Management of secondary mitral regurgitation: from drugs to devices.

Severe secondary mitral regurgitation carries a poor prognosis with one in five patients dying within 12 months of diagnosis. Fortunately, there are now a number of safe and effective therapies available to improve outcomes. Here, we summarise the most up-to-date treatments. Optimal guideline-directed medical therapy is the mainstay therapy and has been shown to reduce the severity of mitral regurgitation in 40-45% of patients. Rapid medication titration protocols reduce heart failure hospitalisation and facilitate earlier referral for device therapy. The pursuit of sinus rhythm in patients with atrial fibrillation has been shown to significantly reduce mitral regurgitation severity, as has the use of cardiac resynchronisation devices in patients who meet guideline-directed criteria. Finally, we highlight the key role of mitral valve intervention, particularly transcatheter edge-to-edge repair (TEER) for management of moderate-severe mitral regurgitation in carefully selected patients with poor left ventricular systolic function, with a number needed to treat of 3.1 to reduce heart failure hospitalisation and 5.9 to reduce all-cause death. To slow the rapid accumulation of morbidity and mortality, we advocate a proactive approach with accelerated medical optimisation, followed by management of atrial fibrillation and cardiac resynchronisation therapy if indicated, then, rapid referral to the Heart Team for consideration of mitral valve intervention in patients with ongoing symptoms and at least moderate-severe mitral regurgitation. Mitral TEER has been shown to be 'reasonably cost-effective' (but not cost-saving) in the UK in selected patients, although TEER remains underused with only 6.5 procedures per million population (pmp) compared with Germany (77 pmp), Switzerland (44 pmp) and the USA (32 pmp).

Single high-sensitivity troponin levels to assess patients with potential acute coronary syndromes.

OBJECTIVE: We tested the hypothesis that patients with a potential acute coronary syndrome (ACS) and very low levels of high-sensitivity cardiac troponin I can be efficiently and safely discharged from the emergency department after a single troponin measurement. METHODS: This prospective cohort study recruited 2255 consecutive patients aged ≥18 years presenting to the Emergency Department, Royal Perth Hospital, Western Australia, with chest pain without high-risk features but requiring the exclusion of ACS. Patients were managed using a guideline-recommended pathway or our novel Single Troponin Accelerated Triage (STAT) pathway. The primary outcome was the percentage of patients discharged in <3 hours. Secondary outcomes included the duration of observation and death or acute myocardial infarction in the next 30 days. RESULTS: The study enrolled 1131 patients to the standard cohort and 1124 to the STAT cohort. Thirty-eight per cent of the standard cohort were discharged directly from emergency department compared with 63% of the STAT cohort (p<0.001). The median duration of observation was 4.3 (IQR 3.3-7.1) hours in the standard cohort and 3.6 (2.6-5.4) hours in the STAT cohort (p<0.001), with 21% and 38% discharged in <3 hours, respectively (p<0.001). No patients discharged directly from the emergency department died or suffered an acute myocardial infarction within 30 days in either cohort. CONCLUSIONS: Among low-risk patients with a potential ACS, a pathway which incorporates early discharge based on a single very low level of high-sensitivity cardiac troponin increases the proportion of patients discharged directly from the emergency department, reduces length of stay and is safe. TRIAL REGISTRATION NUMBER: ACTRN12618000797279.

Self-monitoring for recurrence of secondary atrial fibrillation following non-cardiac surgery or acute illness: A pilot study.

BACKGROUND: Atrial fibrillation (AF) secondary to non-cardiac surgery and medical illness is common and, although often transient, is associated with an increased risk of stroke and mortality. This pilot study tested the feasibility of self-monitoring to detect recurrent AF in this setting and the frequency with which it occurred. METHODS: Patients with new secondary AF after non-cardiac surgery or medical illness that reverted to sinus rhythm before discharge were recruited in three tertiary hospitals in Australia. Participants performed self-monitoring for AF recurrence using a Handheld single-lead ECG device 3-4 times/day for 4-weeks. RESULTS: From 16,454 admissions, 224 (1.4%) secondary AF cases were identified. Of these, 94 were eligible, and 29 agreed to participate in self-monitoring (66% male; median age 67 years). Self-monitoring was feasible and acceptable to participants in this setting. Self-monitoring identified AF recurrence in 10 participants (34%; 95% CI, 18% -54%), with recurrence occurring ≤ 9 days following discharge in 9/10 participants. Only 4 participants (40%) reported associated palpitations with recurrence. Six participants (60%) with recurrence had a CHA2DS2-VA score ≥ 2, suggesting a potential indication for oral anticoagulation. CONCLUSIONS: Approximately 1 in 3 patients with transient secondary AF will have recurrent AF within nine days of discharge. These recurrent episodes are often asymptomatic but can be detected promptly using patient self-monitoring, which was feasible and acceptable. Future research is warranted to further investigate the incidence of secondary AF, the rate of recurrence after discharge and its prognosis, and whether use of oral anticoagulation can reduce stroke in this setting.

National survey of anticoagulation policy in endoscopy.

BACKGROUND: Anticoagulated patients who need to undergo endoscopy present unique challenges to the gastroenterologist. The continuation of anticoagulant therapy increases the risk of haemorrhagic complications of gastrointestinal endoscopy. Reversing the anticoagulation increases the risk of thromboembolism. In our experience in various endoscopy units, there are variable policies on the management of anticoagulated patients undergoing gastrointestinal endoscopy. METHODS: To study the current practice, survey questionnaires were sent to 2320 doctors, working in 231 hospitals across the United Kingdom. RESULTS: Responses were obtained from 219 hospitals (94.8%), but only from 434 doctors (18.7%). The results show 40.8% endoscopists continued the patients on warfarin when performing a planned upper gastrointestinal endoscopy, whereas 26% stopped it; 33.2% gave varying reports, that is, they used their own judgement according to the disease for which the anticoagulant was being given. For planned lower gastrointestinal endoscopy, 48.7% doctors preferred to stop warfarin; 53.3% of the endoscopists stated that they have a policy in place at their hospital for both upper and lower gastrointestinal endoscopy in anticoagulated patients; 5.5% had a policy for upper gastrointestinal endoscopy only and 6.2% for lower gastrointestinal endoscopy only. Thirty-five per cent doctors reported that they did not have any standard policy. We compared the responses from within a hospital to see whether the doctors were uniformly aware of an existing policy in their hospital. For upper gastrointestinal endoscopy, the responses were the same (either yes or no) by 51% of the doctors, whereas they were different by 49%. For lower gastrointestinal endoscopies, the same response was given by 49% of the doctors, whereas 51% gave different answers. The poor response rate from the doctors, however, makes firm interpretation of the data difficult. CONCLUSIONS: A wide variation in practice is seen across the country. A robust national guideline to streamline the endoscopy practice in anticoagulated patients is needed.