Physician perceptions of medication prescribing in heart failure: a scoping review.

INTRODUCTION: The swift uptake of new medications into clinical practice has many benefits, however slow uptake has been seen previously with other guideline-directed medical therapies (GDMT) in heart failure (HF). Sodium glucose co-transporter 2 inhibitors are a novel therapy in HF proven to be efficacious and will have beneficial clinical outcomes if prescribed. Understanding physician perspectives on prescribing GDMT in HF can help target strategies to bridge the gap between guidelines and practice. METHODS: The study followed the PRISMA guide for scoping reviews and the JBI Manual for scoping reviews. A search was conducted using EMBASE, Medline and PubMed databases in April 2024. Studies included were those using qualitative methods to assess physician perspectives towards prescribing any HF medication. Common themes were identified through thematic synthesis following the methods from Cochrane Training and using software MAXQDA Analysis Pro. RESULTS: 708 studies were found in the search, with 23 full studies included. The most pertinent barriers identified were concern for medication adverse effects, unclear role responsibilities between physicians of different specialties, patient comorbidities and unwillingness to alter therapies of stable patients. The most identified enablers included awareness of efficacy, influence from colleagues and the use of multi-media approaches for information dissemination. Perceptions were also found to change over time and vary among prescriber groups. CONCLUSIONS: Physicians perceive common barriers and enablers of prescribing GDMT in HF, despite differences in prescriber groups and time periods. The identified barriers and enablers may be targeted to improve implementation of GDMT into clinical practice.

Transcatheter Aortic Valve Therapy for Bicuspid Aortic Valve Stenosis.

Transcatheter aortic valve implantation (TAVI) has become first-line treatment for older adults with severe aortic stenosis (AS), however, patients with bicuspid aortic valve (BAV) have been traditionally excluded from randomised trials and guidelines. As familiarity and proficiency of TAVI operators have improved, case-series and observational data have demonstrated the feasibility of successful TAVI in bicuspid aortic valve aortic stenosis (BAV-AS), however, patients with BAV-AS have several distinct characteristics that influence the likelihood of TAVI success. This review aims to summarise the pathophysiology and classification of BAV, published safety data, anatomical challenges and procedural considerations essential for pre-procedural planning, patient selection and procedural success of TAVI in BAV.

An Opportunity to Seize From Low Hanging Fruits: Capitalising on Incidentally Reported Coronary Artery Calcification.

AIM: We investigated the prevalence of incidental coronary artery calcifications (CAC) from non-electrocardiogram (ECG)-gated computed tomography (CT) chest (both contrast and non-contrast) for inpatients. We also assessed for downstream investigation and statin prescription from the inpatient teams. Incidental CAC are frequent findings on non-ECG-gated CT chest. It is associated with adverse prognosis in multiple patient cohorts. METHOD: All non-ECG-gated CT chest done as inpatients from a single centre referred from 1 January 2022 to 31 December 2022 with reported incidental CAC were reviewed for inclusion. Patients who had a history of known coronary artery disease, history of coronary stent or bypass, and presence of cardiac devices were excluded. RESULTS: Total of 123 patients were included, making the prevalence 6.2% (123/1,980). The median age is 76 years (interquartile range 69-85) and predominantly male at 54.5%. The majority of CT chest done were contrasted scans (91.1%). Only 26.8% of CAC were reported on severity with visual quantification, with 7.3% each reported for both moderate and severe CAC. Only 2.4% of CAC were reported in the conclusion of the CT report. Most of these patients were asymptomatic (34.1%). A total of 20.3% of patients had further tests done. Inpatient hospital mortality was 8.1%. About 23.6% and 34.1% of patients were on aspirin and statin therapy respectively at baseline. There was only 1 patient (1.2%) who was prescribed with new statin therapy on discharge. CONCLUSION: Incidental CAC is prevalent in inpatient settings and remains under-recognised by ordering clinicians, with low prescription rate of statin therapy. Practice-changing measures to standardise reporting of incidental CAC is needed to identify patients with subclinical coronary disease and initiate preventive interventions.

Combined spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS): a case series.

BACKGROUND: Spontaneous Coronary Artery Dissection (SCAD) and Takotsubo Syndrome (TTS) are two different entities with several shared risk factors, but their management is different. They can co-exist in patients with chest pain which affects their management. We present two cases of combined SCAD and TTS in patients presented with chest pain. CASE PRESENTATION: Case 1: 80F admitted with typical chest pain and dynamic ECG changes on the background of known anxiety/depression and social stresses. Her coronary angiogram showed SCAD affecting distal LAD. The left ventriculogram (LV gram) showed apical ballooning consistent with Takotsubo Syndrome (TTS). Patient was discharged on aspirin as well as angiotensin receptor blocker (ARB). Case 2: 60F admitted with typical chest pain in the setting of emotional trauma on the background of known cardiovascular risk factors. She was found to have ST elevation in inferior leads with no reciprocal changes. Subsequently, coronary angiogram showed SCAD affecting mid-left anterior descending artery (LAD) with normal distal wrap around LAD. Her LV gram showed apical ballooning consistent with TTS. However, transthoracic echocardiogram showed akinetic left ventricular apex. She was discharged on aspirin as well as an ACE inhibitor and warfarin to prevent LV thrombus. CONCLUSIONS: SCAD and TTS can co-exist in patients with chest pain. It is important to identify SCAD in patients with TTS as it may affect their short as well as long-term management.

MINOCA: under recognized and affecting predominantly female patients-an Australian experience.

BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) is now being recognized as an important clinical entity with prognostic implications. There are limited data in relation to MINOCA in our local Australian settings. AIM: We investigated the prevalence, clinical characteristics, major adverse cardiovascular events (MACE), and 1-year mortality of patients with MINOCA at Peninsula Health. METHOD: A single-center retrospective study of all adult patients aged ≥ 18 years who underwent invasive angiography from January 2018 to June 2020 was identified from medical records. We included patients who met the definition of MINOCA as per the 2019 AHA Statement. A simple descriptive statistical analysis was performed. RESULTS: The prevalence of MINOCA at Peninsula Health was 10.9% (131/1199) with a median age of 62 (IQR 53-74). Female patients were predominant, comprising 64% (84/131) of these patients. Chest pain was the most common symptom in 92.3% (121/131) and 58.8% (77/131) had ECG changes. A total of 81% (106/131) had a normal left ventricular systolic function and 47% of patients (66/139) had no luminal disease on invasive angiography. A total of 15.9% (23/144) of patients with an initial working diagnosis of MINOCA were referred for CMR on discharge. MACE was 5.2% (6/115) over a median follow-up of 23 months. The all-cause mortality rate at 1 year was 0.7% (1/131). CONCLUSION: The clinical prevalence rate of MINOCA at Peninsula Health is 10.9% with a MACE of 5.2%. MINOCA is recognized and the low rate of additional testing could be improved given the female predominance and prognostic implications.