Signs and Symptoms Clusters Among Patients With Acute Heart Failure: A Correlational Study.

BACKGROUND: Patients with acute heart failure present to the emergency department with a myriad of signs and symptoms. Symptoms evaluated in clusters may be more meaningful than those evaluated individually by clinicians. OBJECTIVE: Among emergency department patients, we aimed to identify signs and symptoms correlations, clusters, and differences in clinical variables between clusters. METHODS: Medical record data included adults older than 18 years, International Classification of Diseases, Tenth Revisions codes , and positive Framingham Heart Failure Diagnostic Criteria. Exclusion criteria included medical records with a ventricular assist device and dialysis. For analysis, correlation, and the Gower distance, the independent t test, Mann-Whitney U test, χ 2 test, and regression were performed. RESULTS: A secondary analysis was conducted from the data set to evaluate door-to-diuretic time among patients with acute heart failure in the emergency department. A total of 218 patients were included, with an average age of 69 ± 15 years and predominantly White (74%, n = 161). Two distinct symptom clusters were identified: severe and mild congestion. The severe congestion cluster had a more comorbidity burden compared with the mild congestion cluster, as measured by the Charlson Comorbidity index (cluster 1 vs cluster 2, 6 [5-7] vs 5 [4-6]; P = .0019). Heart failure with preserved ejection fraction was associated with the severe congestion symptom cluster ( P = .009), and heart failure with mildly reduced ejection fraction was associated with the mild congestion cluster ( P = .019). CONCLUSIONS: In conclusion, 2 distinct symptom clusters were identified among patients with acute heart failure. Symptom clusters may be related to ejection fraction or overall cardiac output and comorbidity burden.

Disparities in 30-Day Readmission Between Medicare/Medicaid and Private Insurance Among Patients With Heart Failure Screened for Cognitive Impairment.

BACKGROUND: Racial disparities exist among patients with heart failure (HF). HF is often comorbid with cognitive impairment. Appropriate self-care can prevent HF hospital readmissions but requires access to resources through insurance. Racial differences exist between insurance types, and this may influence the disparity between races and patients with HF and cognitive impairment. OBJECTIVE: The objectives of this study were to examine the relationships between insurance type and self-care stratified by race and to assess for differences in time-to-30-day readmission among patients with HF with cognitive impairment. METHODS: This is a secondary analysis of data collected among hospitalized patients with HF with cognitive impairment. Patients completed surveys on self-care (Self-Care of Heart Failure Index), HF knowledge (Dutch Heart Failure Knowledge Scale), depression (Geriatric Depression Scale), and social support (Enhancing Recovery in Coronary Heart Disease Social Support Inventory). Socioeconomic data were collected. Linear models were created to examine the relationships between insurance type and self-care by race. Kaplan-Meier curves and Cox regression were used to assess readmission. RESULTS: The sample of 125 patients with HF with cognitive impairment was predominantly Black (68%, n = 85) and male (53%, n = 66). The sample had either Medicare/Medicaid (62%, n = 78) or private insurance (38%, n = 47). Black patients with HF with cognitive impairment and private insurance reported higher self-care confidence compared with Black patients with HF with cognitive impairment and Medicare/Medicaid (P < .05). Medicare/Medicaid was associated with a higher frequency of 30-day readmission and a faster time-to-readmission. CONCLUSIONS: Patients with HF with cognitive impairment and Medicare/Medicaid insurance reported lower self-care confidence and more likely to be readmitted within 30 days.

Trends in NIH-funding to schools of nursing in the last 17 years.

BACKGROUND: Growing clinical demands, faculty retirements, fewer PhD-prepared graduates, and funding instability are challenges for nursing science. PURPOSE: The purpose of this analysis was to investigate National Institutes of Health (NIH) funding patterns in schools of nursing (SONs). METHODS: Data were extracted from the Blue Ridge Institute for Medical Research between 2006 and 2022. Growth modeling examined changes in funding over time between private and public SONs. DISCUSSION: In the last 17 years, NIH funding for SONs has risen nearly 25% but remains only 1% of the total NIH budget for extramural research. Overall, 109 (75%) of the SONs were public and 36 (25%) were private institutions. Regarding geography, 90% of the States received NIH funding except six: ID, ME, MS, NH, VT, and WY. Private SONs consistently received more funding than public SONs but the difference was only statistically significant in 2022. CONCLUSION: NIH funding has significantly increased to SONs, there is better geographic distribution but a funding disparity exists between public and private SONs.

The Use of Interactive Technology to Improve Student Accuracy on Electrocardiographic Interpretation.

ABSTRACT: Electrocardiography (ECG) instruction relies heavily on memorization of interpretation rules and lacks opportunities for hands-on practice. Consequently, nursing students struggle with ECG interpretation. In an online undergradute nursing course, we implemented interactive technology to facilitate kinesthetic pedagogy. Accuracy was evaluated at midterm and during final assessments by two experts using a standardized rubric. Students who engaged with interactive technology at both assessments demonstrated consistent accuracy of ECG interpretation; students who did not failed to demonstrate consistent accuracy with ECG interpretation. Incorporating interactive technology to facilitate psychomotor learning may be essential in improving the accuracy of ECG interpretation.

Delays in Door-to-Diuretic Time and 1-Year Mortality Among Patients With Heart Failure.

BACKGROUND: Achieving prompt euvolemic state in heart failure (HF) is associated with reduced mortality. Time-sensitive metrics such as door-to-diuretic time , or the time between presentation and administration of intravenous diuretics, may be an important facilitator of achieving a faster euvolemic state and reducing mortality. OBJECTIVE: The aim of this study was to investigate whether reduced door-to-diuretic time was associated with lower odds of death among hospitalized patients with HF. METHODS: A retrospective chart review of patients with HF admitted to a medical center was performed between 2020 and 2021. Inclusion criteria were an International Classification of Diseases, 10th Revision code for HF with positive Framingham Criteria and the use of intravenous bolus furosemide. Exclusion criteria included ventricular assist devices, dialysis, and ultrafiltration therapy. Data collected from the medical records included demographics, echocardiography, staff notes, and medications. The end point was 1-year all-cause mortality. Descriptive statistics, t tests or median test, and multivariate logistic regression were used to describe the sample, evaluate group differences, and determine odds of mortality, respectively. RESULTS: Among 160 charts from patients with HF (age, 70 ± 14.4 years; 52%, n = 83, male; 53%, n = 85, ischemic cardiomyopathy; 83%, n = 134, New York Heart Association classes III-IV), 30% (n = 48) died within 1 year. The median diuretic dose was 40 mg (interquartile range, 20 mg), with a median time of administration of 247 minutes (4.12 hours) (interquartile range, 294 minutes to 4.9 hours). After covariate adjustment, prolonged door-to-diuretic time more than doubled (2.22; 95% confidence interval, 1.03-4.8; P = .04) the odds of 1-year mortality. CONCLUSIONS: On the basis of this sample of charts from older highly symptomatic patients with HF, delayed door-to-diuretic time was associated with significantly greater odds of 1-year all-cause mortality.

Comparing an All-RN Unit to a Mixed-Skill Unit at a Hospital.

OBJECTIVE: The aim of this study was to assess the differences in patient complications as well as patient and staff satisfaction between a mixed-skill unit and an all-registered nurse (RN) unit. BACKGROUND: It is recognized that nursing care delivered by RNs results in better outcomes; however, more evidence is needed to support a change to an all-RN unit. METHODS: A mixed unit with RNs and unlicensed assistive personnel was compared with an all-RN unit. Each unit had similar resources. Patient complications and patient and staff satisfaction were measured. Patient complications were reported in terms of 1,000 patient days over the study period to minimize noise fluctuations; t test and χ compared means and frequencies, respectively. RESULTS: The all-RN unit had a lower prevalence of patient complications. Patients reported better pain management, and nurse explanation, and reported higher satisfaction on the all-RN unit. CONCLUSIONS: An all-RN unit provided superior outcomes compared with a mixed-skill unit without additional costs.

Obesity and hypertension contribute to prolong QRS complex duration among middle-aged adults.

BACKGROUND: Obesity and hypertension are comorbid diseases, which influence cardiac structure, and are associated with increased risk for cardiovascular events. The QRS duration (QRSd) reflects ventricular depolarization, and increased QRSd is associated with poor cardiovascular outcomes. QRS duration may be influenced by obesity and HTN, and reflect the increased risk factor for poor cardiovascular outcomes. The purpose of this analysis was to assess the relations between obesity, hypertension, and the interaction between them on QRSd. METHODS: In this secondary data analysis, firefighters without documented cardiovascular disease in normal sinus rhythm were included. Twelve-lead 24-hr ECG Holter monitors measured mean QRSd. Body mass index (BMI) and resting blood pressure (BP) were measured and categorized. Univariate linear regression models were produced using BMI, BP, and the interaction between BMI and BP as factors associated with QRSd. Multivariate models adjusting for multiple covariates were also produced. RESULTS: Seventy-seven firefighters were included and most (89.4%) were overweight or obese. After covariate adjustment, BMI (p = 0.028), BMI categorization (p = 0.020), and the interaction between BMI and systolic BP (p = 0.021) were associated with prolong QRSd. CONCLUSIONS: Increased BMI and an interaction between BMI and systolic BP were independently associated with prolongation of the QRS complex. Determination of the underlying cardiac structures responsible prolongation of the QRSd is recommended for further research.

Widened QRS-T Angle May Be a Measure of Poor Ventricular Stretch During Exercise Among On-duty Firefighters.

BACKGROUND: The spatial QRS-T angle is a measure of repolarization heterogeneity and may be a predictor of poor ventricular health. It is unknown whether a relationship exists between QRS-T angle and blood pressure (BP) during exercise. OBJECTIVE: The purpose of this study was to evaluate the potential relationship between QRS-T angle and BP during exercise, which may be indicative of ventricular stretch. METHODS: Ambulatory 12-lead 24-hour Holter electrocardiographic monitoring for QRS-T angle measurement was followed by exercise testing with BP (mm Hg) recordings taken preexercise, maximum achieved BP during exercise, and 2 minutes postexercise. Blood pressure recovery was calculated by subtracting the maximal and 2-minute postexercise BPs. Means (± standard deviation) and percentages are presented. Pearson correlations (r) among all QRS-T angles and all BP measures were performed. One-way analysis of variance was conducted on classification of QRS-T angle and all BP measures. RESULTS: One hundred eleven firefighters (95.5% male; mean age, 44 years) were included in this analysis. Twenty-seven percent of the firefighters had either a borderline (100°-139°) or widened (≥140°) QRS-T angle. Although the analysis of variance was not statistically significant, a near-statistically significant negative correlation existed between QRS-T angle and maximum diastolic BP (r = -0.190, P = .05), and a statistically significant relationship existed between QRS-T angle and postexercise diastolic BP (r = -0.261, P = .008). CONCLUSIONS: A negative correlation existed between QRS-T angle and maximal diastolic BP and postexercise diastolic BP. Lower maximum diastolic BP during and after exercise may be a sign of poor ventricular stretch. A widened spatial QRS-T angle may represent poor ventricular stretch.

A Scoping Review of Varying Mobile Electrocardiographic Devices.

The electrocardiogram (ECG) can now be measured using mobile devices. Mobile ECG devices, which are defined as devices capable of recording and transmitting non-standard ECGs, offer numerous advantages such as cost-effectiveness and being user-friendly. Mobile ECG can also extend recording lengths (e.g., 2 days, 14 days), which is necessary to capture important intermittent events (e.g., cardiac arrhythmias) and evaluate prognostic risk markers (e.g., prolonged corrected QT (QTc) interval). Some mobile ECG devices can even connect to broadband networks allowing patients to remotely transmit their ECG to a clinician. This article systematically examines different mobile ECG devices used in prior studies and provides a detailed assessment of five diverse yet commonly used mobile ECG devices: AliveCor KardiaMobile; AliveCor KardiaMobile 6L; iRhythm ZioPatch; Apple Smartwatch ECG; and CardioSecur System. These mobile ECG devices are diverse in the number of leads measured and the duration of monitoring. Similar to their diversity, there has been a wide range of clinical applications of mobile ECG devices. Despite significant progress, questions regarding data quality, and clinican and patient acceptance and compliance persist.

Association Between Serum Albumin and the Length of Hospital Stay Among Patients With Acute Heart Failure.

Introduction: Albumin plays a vital role in improving osmotic pressure and hemodynamics. A lower serum albumin level may cause pulmonary congestion and edema and contribute to myocardial dysfunction, diuresis resistance, and fluid retention in acute heart failure. Hypothesis: We hypothesized that AHF patients with normal serum albumin have shorter hospital stays. Methods: Using Electronic Medical Records, patients admitted from May 2020 through May 2021 aged >18, ICD-10, and positive Framingham Heart Failure Diagnostic Criteria were included. We excluded patients without albumin records and eGFRs less than 30 mL/min/1.73 m2. Prolonged hospitalization was defined as >8 days of hospitalization. Results: During index emergency department visits, patients were symptomatic (New York Heart Association), aged median of 70 years (Interquartile range (IQR) 18), 59% (n = 103) were male, predominantly White (73%, n = 128), and had a high Charleston Comorbidity index score [5, IQR (4-7)]. Nearly one-fourth (23%, n = 41) of the patients had <3.5 g/dL albumin levels. The median length of hospital stay was eight days (IQR of 11). Comparing differences between lengths of hospital stays (<8 vs. >8 days), there was different serum albumin (3.9 + 0.48 vs. 3.6 + 0.53, p < .001) and left ventricular ejection fraction (45% (range 26-63) versus 30% (range 24-48), p = .004). An increased serum albumin decreased prolonged hospitalization (odds ratio (OR), 0.28; 95% confidence interval (CI), 0.14-0.55, p = <0.001). Patients in the lower albumin group had higher NT-proBNP (median: 8521 (range 2025-9134) versus 5147 (range 2966-14,795) pg/ml, p = .007) and delay in administering intravenous diuretics (391 (167-964) minutes versus 271 (range 157-533) minutes, p = .02). Conclusion: Hypoalbuminemia is strongly associated with prolonged hospitalization. Timely and effective diuretic therapy may reduce hospital stay durations, particularly with albumin supplementation.

The Effect of Mandatory Fitness Requirements on Cardiovascular Events: A State-by-State Analysis Using a National Database.

BACKGROUND: Cardiovascular events are known to be the leading cause of death among on-duty firefighters. Implementing fitness standards may help reduce the incidence of cardiovascular deaths; however, standards vary between firefighter type and states. We aimed to investigate the rate of cardiovascular events among firefighters across states. METHODS: Using publicly available data from the United States Fire Administration, we explored the rates of cardiovascular deaths between firefighter type (e.g., career, volunteer, and wildland) and state. Specifically, we examined rates of cardiovascular deaths between California and Tennessee, which have fitness standards for all firefighters, and New York, which does not have fitness standards for volunteer firefighters. We used descriptive statistics and trend analysis to examine the data. FINDINGS: Most cardiovascular events occur among volunteer firefighters (60.6%, n = 877). Volunteer firefighters had 7.5 (95% CI = [4.8, 11.7], p < .001) greater odds of cardiovascular events compared to wildland firefighters, who had the lowest incidence of cardiovascular events (1.7%, n = 24). New York reported the most cardiovascular events (n = 161), primarily among volunteer firefighters (73.9%, n = 119). After the passage of legislation mandating fitness standards in California, a downtrend in the number of volunteer firefighter fatalities is observed. However, a null effect was observed in Tennessee after the passage of similar fitness standards as in California. CONCLUSIONS/APPLICATIONS TO PRACTICE: Volunteer firefighters are significantly more likely to die of a cardiovascular event than career and wildland firefighters, both of which have stricter fitness standards. However, the effect of legislation mandating stricter fitness standards among volunteers did not produce a clear benefit for preventing fatalities. Nurses need to promote cardiovascular health among volunteer firefighters.

Estimating Ejection Fraction from the 12 Lead ECG among Patients with Acute Heart Failure.

Background: Identifying patients with low left ventricular ejection fraction (LVEF) in the emergency department using an electrocardiogram (ECG) may optimize acute heart failure (AHF) management. We aimed to assess the efficacy of 527 automated 12-lead ECG features for estimating LVEF among patients with AHF. Method: Medical records of patients >18 years old and AHF-related ICD codes, demographics, LVEF %, comorbidities, and medication were analyzed. Least Absolute Shrinkage and Selection Operator (LASSO) identified important ECG features and evaluated performance. Results: Among 851 patients, the mean age was 74 years (IQR:11), male 56% (n=478), and the median body mass index was 29 kg/m2 (IQR:1.8). A total of 914 echocardiograms and ECGs were matched; the time between ECG-Echocardiogram was 9 hours (IQR of 9 hours); ≤30% LVEF (16.45%, n=140). Lasso demonstrated 42 ECG features important for estimating LVEF ≤30%. The predictive model of LVEF ≤30% demonstrated an area under the curve (AUC) of 0.86, a 95% confidence interval (CI) of 0.83 to 0.89, a specificity of 54% (50% to 57%), and a sensitivity of 91 (95% CI: 88% to 96%), accuracy 60% (95% CI:60 % to 63%) and, negative predictive value of 95%. Conclusions: An explainable machine learning model with physiologically feasible predictors may be useful in screening patients with low LVEF in AHF.

Correlates of Autonomic Function, Hemodynamics, and Physical Activity Performance During Exercise Stress Testing Among Firefighters.

BACKGROUND: Autonomic dysfunction is an important propagator of cardiometabolic disease and can be measured using multiple metrics such as heart rate variability (HRV) and heart rate recovery (HRR). The relationships between HRV and HRR have not been fully examined, nor have the relationships between HRV, HRR, and other physiological measures linked to cardiometabolic disease (e.g., blood pressure recovery). Evaluation of these additional relationships may provide new insights into the association between autonomic function and cardiometabolic disease especially among high-risk groups like firefighters. METHODS: 92 firefighters (96% male, 81% white) without overt cardiovascular disease underwent exercise testing with continuous heart rate (HR) and blood pressure (BP) monitoring. HRR was the difference between maximal HR and HR 1-minute post-exercise; BP recovery (BPR) was the difference between maximal BP and BP 2-minute post-exercise. Afterwards, participants underwent 24-hour electrocardiographic monitoring to measure HRV. Unadjusted Spearman correlations and adjusted partial Spearman correlations were computed. Between group analyses were also conducted with Kruskal-Wallis test. RESULTS: Associations between HRV and HRR poorly converged (RMSSD and HRR, unadjusted = 0.235; adjusted = 0.144). SDNN Index exhibited the strongest association with parasympathetic tone exhibited by overall lower HRs (unadjusted = -0.600; adjusted = -0.631). HRR demonstrated stronger associations with systolic and diastolic BP responses during exercise (SBP Recovery unadjusted = 0.267; adjusted = 0.297; DBP Recovery unadjusted = -0.276; adjusted = -0.232). CONCLUSIONS: Overall, while HRV metrics converged and were associated with lower resting heart rates, HRV and HRR poorly converged. Interestingly, HRR was related with measures of hemodynamics indicating a potential relationship with vascular function during both maximal exercise and exercise recovery.

Secondary electrocardiographic stratification of NSTEMI to identify an acutely occluded culprit artery.

In the United States, approximately 720 000 adults will experience a myocardial infarction (MI) every year. The 12-lead electrocardiogram (ECG) is quintessential for the classification of a MI. About 30% of all MIs exhibit ST-segment elevation on the 12-lead ECG and is therefore classified as an ST-Elevation Myocardial Infarction (STEMI), which is treated emergently with percutaneous coronary intervention to restore blood flow. However, in the remaining 70% of MIs, the 12-lead ECG lacks ST-segment elevation and instead exhibits a motley of changes, including ST-segment depression, T-wave inversion, or, in up to 20% of patients, have no changes whatsoever; as such, these MIs are classified as a Non-ST Elevation Myocardial Infarction (NSTEMI). Of this larger classification of MIs, 33% of NSTEMI actually have an occlusion of the culprit artery consistent with a Type I MI . This is a serious clinical problem because NSTEMI with an occluded culprit artery have similar myocardial damage like STEMI and are more likely to suffer from adverse outcomes compared to NSTEMI without an occluded culprit artery. In this review article, we review the extant literature on NSTEMI with an occluded culprit artery. Afterward, we generate and discuss hypotheses for the absence of ST-segment elevation on the 12-lead ECG: (1) transient occlusion (2) collateral blood flow and chronically occluded artery and (3) ECG-silent myocardial regions. Lastly, we describe and define novel ECG features that are associated with an occluded culprit artery in NSTEMI which include T-wave morphology abnormalities and novel markers of ventricular repolarization heterogeneity.

Implementing interactive technology to teach electrocardiographic interpretation online.

BACKGROUND: Nurses need to accurately interpret electrocardiography (ECG) in order to intervene appropriately and quickly. Unfortunately, nurses struggle with ECG interpretation. PROBLEM: One reason for poor ECG interpretation is the lack of kinesthetic pedagogy on properly measuring ECG intervals and durations. Proper measurement of ECG intervals and durations can help nurses accurately interpret the ECG. This manuscript describes the use of interactive technology to develop the skills for measuring ECG intervals and durations for ECG interpretation in an online ECG course. APPROACH: Using constructivist theory, faculty implemented interactive technology (e.g. tablet and E-Pencil) to enable students to measure ECG intervals and durations. Students utilized a checklist to systematically analyze the ECG. The accuracy of ECG interpretation, student satisfaction, and student confidence were assessed at mid-term and final assessments. OUTCOMES: Accuracy of ECG interpretation increased among students who engaged with the interactive technology. Students reported satisfaction or high satisfaction with the overall course as well as with the interactive technology. Many students faced technical challenges which is an area of improvement. CONCLUSIONS: Despite technical challenges, integration of interactive technology into an online ECG course resulted in greater accuracy of ECG interpretation, high satisfaction, and improved confidence.

Severity of Myocardial Ischemia Is Related to Career Length Rather Than Age Among Professional Firefighters.

BACKGROUND: Ischemic heart disease (IHD) is the major cause of duty-related fatalities in the fire service. Age and career length are not only important risk factors associated with IHD, but are also highly correlated. The aim of this secondary analyses was to assess the relationship between age, career length, and IHD, based on ischemic severity, to identify whether age or career length had a stronger relationship to IHD. METHODS: This was a secondary, correlational analysis of on-duty firefighters without known cardiovascular or respiratory disease who underwent exercise treadmill testing with 12-lead electrocardiography. Ischemia was defined based on current guidelines. Maximum ST-segment depression was measured to determine IHD ischemic severity. Age, years of employment, demographics, weight, blood pressure were recorded. Multiple correlations were computed between age, career length, and IHD. FINDINGS: Twenty-two firefighters were included (96% male, 82% White, 82% overweight or obese, 77% hypertensive). The partial correlation between maximum ST-segment depression and age controlled for career length was not significant (r = -.392, p = .079). The partial correlation between maximum ST-segment depression and career length controlled for age was statistically significant (r = .466, p = .033). CONCLUSION/APPLICATION TO PRACTICE: Career length, not age, moderately correlates with IHD ischemic severity among firefighters. Career length is a proxy measure of occupational exposures which contributes to IHD. When assessing IHD risk in firefighters, health practitioners should consider incorporating the occupational exposure history (i.e., career length) in addition to age when providing risk reduction services.

Low voltage on the 12-lead ECG: A warning sign.

A 12-lead ECG showing low voltage should be a red flag to providers; it can be caused by several serious conditions. This clinical case describes how an NP correctly treated a patient with low voltage on an ECG by discerning and managing the underlying causes.