sistémico son prácticamente iguales, y el cociente Qp/Qs = 1. En los pacientes con cortocircuitos entre la circulación sistémica y la pulmonar este cociente se altera. Dependiendo de la localización del cortocircuito (intra o extracardiaco), y de las alteraciones estructurales o posquirúrgicas asociadas, la interpretación de los hallazgos es diferente. Revisamos el concepto de Qp/Qs, los métodos para calcularlo con especial énfasis en la RM, y el significado de los resultados obtenidos, haciendo hincapié en la relevancia de estos datos dependiendo de la patología de base y los procedimientos terapéuticos que se hayan realizado al paciente (AU)

Cardiac magnetic resonance imaging (cMRI) provides abundant morphological and functional information in the study of congenital heart disease. The functional information includes pulmonary output and systemic output; the ratio between these two (Qp/Qs) is the shunt fraction. After birth, in normal conditions the pulmonary output is practically identical to the systemic output, so Qp/Qs = 1. In patients with «shunts» between the systemic and pulmonary circulations, the ratio changes, and the interpretation of these findings varies in function of the location of the shunt (intracardiac or extracardiac) and of the associated structural or postsurgical changes. We review the concept of Qp/Qs; the methods to calculate it, with special emphasis on cMRI; and the meaning of the results obtained. We place special emphasis on the relevance of these findings depending on the underlying disease and the treatment the patient has undergone (AU)

Using Cardiac Biomarkers in Veterinary Practice.

Blood-based assays for various cardiac biomarkers can assist in the diagnosis of heart disease in dogs and cats. The two most common markers are cardiac troponin-I and N-terminal pro-B-type natriuretic peptide. Biomarker assays can assist in differentiating cardiac from noncardiac causes of respiratory signs and detection of preclinical cardiomyopathy. Increasingly, studies indicate that cardiac biomarker testing can help assess the risk of morbidity and mortality in animals with heart disease. Usage of cardiac biomarker testing in clinical practice relies on proper patient selection, correct interpretation of test results, and incorporation of biomarker testing into existing diagnostic methods.

The Fetal Modified Myocardial Performance Index: Is Automation the Future?

The fetal modified myocardial performance index (Mod-MPI) is a noninvasive, pulsed-wave Doppler-derived measure of global myocardial function. This review assesses the progress in technical refinements of its measurement and the potential for automation to be the crucial next step. The Mod-MPI is a ratio of isovolumetric to ejection time cardiac time intervals, and the potential for the left ventricular Mod-MPI as a tool to clinically assess fetal cardiac function is well-established. However, there are wide variations in published reference ranges, as (1) a standardised method of selecting cardiac time intervals used in Mod-MPI calculation has not been established; (2) cardiac time interval measurement currently requires manual, inherently subjective placement of callipers on Doppler ultrasound waveforms; and (3) ultrasound machine settings and ultrasound system type have been found to affect Mod-MPI measurement. Collectively these factors create potential for significant inter- and intraobserver measurement variability. Automated measurement of the Mod-MPI may be the next key development which propels the Mod-MPI into routine clinical use. A novel automated system of Mod-MPI measurement is briefly presented and its implications for the future of the Mod-MPI in fetal cardiology are discussed.

Methods used for the assessment of LV systolic function: common currency or tower of Babel?

The last decade has produced a proliferation of techniques for the assessment of left ventricular systolic function, and there now seems to be more choice than seems rational for the questions that we need answers to. In some instances, simple estimation is all that is required-the risk stratification process is inexact, as emphasised by the variety of modalities used to characterise ejection fraction (EF) in studies that validated the efficacy of treatments selected on the basis of EF. Nonetheless, while technical advances often cause disruption and confusion, it would be wrong to dismiss them as lacking benefit. The purpose of this review is to try to provide rational grounds for selecting both test modality and physiological parameter in various specific clinical situations.

Patterns and predictors of stress testing modality after percutaneous coronary stenting: data from the NCDR(®).

OBJECTIVES: We evaluated temporal trends and geographic variation in choice of stress testing modality after percutaneous coronary intervention (PCI), as well as associations between modality and procedure use after testing. BACKGROUND: Stress testing is frequently performed post-PCI, but the choices among available modalities (electrocardiography only, nuclear, or echocardiography; pharmacological or exercise stress) and consequences of such choices are not well characterized. METHODS: CathPCI Registry(®) data were linked with identifiable Medicare claims to capture stress testing use between 60 and 365 days post-PCI and procedures within 90 days after testing. Testing rates and modality used were modeled on the basis of patient, procedure, and PCI facility factors, calendar quarter, and Census Divisions using Poisson and logistic regression. Post-test procedure use was assessed using Gray's test. RESULTS: Among 284,971 patients, the overall stress testing rate after PCI was 53.1 per 100 person-years. Testing rates declined from 59.3 in quarter 1 (2006) to 47.1 in quarter 4 (2008), but the relative use of modalities changed little. Among exercise testing recipients, adjusted proportions receiving electrocardiography-only testing varied from 6.8% to 22.8% across Census Divisions; and among exercise testing recipients having an imaging test, the proportion receiving echocardiography (versus nuclear) varied from 9.4% to 34.1%. Post-test procedure use varied among modalities; exercise electrocardiography-only testing was associated with more subsequent stress testing (13.7% vs. 2.9%; p < 0.001), but less catheterization (7.4% vs. 14.1%; p < 0.001) than imaging-based tests. CONCLUSIONS: Modest reductions in stress testing after PCI occurring between 2006 and 2008 cannot be ascribed to trends in use of any single modality. Additional research should assess whether this trend represents better patient selection for testing or administrative policies (e.g., restricted access for patients with legitimate testing needs). Geographic variation in utilization of stress modalities and differences in downstream procedure use among modalities suggest a need to identify optimal use of the different test modalities in individual patients.

Evolución a largo plazo de la función ventricular tras la terapia celular intracoronaria en el infarto agudo de miocardio / Long-term changes in left ventricular function following intracoronary stem cell transplantation for acute myocardial infarction

El efecto a largo plazo del trasplante intracoronario de células madre de médula ósea tras un síndrome coronario agudo con elevación del ST (SCACEST) es controvertido. Exponemos la evolución a largo plazo de los parámetros relacionados con la función ventricular izquierda en 29 pacientes con SCACEST sometidos a esta técnica. Se realizó resonancia magnética cardiaca basal, al sexto mes y a largo plazo (27 [24-35] meses). La fracción de eyección del ventrículo izquierdo mejoró significativamente al sexto mes (47,6±8,9% frente a 52,7±11,6%; p=0,001), mejora que se mantuvo en el seguimiento a largo plazo (52,4±11,8%; p=0,01 frente a basal, y p=0,999 frente a sexto mes). No se produjeron cambios significativos en los parámetros basales de volumen telediastólico o telesistólico ventricular izquierdo. Nuestro análisis indica que la mejora de la fracción de eyección tras el trasplante celular ocurre tempranamente, dentro de los primeros 6 meses y no se modifica a largo plazo (AU)

Controversy surrounds the long-term effects of intracoronary bone marrow stem cell transplantation after ST-elevation acute myocardial infarction (STEAMI). We report on the long-term changes in left ventricular function observed in 29 patients with STEAMI who were treated using this technique. Cardiac magnetic resonance imaging was performed at baseline, 6 months after transplantation, and long-term follow-up (median 27 months, interquartile range 24–35 months). The left ventricular ejection fraction had improved significantly by 6 months (from 47.6±8.9% to 52.7±11.6%; P=.001) and this improvement was maintained long-term, at 52.4±11.8% (P=.01 vs. baseline and P=.999 vs. 6 months). There was no significant change from baseline in end-diastolic or end-systolic ventricular volume. Our findings indicate the improvement in injection fraction occurs soon after stem cell transplantation, within the first 6 months, and remains unchanged at long-term follow-up (AU)

Recent developments in heart failure imaging.

Despite the central role of echocardiography in its primary assessment, heart failure is a condition in which access to multiple cardiovascular imaging modalities is important. A number of important observations relative to this topic have been made in the last year, including the assessment of left ventricular synchrony, myocardial mechanics, heart failure with preserved ejection fraction, metabolic imaging, assessment of myocardial viability, and fusion imaging.