What Are the Causes of Death among Patients Admitted to a Contemporary Tertiary-Level Cardiology Department? An Analysis of 10 Years of Morbidity and Mortality Meetings.

Despite the efforts to deliver the best evidence-based care, in-hospital death is an inevitable event among some patients hospitalized in cardiology departments. We conducted a retrospective evaluation of mortality events from inpatient admissions to the cardiology department between 2010 and 2019. Data were collected from morbidity and mortality meeting presentations that evaluated comorbidities, medical history, treatments, and causes of death for the overall cohort and according to age group and sex. There were 1182 registered deaths. The most common causes of death among patients were acute myocardial infarction (AMI, 53.0%), heart failure (HF, 11.7%), cardiac arrest (CA, 6.6%), HF with complication/defined cardiomyopathy (6.3%), and sepsis (4.4%). We observed a decline in deaths from AMI from 61.9% in 2010 to 46.7% in 2019, while there was a clear increase in deaths from HF (11.1% in 2010 to 25.9% in 2019). Compared to patients ≥65 years, younger patients were more likely to have died from CA (15.7% vs. 4.3%, p < 0.001) and other cardiac reasons (3.0% vs. 0.4%, p < 0.001). The majority of deaths were due to AMI, HF, and CA. We observed a significant declining trend in the proportion of deaths due to AMI in recent years, with an increase in deaths due to HF.

A Critical Evaluation of Patient Pathways and Missed Opportunities in Treatment for Heart Failure.

BACKGROUND: Heart failure (HF) is a global problem responsible for significant morbidity and mortality. METHODS: This review describes the patient pathways and missed opportunities related to treatment for patients with HF. RESULTS: The contemporary management strategies in HF, including medical therapies, device therapy, transplant, and palliative care. Despite the strong evidence base for therapies that improve prognosis and symptoms, there remains a large number of patients that are not optimally managed. The treatment of patients with HF is highly influenced by those who are caring for them and varies widely across geographical regions. HF patients can be broadly classified into two key groups: those who have known HF, and those who are incidentally found to have reduced left ventricular systolic dysfunction or other cardiac abnormality when an echocardiogram is performed. While all patients are under the care of a general practitioner or family doctor, in other instances, non-cardiologist physicians, cardiologists, and specialist HF nurses-each will have varying levels of expertise in managing HF-are part of the broader team involved in the specialist management of patients with HF. CONCLUSIONS: There are many potential missed opportunities in HF treatment, which include general opportunities, medications, etiology-specific therapy, device therapy, therapies when initial treatments fail, and palliative care.

The Impact of Concomitant Diagnosis of Viral Infections on in-Hospital Mortality in Patients Hospitalized with a Diagnosis of Heart Failure in the United States: Insights from the National Inpatient Sample.

The impact of viral infections on patients admitted with a diagnosis of heart failure is not well understood. We conducted a retrospective cohort study using data from the National Inpatient Sample in the United States to evaluate the proportion of admissions with a diagnosis of heart failure and viral infections, and we explored how viral infections had impact on in-hospital mortality and length of stay. There were a total of 20,713,539 admission records with a diagnosis of heart failure included in the analysis and 3.8% had a concomitant diagnosis of viral infection. The mean length of stay was 20.1 ± 26.9 days, 12.9 ± 13.6 days, 12.1 ± 13.8 days, and 5.1 ± 6.5 days for records with a diagnosis of cytomegalovirus, viral meningitis/encephalitis, herpes simplex infection, and no viral infection, respectively. The most common diagnoses of viral infections were influenza (n = 240,260) and chronic viral hepatitis (n = 194,400), and the highest rates of mortality were observed for records with a diagnosis of cytomegalovirus (13.2%), acute viral hepatitis (12.5%), and viral meningitis/encephalitis (11.1%). The viral infections significantly associated with increased odds of mortality were cytomegalovirus infection (OR 1.84 95% CI 1.57-2.16), acute hepatitis (OR 1.29 95% CI 1.15-1.45), and HIV (OR 1.22 95% CI 1.11-1.34). In conclusion, viral infections are co-diagnosis in 3.8% of patient records with heart failure and detection of some viruses may be important as they increase mortality and may prolong length of stay in hospital.

The role of multi-modality cardiovascular imaging in a patient presenting with acute liver failure secondary to constrictive pericarditis: a case report.

Background: Constrictive pericarditis is a rare cause of heart failure which often presents a diagnostic challenge to clinicians. Case summary: We describe the case of a 62-year-old male who presented to our institution with symptoms and signs suggestive of acute liver failure. Abdominal imaging demonstrated congestive hepatopathy. Clinical suspicion despite a 'normal' echocardiogram and sub-threshold NT-proBNP led to multi-modality cardiovascular imaging investigations to determine the cause of the heart failure syndrome. His cardiovascular magnetic resonance scan confirmed ventricular interdependence and extensive late enhancement in the pericardium with associated pericardial effusion. An 18F-fluorodeoxyglucose-positron emission tomography scan confirmed active pericardial inflammation. Cardiac computed tomography showed minimal pericardial calcification. Following confirming the diagnosis of effusive-constrictive pericarditis with evidence of active pericardial inflammation on imaging, a discussion within the Heart multidisciplinary team concluded that a trial of medical therapy with steroids is justifiable to avoid high-risk pericardiectomy. The patient was successfully treated with a combination of ibuprofen, colchicine, and prednisolone resulting in clinical improvement and remission of his symptoms. The imaging investigations were repeated 6 months later and confirmed radiological remission and medical therapy was discontinued. Discussion: We stress the importance of multi-modality cardiovascular imaging in the diagnosis of constrictive pericarditis and also emphasize its role in identifying the subset of patients who may respond to medical therapy, therefore reducing the risk of high need surgical pericardiectomy.

Missed Opportunities in the Diagnosis of Heart Failure: Evaluation of Pathways to Determine Sources of Delay to Specialist Evaluation.

Missed opportunities are incidents where different actions by those involved could have resulted in more desirable events. Heart failure is a complex clinical syndrome presenting as symptoms and signs common to other diagnoses, in patients frequently with multiple co-morbidities. Heart failure itself is not a diagnosis, but is the common clinical presentation of a variety of cardiac conditions. Correct diagnosis involves amalgamation of the clinical presentation, the results of general and specific investigations, and the clinician's ability to synthesize the overall picture. It is not surprising therefore that misdiagnosis can occur at any level of the heart failure journey and can occur because of patient, clinician, and health economy related factors. Delayed diagnosis leads to excess morbidity and mortality in these patients. In this review, we define the pathways for diagnosis of heart failure and then highlight missed opportunities related to delay and misdiagnosis. In addition, we consider how the earlier opportunity may impact patients, clinicians and health services.

Missed opportunities in coronary artery disease: reflection on practice to improve patient outcomes.

Missed opportunities refer to incidents where different actions by those involved could result in more desirable outcomes. While missed opportunities are not an established concept in coronary artery disease (CAD), they are important because CAD is common and potentially life-threatening. Treatment of CAD has the potential to prevent poor patient outcomes which can have a downstream consequence on resource utilization and costs for healthcare providers. The missed opportunities in CAD could be divided into those related to prevention, early detection, diagnosis and treatment. The primary prevention opportunities include the management of patients with risk factors and comorbidities. In terms of diagnosis, a proportion of patients who have underlying CAD are admitted beforehand with symptoms which may be attributed to CAD. However, some may have been misdiagnosed with other conditions and are subsequently readmitted with a delayed diagnosis of acute coronary syndrome. In acute coronary syndrome, there is a need for acute treatment and missed opportunities may arise from delay in diagnosis and missed reperfusion therapy. Finally, after coronary revascularization or medication management, there may be missed opportunities for patients related to secondary prevention such as smoking cessation, exercise, weight loss, attendance at cardiac rehabilitation and receipt evidenced-based therapies including antihypertensives, antiplatelet and statin therapy. Our review finds that missed opportunities can become apparent if looked for in the care of patients with CAD. While the term is nonspecific, it should be contextualized and described as those which are related to prevention, diagnosis and treatment. Only through reflection on clinical activities in relation to patient outcomes and the use of healthcare services can missed opportunities be identified so that better care can be delivered.

Patient, Clinician, and Healthcare Perspectives in Evaluating Care Pathways for Stable Chest Pain.

Chest pain is one of the most common reasons for patients to present to healthcare professionals. One of the main challenges with the management of chest pain is the wide differential diagnosis, ranging from minor chest trauma to potentially life-threatening acute myocardial infarction. In a patient-centered health service pathway, the aim is to assess, investigate, diagnose, and treat patients in the safest and most accurate, time, and cost-efficient manner. This report describes the concept of clinical pathways and their importance. It iterates different perspectives of the investigation of chest pain and the barriers to understanding the clinical sequence of events. By considering the patient, clinician, and healthcare service perspective, it is possible to critically evaluate the current stable chest pain pathway. This exercise gives consideration into the way in which patient care could be improved.

Misdiagnosis of Heart Failure: A Systematic Review of the Literature.

BACKGROUND: Heart failure (HF) is a chronic disease associated with a significant burden to patients, families, and health services. The diagnosis of HF can be easily missed owing to similar symptoms with other conditions especially respiratory diseases. METHODS AND RESULTS: We conducted a systematic review to determine the rates of HF and cardiomyopathy misdiagnosis and explored the potential causes. The included studies were narratively synthesized. Ten studies were identified including a total of 223,859 patients. There was a lack of definition of HF misdiagnosis in the studies and inconsistent diagnostic criteria were used. The rates of HF misdiagnosis ranged from 16.1% in hospital setting to 68.5% when general practitioner referred patients to specialist setting. The most common cause for misdiagnosis was chronic obstructive pulmonary disease (COPD). One study using a COPD cohort showed that HF was unrecognized in 20.5% of patients and 8.1% had misdiagnosis of HF as COPD. Another study suggests that anemia and chronic kidney disease are associated with an increase in the odds of unrecognized left ventricular systolic dysfunction. Other comorbidities such as obesity, old age, atrial fibrillation, and ischemic heart disease are prevalent in patients with a misdiagnosis of HF. CONCLUSIONS: The misdiagnosis of HF is an unfortunate part of everyday clinical practice that occurs with a variable rate depending on the population studied. HF is frequently misdiagnosed as COPD. More research is needed to better understand the missed opportunities to correctly diagnose HF so that harm to patients can be avoided and effective treatments can be implemented.

The role of the Tei index in assessing for cardiotoxicity from anthracycline chemotherapy: a systematic review.

BACKGROUND: Anthracycline agents are known to be effective in treating tumors and hematological malignancies. Although these agents improve survival, their use is associated with cardiotoxic effects, which most commonly manifests as left ventricular systolic dysfunction (LVSD). As such, guidelines recommend the periodic assessment of left ventricular ejection fraction (LVEF). However, as diastolic dysfunction likely proceeds systolic impairment in this setting, the role of Tei index may offer additional benefit in detecting subclinical LVSD. METHODS: We conducted a systematic review to investigate the evidence for the use of Tei index in assessing subclinical cardiotoxicity in patients receiving anticancer agents. A search of Medline and EMBASE was performed and relevant studies were reviewed and narratively synthesized. RESULTS: A total of 13 studies were included with a total of 800 patients (mean age range 46-62 years, percentage of male participants ranged from 0-86.9%). An increase in Tei index was observed in 11 studies, which suggested a decline in cardiac function following chemotherapy. Out of these, six studies indicated that the Tei index is a useful parameter in predicting cardiotoxic LVSD. Furthermore, five studies indicated Tei index to be superior to LVEF in detecting subclinical cardiotoxicity. CONCLUSIONS: Though there are some studies that suggest that Tei index may be a useful indicator in assessing subclinical anthracycline-related cardiotoxicity, the findings are inconsistent and so more studies are needed before the evaluation of Tei index is performed routinely in patients receiving chemotherapy.

The impact of COVID-19 on the management of heart failure: a United Kingdom patient questionnaire study.

AIMS: The coronavirus disease 2019 (COVID-19) pandemic has created significant challenges to healthcare globally, necessitating rapid restructuring of service provision. This questionnaire survey was conducted amongst adult heart failure (HF) patients in the United Kingdom (UK), to understand the impact of COVID-19 upon HF services. METHODS AND RESULTS: The survey was conducted by the Pumping Marvellous Foundation, a UK HF patient charity. 'Survey Monkey' was used to disseminate the questionnaire in the Pumping Marvellous Foundation 's online patient group and in 10 UK hospitals (outpatient hospital and community HF clinics). There were 1050 responses collected (693/1050-66% women); 55% (579/1050) were aged over 60 years. Anxiety level was significantly higher regarding COVID-19 (mean 7 ± 2.5 on anxiety scale of 0 to 10) compared with anxiety regarding HF (6.1 ± 2.4; P < 0.001). Anxiety was higher amongst patients aged ≤60 years about HF (6.3 ± 2.2 vs. 5.9 ± 2.5 in those aged >60 years; P = 0.005) and COVID-19 (7.3 ± 2.3 vs. 6.7 ± 2.6 those aged >60 years; P < 0.001). Sixty-five per cent of respondents (686/1050) reported disruption to HF appointments (cancellation or postponement) during the lockdown period. Thirty-seven per cent reported disruption to medication prescription services, and Thirty-four per cent reported inability to access their HF teams promptly. Thirty-two per cent expressed reluctance to attend hospital (25% stated they would only attend hospital if there was no alternative, and 7% stated that they would not attend hospital at all). CONCLUSIONS: The COVID-19 pandemic has caused significant anxiety amongst HF patients regarding COVID-19 and HF. Cancellation or postponement of scheduled clinic appointments, investigations, procedures, prescription, and monitoring services were implicated as sources of anxiety.

Characteristics and outcome of acute heart failure patients according to the severity of peripheral oedema.

BACKGROUND: Most trials of patients hospitalized for heart failure focus on breathlessness (alveolar pulmonary oedema) but worsening peripheral oedema is also an important presentation. We investigated the relationship between the severity of peripheral oedema on admission and outcome amongst patients with a primary discharge death or diagnosis of heart failure. OBJECTIVES: We tested the hypothesis that severity of peripheral oedema is associated with length of hospital stay and mortality. METHODS: Patient variables reported to the National Heart Failure Audit for England & Wales between April 2008 and March 2013 were included in this analysis. Peripheral oedema was classified as 'none', 'mild', 'moderate' or 'severe'. Length of stay, mortality during the index admission and for up to three years after discharge are reported. RESULTS: Of 121,214 patients, peripheral oedema on admission was absent in 24%, mild in 24%, moderate in 33% and severe in 18%. Median length of stay was, respectively, 6, 7, 9 and 12 days (P- < 0.001), index admission mortality was 7%, 8%, 10% and 16% (P- < 0.001) and mortality at a median follow-up of 344 (IQR 94-766) days was 39%, 46%, 52% and 59%. In an adjusted multi-variable Cox model, the hazard ratio for death was 1.51 for severe (P- < 0.001, CI 1.50-1.53), 1.21 for moderate (P- < 0.001, CI 1.20-1.22) and 1.04 (P- < 0.001, CI 1.02-1.05) for mild peripheral oedema compared to patients without peripheral oedema at presentation. CONCLUSION: Length of hospital stay and mortality during index admission and after discharge increased progressively with increasing severity of peripheral oedema at admission.

The use of Apixaban for the treatment of an LV thrombus

Summary: A 42-year-old male was admitted with shortness of breath secondary to suspected heart failure and chest infection. An echocardiogram revealed a dilated and impaired left ventricle; ejection fraction 29%, with a large, mobile thrombus within the left ventricular apex. Due to the presence of liver dysfunction, vitamin K antagonists were deemed inappropriate; thus, the decision was taken to use the novel anticoagulation agent Apixaban. After 6 days of receiving Apixaban, a cardiac magnetic resonance scan was preformed, which showed complete resolution of the LV apical thrombus. Learning points: Patients with a dilated and impaired LV are at an increased risk of developing LV thrombus. A large and mobile LV thrombus is associated with an increased risk of embolic events. Vitamin K antagonists (VKAs) are often the first-line therapy for LV thrombus; however, these may be inappropriate in some patients. NOACs are advantageous in comparison to VKAs and are used to treat: non-valvular atrial fibrillation, pulmonary embolisms and used in the prevention of recurrent deep vein thrombosis in adults. To date, NOACs are not licensed for the treatment of an LV thrombus; however, there are growing evidence whereby there use has shown promise in reducing the risk of embolic events and demonstrate rapid reduction in size/full resolution of an LV thrombus. Large, randomised research trials comparing NOACs and VKAs in the treatment of LV thrombus are needed, which may lead to a change in standard clinical practice that could benefit patients.

Ultrafiltration for acute decompensated cardiac failure: A systematic review and meta-analysis.

BACKGROUND: Ultrafiltration is a method used to achieve diuresis in acute decompensated heart failure (ADHF) when there is diuretic resistance, but its efficacy in other settings is unclear. We therefore conducted a systematic review and meta-analysis to evaluate the use of ultrafiltration in ADHF. METHODS: We searched MEDLINE and EMBASE for studies that evaluated outcomes following filtration compared to diuretic therapy in ADHF. The outcomes of interest were body weight change, change in renal function, length of stay, frequency of rehospitalization, mortality and dependence on dialysis. We performed random effects meta-analyses to pool studies that evaluated the desired outcomes and assessed statistical heterogeneity using the I2 statistic. RESULTS: A total of 10 trials with 857 participants (mean age 68years, 71% male) compared filtration to usual diuretic care in ADHF. Nine studies evaluated weight change following filtration and the pooled results suggest a decline in mean body weight -1.8; 95% CI, -4.68 to 0.97 kg. Pooled results showed no difference between the filtration and diuretic group in change in creatinine or estimated glomerular filtration rate. The pooled results suggest longer hospital stay with filtration (mean difference, 3.70; 95% CI, -3.39 to 10.80days) and a reduction in heart failure hospitalization (RR, 0.71; 95% CI, 0.51-1.00) and all-cause rehospitalization (RR, 0.89; 95% CI, 0.43-1.86) compared to the diuretic group. Filtration was associated with a non-significant greater risk of death compared to diuretic use (RR, 1.08; 95% CI, 0.77-1.52). CONCLUSIONS: There is insufficient evidence supporting routine use of ultrafiltration in acute decompensated heart failure.

The importance of interactions between atrial fibrillation and heart failure.

Heart failure (HF) and atrial fibrillation (AF) are among the commonest cardiovascular conditions encountered in clinical practice and frequently coexist. Over the last decade, they have evolved into global cardiovascular epidemics. This, in turn, has huge clinical and economic implications. There is ample evidence that AF and HF have a mutually deleterious effect on each other. AF is not only a marker of HF severity but also affects HF prognosis independently. This article presents the close pathophysiological relationship between AF and HF and the adverse prognostic consequences of this bidirectional interaction. The scope of various therapeutic modalities and their potential impacts are discussed briefly.

Prolonged PR interval, first-degree heart block and adverse cardiovascular outcomes: a systematic review and meta-analysis.

OBJECTIVE: First-degree atrioventricular block is frequently encountered in clinical practice and is generally considered a benign process. However, there is emerging evidence that prolonged PR interval may be associated with adverse outcomes. This study aims to determine if prolonged PR interval is associated with adverse cardiovascular outcomes and mortality. METHODS: We searched MEDLINE and EMBASE for studies that evaluated clinical outcomes associated with prolonged and normal PR intervals. Relevant studies were pooled using random effects meta-analysis for risk of mortality, cardiovascular mortality, heart failure, coronary heart disease, atrial fibrillation and stroke or transient ischaemic attack (TIA). Sensitivity analyses were performed considering the population type and the use of adjustments. RESULTS: Our search yielded 14 studies that were undertaken between 1972 and 2011 with 400,750 participants. Among the studies that adjusted for potential confounders, the pooled results suggest an increased risk of mortality with prolonged PR interval risk ratio (RR) 1.24 95% CI 1.02 to 1.51, five studies. Prolonged PR interval was associated with significant risk of heart failure or left ventricular dysfunction (RR 1.39 95% CI 1.18 to 1.65, three studies) and atrial fibrillation (RR 1.45 95% CI 1.23 to 1.71, eight studies) but not cardiovascular mortality, coronary heart disease or myocardial infarction or stroke or TIA. Similar observations were recorded when limited to studies of first-degree heart block. CONCLUSIONS: Data from observational studies suggests a possible association between prolonged PR interval and significant increases in atrial fibrillation, heart failure and mortality. Future prospective studies are needed to confirm the relationships reported, consider possible mechanisms and define the optimal monitoring strategy for such patients.

Cardiac resynchronisation therapy is not associated with a reduction in mortality or heart failure hospitalisation in patients with non-left bundle branch block QRS morphology: meta-analysis of randomised controlled trials.

OBJECTIVES: Recently published clinical guidelines recommend cardiac resynchronisation therapy (CRT) for patients with heart failure (HF) with reduced LVEF and non-left bundle branch block (non-LBBB) QRS morphology. We sought to define the potential benefit of CRT in these patients through meta-analysis of randomised controlled trials (RCTs) that have reported outcomes in patients with non-LBBB QRS morphology. METHODS: We searched MEDLINE and EMBASE for RCTs of CRT that reported outcomes according to QRS morphology. We performed meta-analysis of these RCTs to assess the effect of CRT on the end points of death, HF hospitalisation, and the composite of death and HF hospitalisation. RESULTS: Five RCTs were analysed, including 6523 participants (1766 with non-LBBB QRS morphology). CRT was not associated with a reduction in death and/or HF hospitalisation in subjects with non-LBBB QRS morphology (HR 0.99 95% CI 0.82 to 1.20). CONCLUSIONS: CRT is not associated with a reduction in death or HF hospitalisation in patients with non-LBBB QRS morphology. Wide QRS with non-LBBB morphology remains an area of uncertainty for CRT, which is included in the recent European Society of Cardiology guidelines with a weaker strength of recommendation, but is not supported by a dedicated RCT.

Heart failure and chronic obstructive pulmonary disease multimorbidity at hospital discharge transition: a study of patient and carer experience.

BACKGROUND: Care for patients with multimorbidity represents a major challenge not only for patients and carers but to health-care systems. Hospital discharge transition is a critical point at which challenges for multimorbidity may amplify. OBJECTIVES: The main objective of the study was to explore the experiences of heart failure (HF) and chronic obstructive pulmonary disease (COPD) multimorbid patients and their carers on hospital discharge. Secondary objectives included identification of gaps in the health care of multimorbidity and optimal solutions from patients and carers' perspectives. DESIGN: Mixed methods were applied to collect data using patient self-completion questionnaire from an adapted version of the American Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and in-depth interviews. SETTING: Participants were recruited from two cardiology and respiratory wards at a large regional hospital in England, and all had a multimorbidity diagnosis of COPD and HF. RESULTS AND CONCLUSIONS: Findings revealed that patients experienced difficulties in their communication with health-care professionals and there were specific challenges with information about medication. Qualitative descriptions revealed that experiences fell into two main categories: (i) information transfer to patients with multimorbidity in terms of issues with medication and clarity of information on diagnosis and (ii) communication and continuity of care after discharge. Respondents highlighted gaps in the management of patients with multimorbidity of HF and COPD at the critical time of care transition. They suggested the need for a comprehensive, coordinated and integrated approach to incorporate patients, carers and staff preferences for treatment on discharge from hospital.