Coordinating Cardiology clinics randomized trial of interventions to improve outcomes (COORDINATE) - Diabetes: rationale and design.

Several medications that are proven to reduce cardiovascular events exist for individuals with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease, however they are substantially underused in clinical practice. Clinician, patient, and system-level barriers all contribute to these gaps in care; yet, there is a paucity of high quality, rigorous studies evaluating the role of interventions to increase utilization. The COORDINATE-Diabetes trial randomized 42 cardiology clinics across the United States to either a multifaceted, site-specific intervention focused on evidence-based care for patients with T2DM or standard of care. The multifaceted intervention comprised the development of an interdisciplinary care pathway for each clinic, audit-and-feedback tools and educational outreach, in addition to patient-facing tools. The primary outcome is the proportion of individuals with T2DM prescribed three key classes of evidence-based medications (high-intensity statin, angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and either a sodium/glucose cotransporter-2 inhibitor (SGLT-2i) inhibitor or glucagon-like peptide 1 receptor agonist (GLP-1RA) and will be assessed at least 6 months after participant enrollment. COORDINATE-Diabetes aims to identify strategies that improve the implementation and adoption of evidence-based therapies.

The relevance of specific heart failure outpatient programs in the COVID era: an appropriate model for every disease.

Heart Failure (HF) is characterized by an elevated readmission rate, with almost 50% of events occurring after the first episode over the first 6 months of the post-discharge period. In this context, the vulnerable phase represents the period when patients elapse from a sub-acute to a more stabilized chronic phase. The lack of an accurate approach for each HF subtype is probably the main cause of the inconclusive data in reducing the trend of recurrent hospitalizations. Most care programs are based on the main diagnosis and the HF stages, but a model focused on the specific HF etiology is lacking. The HF clinic route based on the HF etiology and the underlying diseases responsible for HF could become an interesting approach, compared with the traditional programs, mainly based on non-specific HF subtypes and New York Heart Association class, rather than on detailed etiologic and epidemiological data. This type of care may reduce the 30-day readmission rates for HF, increase the use of evidence-based therapies, prevent the exacerbation of each comorbidity, improve patient compliance, and decrease the use of resources. For all these reasons, we propose a dedicated outpatient HF program with a daily practice scenario that could improve the early identification of symptom progression and the quality-of-life evaluation, facilitate the access to diagnostic and laboratory tools and improve the utilization of financial resources, together with optimal medical titration and management.

Organization and procedures in contemporary catheter ablation centres: data from the 2018 Italian Catheter Ablation Registry.

AIMS: This report describes the findings of the 2018 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC). METHODS: The Italian Catheter Ablation Registry systematically collects data on the ablation procedures performed in Italy. Data collection was retrospective. A standardized questionnaire was completed by participating centres. RESULTS: We collected data on 15 714 catheter ablation procedures performed in Italy during 2018 in 94 electrophysiology centres. In most centres (75/94, 80%), a single electrophysiology laboratory was available, and a hybrid electrophysiology laboratory was available in 15% (14/94) of centres. In most (93%) centres, at least two electrophysiologists were involved in the catheter ablation procedures. In only 13 out of 94 (14%) electrophysiology laboratories, an anaesthesiologist assists every electrophysiology procedure; in most cases (74/94, 79%), an on-demand anaesthesiology service was available. On-site cardiothoracic surgery was reported in 43 out of 94 (46%) centres.Nonfluoroscopic navigation systems were available in most centres (88/94, 93%). Intracardiac echocardiography was used in 59 out of 94 (63%) electrophysiology laboratories. Atrial fibrillation (31%) was the most frequently treated ablation target, followed by atrioventricular nodal re-entrant tachycardia (20%) and cavo-tricuspid isthmus (15%). In 61.7% of all procedures, a 3D mapping system was used. In about one-third of procedures, a near-zero approach was performed. CONCLUSION: In most Italian electrophysiology centres, a single electrophysiology laboratory was available and at least two electrophysiologists were involved in the ablation procedures. An increasing number of procedures were performed by means of a nonfluoroscopic mapping system with a near-zero approach.

Cardiac teleconsulting in the time of COVID-19 global pandemic: The "Antonio Cardarelli" Hospital project.

Dear Editor, Teleconsulting - defined as real-time consultation between doctors by exploiting video conferencing technology over the Internet network - is exponentially being implemented through the western world lastly triggered by COVID-19 pandemic...

Reintroduction of elective cardiac interventions in the era of COVID-19: the Barts experience.

BACKGROUND: The response to COVID-19 has required cancellation of all but the most urgent procedures; there is therefore a need for the reintroduction of a safe elective pathway. METHODS: This was a study of a pilot pathway performed at Barts Heart Centre for the admission of patients requiring elective coronary and structural procedures during the COVID-19 pandemic (April-June 2020). All patients on coronary and structural waiting lists were screened for procedural indications, urgency and adverse features for COVID-19 prognosis and discussed at dedicated multidisciplinary teams. Dedicated admission pathways involving preadmission isolation, additional consent, COVID-19 PCR testing and dedicated clean areas were used. RESULTS: 143 patients (101 coronary and 42 structural) underwent procedures (coronary angiography, percutaneous coronary intervention, transcatheter aortic valve intervention and MitralClip) during the study period. The average age was 68.2; 74% were male; and over 93% had one or more moderate COVID-19 risk factors. All patients were COVID-19 PCR negative on admission with (8.1%) COVID-19 antibody positive (swab negative). All procedures were performed successfully with low rates of procedural complications (9.8%). At 2-week follow-up, no patients had symptoms or confirmed COVID-19 infection with significant improvements in quality if life and symptoms. CONCLUSION: We demonstrated that patients undergoing coronary and structural procedures can be safely admitted during the COVID-19 pandemic, with no patients contracting COVID-19 during their admission. Reassuringly, patients reflective of typical practice, that is, those at moderate or higher risk, were treated successfully. This pilot provides important information applicable to other settings, specialties and areas to reintroduce services safely.

The Effect of a Quality Improvement Intervention on Sleep and Delirium in Critically Ill Patients in a Surgical ICU.

BACKGROUND: Delirium is a deleterious condition affecting up to 60% of patients in the surgical ICU (SICU). Few SICU-focused delirium interventions have been implemented, including those addressing sleep-wake disruption, a modifiable delirium risk factor common in critically ill patients. RESEARCH QUESTION: What is the effect on delirium and sleep quality of a multicomponent nonpharmacologic intervention aimed at improving sleep-wake disruption in patients in the SICU setting? STUDY DESIGN AND METHODS: Using a staggered pre-post design, we implemented a quality improvement intervention in two SICUs (general surgery or trauma and cardiovascular) in an academic medical center. After a preintervention (baseline) period, a multicomponent unit-wide nighttime (ie, efforts to minimize unnecessary sound and light, provision of earplugs and eye masks) and daytime (ie, raising blinds, promotion of physical activity) intervention bundle was implemented. A daily checklist was used to prompt staff to complete intervention bundle elements. Delirium was evaluated twice daily using the Confusion Assessment Method for the Intensive Care Unit. Patient sleep quality ratings were evaluated daily using the Richards-Campbell Sleep Questionnaire (RCSQ). RESULTS: Six hundred forty-six SICU admissions (332 baseline, 314 intervention) were analyzed. Median age was 61 years (interquartile range, 49-70 years); 35% of the cohort were women and 83% were White. During the intervention period, patients experienced fewer days of delirium (proportion ± SD of ICU days, 15 ± 27%) as compared with the preintervention period (20 ± 31%; P = .022), with an adjusted pre-post decrease of 4.9% (95% CI, 0.5%-9.2%; P = .03). Overall RCSQ-perceived sleep quality ratings did not change, but the RCSQ noise subscore increased (9.5% [95% CI, 1.1%-17.5%; P = .02). INTERPRETATION: Our multicomponent intervention was associated with a significant reduction in the proportion of days patients experienced delirium, reinforcing the feasibility and effectiveness of a nonpharmacologic sleep-wake bundle to reduce delirium in critically ill patients in the SICU. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03313115; URL: www.clinicaltrials.gov.

Establishing a Cardiac Amyloidosis Clinic: A Practical Primer for Cardiologists.

Cardiac amyloidosis is an emerging and important cause of heart failure, arrhythmia, and other cardiovascular disease in Canada. In this context, many centres have expressed interest in the development of effective care pathways for screening, evaluating, and treating this rapidly growing patient population. In October 2019, a group of Canadian stakeholders met, including specialists in cardiac amyloidosis, experts in heart failure and chronic disease management, and academic and community-based cardiologists at various stages of cardiac amyloidosis clinic development. Objectives of the meetings included discussion of existing care pathways, consideration of barriers to program development, and achieving a consensus on essential and desirable components of a best-practice cardiac amyloidosis program. Topics discussed included optimal settings for cardiac amyloidosis clinics and integration with other specialty clinics, funding limitations that act as barriers to program development and potential solutions to these barriers, the roles of the multidisciplinary team and specialist physicians in amyloidosis care, and diagnostic pathways and strategies for the identification of patients with cardiac amyloidosis. In this report, we summarize the discussion points and key recommendations for the development of a cardiac amyloidosis clinic that emerged from this meeting, focused on program integration and care coordination, human resource elements, access to care, and quality improvement and outcome measures in cardiac amyloidosis.

Impact of COVID-19 on cardiac procedure activity in England and associated 30-day mortality.

AIMS: Limited data exist on the impact of COVID-19 on national changes in cardiac procedure activity, including patient characteristics and clinical outcomes before and during the COVID-19 pandemic. METHODS AND RESULTS: All major cardiac procedures (n = 374 899) performed between 1 January and 31 May for the years 2018, 2019, and 2020 were analysed, stratified by procedure type and time-period (pre-COVID: January-May 2018 and 2019 and January-February 2020 and COVID: March-May 2020). Multivariable logistic regression was performed to examine the odds ratio (OR) of 30-day mortality for procedures performed in the COVID period. Overall, there was a deficit of 45 501 procedures during the COVID period compared to the monthly averages (March-May) in 2018-2019. Cardiac catheterization and device implantations were the most affected in terms of numbers (n = 19 637 and n = 10 453), whereas surgical procedures such as mitral valve replacement, other valve replacement/repair, atrioseptal defect/ventriculoseptal defect repair, and coronary artery bypass grafting were the most affected as a relative percentage difference (Δ) to previous years' averages. Transcatheter aortic valve replacement was the least affected (Δ -10.6%). No difference in 30-day mortality was observed between pre-COVID and COVID time-periods for all cardiac procedures except cardiac catheterization [OR 1.25 95% confidence interval (CI) 1.07-1.47, P = 0.006] and cardiac device implantation (OR 1.35 95% CI 1.15-1.58, P < 0.001). CONCLUSION: Cardiac procedural activity has significantly declined across England during the COVID-19 pandemic, with a deficit in excess of 45 000 procedures, without an increase in risk of mortality for most cardiac procedures performed during the pandemic. Major restructuring of cardiac services is necessary to deal with this deficit, which would inevitably impact long-term morbidity and mortality.

Surge-in-Place: Conversion of a Cardiac Catheterization Laboratory Into a COVID-19 Intensive Care Unit and Back Again.

In Spring 2020, the United States epicenter of COVID-19 was New York City, in which the borough of the Bronx was particularly affected. This Fall, there has been a resurgence of COVID-19 in Europe and the Midwestern United States. We describe our experience transforming our cardiac catheterization laboratories to accommodate an influx of COVID-19 patients so as to provide other hospitals with a potential blueprint. We transformed our pre/postprocedural patient care areas into COVID-19 intensive care and step-down units and maintained emergent invasive care for ST-segment elevation myocardial infarction using existing space and personnel.

Reorganización de la actividad asistencial ambulatoria en la era de la COVID-19. La hora de la e-consulta / Reorganizing outpatient care in the era of COVID-19. Time for e-consultations

La situación actual consecuencia de la pandemia de COVID-19 nos apremia a la reorganización de la atención ambulatoria, entre otras actividades médicas. Las medidas urgentes que se impusieron durante el periodo de confinamiento obligaron a una reestructuración de las consultas que se ha convertido en una oportunidad de cambio y una necesidad para el futuro. Es el momento de innovar con la implantación de nuevas modalidades de asistencia, apostando por la atención no presencial, con el propósito de garantizar la seguridad de los pacientes, pero también optimizar los recursos y el gasto sanitarios, evitando consultas innecesarias y repetición de actos médicos. Hay exitosas experiencias previas de la telemedicina tanto para comunicación entre profesionales como para la relación médico-paciente. El desarrollo de las tecnologlas de la información y la comunicación nos brinda multitud de oportunidades para está reorganización, que deben adaptarse a cada realidad, pero siempre primando la calidad asistencial

The current situacion caused by the COVID-19 pandemic has forced us to reorganize outpatient care, along with other healthcare activities. Urgent measures imposed during the lockdown period have necessitated the reorganization of patient consultations, which has provided an opportunity to make changes that may become essential in the future. Now is the time to innovate by implementing new modalities of care, for example by trying out remote patient care, not only to guarantee patient safety, but also to optimize the use of health-care resources and expenditure and to avoid unnecessary consultations and the duplication of medical efforts. Previously, telemedicine has been used successfully both for communications between professionals and in the doctor-patient relationship. The development of Información and communication technologies has given us a plethora of opportunities for reorganization, which must be adapted to each real-life situación while bearing in mind that care quality is a priority

Cardiopatías congénitas del adulto en España: situación actual y perspectivas futuras / Adult congenital heart disease in Spain: present situation and future perspectives

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