Carotid Plaque Score is Associated with 10-year Major Adverse Cardiovascular Events in Low-Intermediate Risk Patients Referred to a General Cardiology Community Clinic.

AIMS: Atherosclerotic carotid plaque assessments have not been integrated into routine clinical practice due to the time-consuming nature of both imaging and measurements. Plaque score, Rotterdam method, is simple, quick, and only requires 4-6 B-mode ultrasound images. The aim was to assess the benefit of plaque score in a community cardiology clinic to identify patients at risk for major adverse cardiovascular events (MACE). METHODS AND RESULTS: Patients ≥40 years presenting for risk assessment were given a carotid ultrasound. Exclusions included a history of vascular disease or MACE and being >75 years. Kaplan-Meier curves and hazard ratios were performed. The left and right common carotid artery (CCA), bulb, and internal carotid artery (ICA) were given 1 point per segment if plaque present (plaque score 0 to 6). Administrative data holdings at ICES were used for 10-year event follow-up. Of 8,472 patients, 60% were females (n = 5,121). Plaque was more prevalent in males (64% vs 53.9%; P <0.0001). The 10-year MACE cumulative incidence estimate was 6.37% with 276 events (males 6.9 % vs females 6.0%; P = 0.004). Having both maximal CCA IMT <1.00 mm and plaque score = 0, was associated with less events. A plaque score <2 was associated with a low 10-year event rate (4.1%) compared to 2-4 (8.7%) and 5-6 (20%). CONCLUSION: A plaque score ≥2 can re-stratify low-intermediate risk patients to a higher risk for events. Plaque score may be used as a quick assessment in a cardiology office to guide treatment management of patients.

Rapid development and implementation of a behaviour change strategy to improve COVID-19 personal protective equipment use in a regional Australian emergency department.

OBJECTIVE: To identify barriers to, describe the development of and evaluate the implementation of a behavioural theory informed strategy to improve staff personal protective equipment (PPE) compliance during COVID-19 in a regional Australian Emergency Department. METHODS: Barriers to PPE use were identified through staff consultation then categorised using the Theoretical Domains Framework. The Behaviour Change Wheel was used to develop a strategy to address the barriers to PPE compliance. The strategy was refined and endorsed by the site COVID taskforce. Data were collected through direct observation. Descriptive statistics were used to summarise PPE compliance and inductive content analysis for free text data of staff behaviours. RESULTS: 73 barriers were identified, mapped to 9 intervention functions and 42 behaviour change techniques. The predominant mechanisms were: (1) Executive communication reinforcing policy and consequences; (2) implementation of a PPE Marshal; (3) face to face reinforcement / modeling; (4) environmental restructuring including electronic medical record modifications. The PPE Marshal observed 281 PPE activities. PPE compliance varied between 47.9% (Buddy check) and 91.8% (Bare below elbow). The PPE Marshal intervened on 121 occasions, predominantly through buddying, explaining and demonstrating correct PPE use, most frequently with medical staff (72%). CONCLUSION: We describe an evidence-based process to overcome barriers to PPE compliance that maximize safe work practice in a time critical situation. Staff require enabling, access to equipment and reinforcement to use PPE correctly.

Automated office blood pressure - being alone and not location is what matters most.

OBJECTIVE: Measurement of office blood pressure using a fully automated sphygmomanometer that takes multiple readings with the patient resting quietly alone has been called automated office blood pressure (AOBP). Almost all AOBP research has involved the patient resting alone in an examining room, which is often impractical in a clinical setting. The possibility that valid AOBP readings can be obtained with the patient resting quietly in a waiting room was examined. METHODS: AOBP readings using the BpTRU device recorded with the patient resting quietly in the waiting room were obtained in patients referred for ambulatory BP monitoring. The relationship between the AOBP and the awake ambulatory blood pressure (AABP) (mmHg) was examined. RESULTS: In 422 patients, the mean (±SD) AABP (139.4±13.4/80.7±10.6) was similar to the mean AOBP recorded in the waiting room (140.5±19.8/83.1±11.2), with both values being significantly lower than a single office BP (155.1±18.7/90.2±12.7) taken by a nurse. In the 178 untreated patients, the mean systolic AOBP and AABP were almost identical, with the diastolic AOBP being 1.5 mmHg higher. Bland-Altman plots for systolic BP showed a relatively consistent relationship for AOBP versus the AABP over the range of BPs recorded. The sensitivity, specificity, and accuracy for AOBP versus AABP were comparable with the values obtained with AOBP recorded previously in an examining room. CONCLUSION: AOBP readings recorded in a waiting room are comparable with the AABP, making it possible to obtain AOBP in clinical practice without the need to occupy an examining room.

ICEBERG: Intimal Carotid Evaluation Before Echocardiography Reveals Global Vascular Risk.

BACKGROUND: There is growing evidence that carotid ultrasonography provides important prognostic information about cardiovascular risk assessment. Our objective was to determine whether abbreviated rapid carotid ultrasonographic screening would reveal important global vascular risk information in statin-naive patients referred for routine transthoracic echocardiography (TTE). METHODS: Abbreviated carotid ultrasonographic imaging was performed in 560 consecutive patients undergoing TTE. The common carotid artery (CCA), the carotid bulb, and the internal carotid artery (ICA) were scanned. Maximal CCA intima-media thickness (IMT) was measured in the far wall. Carotid plaque was defined using the Atherosclerosis Risk in Communities (ARIC) study criteria. RESULTS: Of the 2283 patients who underwent TTE during a 1-year period, a total of 560 patients met inclusion criteria. There were 241 men, with a mean age of 63.2 ± 12.8 years and a mean CCA IMT of 1.11 ± 0.48 mm; 61% (147) had carotid plaque. The 319 women had a mean age of 66.3 ± 10.8 years and a mean CCA IMT of 1.03 ± 0.36 mm; 62.4% (199) had carotid plaque. All patients with plaque were considered to be at high risk. CONCLUSIONS: Of the 560 consecutive statin-naive patients referred for TTE with no history of vascular disease, a large proportion of both men (61%) and women (62.4%) had carotid plaque, indicating a high risk for vascular events according to the Canadian lipid guidelines. Although such patients are seen in the echocardiography laboratory, the addition of an abbreviated carotid ultrasonographic screening provides important information regarding risk stratification and the implementation of preventive therapy.

The effect of the change in the Framingham Risk Score calculator between the 2006 and 2009 Canadian lipid guidelines.

BACKGROUND: Recent Canadian lipid guidelines changed the methodology used for calculating the Framingham Risk Score (FRS). We assessed the impact this would have on management when related to baseline lipid profiles and the possible need for statin drug therapy. METHODS: Patients with their FRS calculated between November 2006 and March 2010 were considered. There were 247 patients categorized as either low or intermediate risk. RESULTS: The study population consisted of 91 men and 156 women with a mean (SD) age of 52.7 ± 15.0 years. The average FRS was 5.6 ± 4.8 vs 11.5 ± 8.3 (2006 vs 2009) (P < .00010). The number of FRS patients categorized as low and intermediate risk requiring some form of lipid-lowering treatment increased from 35 (14.2%) to 81 (32.8%), a 2.3-fold increase. Of 41 high-risk patients, 40 had a baseline low-density lipoprotein cholesterol of ≥ 2.0 mmol/L and would qualify for not only health behaviour interventions but also statin drug treatment. CONCLUSIONS: The new FRS increases the number of 2006 patients with low and intermediate scores who move from low to high risk (n = 11, 5.9%), from low to intermediate risk (n = 50, 26.9%), and from intermediate to high risk (n = 30, 49.2%), leading to a 2.3-fold increase in the need for lipid-lowering treatment. Therapies intended to improve lipid profiles and potentially patient outcomes include both health behaviour interventions alone or in combination with lipid-lowering drug therapy. Given the relationship between low-density lipoprotein cholesterol and cardiovascular events is linear, treating more patients is likely to lead to a further reduction in cardiovascular events.