Point of Care Ultrasound (POCUS) in the Management of Heart Failure: A Narrative Review.

Assessing for volume overload is a key component of both short and long-term management of heart failure patients. Physical examination findings are neither sensitive nor specific for detecting congestion, and subclinical congestion may not be evident at the time of examination. Point of care ultrasound (POCUS) is an efficient and non-invasive way to assess heart failure patients for volume overload. The aim of our narrative review is to summarize how each of the following ultrasound modalities can be used to assess for congestion in the heart failure population: 2D and Doppler echocardiography, lung ultrasound, inferior vena cava ultrasound, internal jugular vein ultrasound, and venous excess grading. While each of these modalities has their limitations, their use in the acute and outpatient space offers the potential to reduce heart failure readmissions and mortality.

Utility of native T1 mapping and myocardial extracellular volume fraction in patients with nonischemic dilated cardiomyopathy: A systematic review and meta-analysis.

Background: Cardiac magnetic resonance imaging (CMR) based T1 mapping and extracellular volume fraction (ECV) are powerful tools for identifying myocardial fibrosis. This systematic review and meta-analysis aims to characterize the utility of native T1 mapping and ECV in patients with non-ischemic cardiomyopathy (NICM) and to clarify the prognostic significance of elevated values. Methods: A literature search was conducted for studies reporting on use of CMR-based native T1 mapping and ECV measurement in NICM patients and their association with major adverse cardiac events (MACE), ventricular arrhythmias (VAs), and left ventricular reverse remodeling (LVRR). Databases searched included: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. Results: Native T1 and ECV were significantly higher in NICM patients compared to controls (MD 78.80, 95 % CI 50.00, 107.59; p < 0.01; MD 5.86, 95 % CI 4.55, 7.16; p < 0.01). NICM patients who experienced MACE had higher native T1 and ECV (MD 52.87, 95 % CI 26.59, 79.15; p < 0.01; MD 6.03, 95 % CI 3.79, 8.26; p < 0.01). There was a non-statistically significant trend toward higher native T1 time in NICM patients who experienced VAs. NICM patients who were poor treatment responders had higher baseline native T1 and ECV (MD 40.58, 95 % CI 12.90, 68.25; p < 0.01; MD 3.29, 95 % CI 2.25, 4.33; p < 0.01). Conclusions: CMR-based native T1 and ECV quantification may be useful tools for risk stratification of patients with NICM. They may provide additional diagnostic utility in combination with LGE, which poorly characterizes fibrosis in patients with diffuse myocardial involvement.

Outcomes and Medical Therapy in Myocardial Infarction With Nonobstructive Coronary Arteries: A Systematic Review and Meta-Analysis.

Myocardial infarction with nonobstructive coronary arteries (MINOCAs) is a disease that has been poorly characterized with unclear clinical and therapeutic outcomes. The association of medical therapy with cardiovascular outcomes in patients with MINOCA has been inadequately assessed. The purpose of this meta-analysis is to evaluate the association of MINOCA at risk of adverse cardiovascular outcomes as compared with myocardial infarction with coronary artery disease (MICAD) and the efficacy of medical therapy in reducing the risk of adverse outcomes. A literature search was conducted for studies reporting on the association of MINOCA at risk of adverse outcomes as compared with MICAD. A literature search was also conducted for studies reporting on the association of medical therapy at risk of adverse outcomes in patients with MINOCA. A total of 29 studies with 893,134 participants met inclusion criteria comparing MINOCA to MICAD. Patients with MINOCA had a significantly lower risk of adverse outcomes as compared with MICAD. Nine studies with 27,731 MINOCA patients met inclusion criteria for evaluating the utility of medical therapy. Medical therapy did not significantly reduce risk of MACE; however, there was a trend toward lower risk in patients treated with ß blockers. In conclusion, our results suggest that MINOCA is associated with a lower risk of in-hospital and long-term adverse outcomes compared with MICAD. Standard medical therapy is not associated with a lower risk of adverse cardiovascular outcomes in patients with MINOCA. Additional high-quality studies are required to evaluate the utility of specific medication classes for the treatment of specific etiologies of MINOCA.

The Use of Quality Improvement Interventions in Reducing Rarely Appropriate Cardiac Imaging.

The use of cardiac imaging has become increasingly prevalent over the last decade. Approximately 10% to 15% of noninvasive cardiac imaging is ordered for rarely appropriate indications. The appropriate use criteria (AUC) for cardiac imaging were issued to decrease unnecessary testing and reduce health care costs. However, it remains unclear whether these efforts have been successful. This meta-analysis evaluates whether AUC quality improvement (QI) interventions effectively reduce inappropriate cardiac imaging. Databases were searched for studies reporting QI intervention effect aiming to reduce rarely appropriate noninvasive cardiac imaging based on AUC. Imaging modalities assessed include transthoracic echocardiography, stress echocardiography, and myocardial perfusion imaging. We searched Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL. The primary end point was a decrease of rarely appropriate testing. The search was not restricted to time or publication status. The literature search identified 2,391 possible studies, 13 studies and 26,557 patients were included. Mean follow-up was 12 months (1 to 60 months). QI interventions were statistically significant in reducing rarely appropriate tests after the intervention compared with the control group (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.41 to 0.64, p <0.01). The QI interventions were also assessed for persistence based on short-term (<3 months) and long-term (>3 months) efficacy. Both the short-term effect and long-term effect were persistent (OR 0.6, 95% CI 0.47 to 0.77, p <0.01 and OR 0.47, 95% CI 0.37 to 0.61, p <0.01, respectively). AUC QI interventions are associated with the successful decrease of inappropriate noninvasive cardiac testing with these effects persisting over time.

The use of quality improvement interventions in reducing rarely appropriate echocardiograms: A systematic review and meta-analysis.

BACKGROUND: The volume of cardiac imaging continues to increase, with many tests performed for rarely appropriate indications. Appropriate use criteria (AUC) documents were published by the American Society of Echocardiography and American College of Cardiology, with quality improvement (QI) interventions developed in various institutions. However, the effectiveness of these interventions has not been assessed in a systematic fashion. METHODS: We searched Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL for studies reporting association between cardiac imaging, AUC and QI. The search was not restricted to time or publication status. We selected studies assessing the effect of QI interventions on performance of rarely appropriate echocardiograms. The primary endpoint was reduction of rarely appropriate testing. RESULTS: Nine studies with 22,070 patients met inclusion criteria. Mean follow up was 15 months (1-60 months). QI interventions resulted in statistically significant reduction in rarely appropriate tests (OR 0.52, 95% CI: .41-.66; p < .01). The effects of QI interventions were analyzed over both the short (<3 months) and long-term (>3 months) post intervention (OR 0.62, 95% CI: .49-.79; p < .01 in the short term, and OR 0.47, 95% CI: .35-.62; p < .01 in the long term). Subgroup analysis of the type of intervention, classified as education tools or decision support tools showed both significantly reduced rarely appropriate testing (OR 0.54, 95% CI: .41-.73; p < .01; OR .47, 95% CI: .36-.61; p < .01). Adding a feedback tool did not change the effect compared to not using a feedback tool (OR 0.49 vs. 0.57, 95% CI: .36-.68 vs. 39-.84; p > .05). CONCLUSION: QI interventions are associated with a significant reduction in performance of rarely appropriate echocardiography testing, the effects of which persist over time. Both education and decision support tools were effective, while adding feedback tools did not result in further reduction of ordering rarely appropriate studies.

Postpartum Cardiovascular Outcomes Among Women With Heart Disease from A Nationwide Study.

There is limited data on postpartum maternal postpartum major adverse cardiovascular and cerebrovascular events (MACCE) among women with heart disease (HD) in the US. Therefore, we aimed to determine the prevalence and predictors of MACCE in the US. The Nationwide Readmissions Databases (2010 to 2014) were screened for patients with and without HD undergoing delivery. HD subtypes included cardiomyopathy (CDM), congenital heart disease, valvular heart disease, and pulmonary hypertension. Rates and reasons of 42-day readmission were determined using weighted national estimates. Independent predictors of postpartum MACCE were determined using multivariable logistic regression for complex survey data. We found among 15,273,247 patients hospitalized for delivery, 33,827 had HD (CDM 22.78%, congenital heart disease 45.98%, valvular heart disease 24.81%, and pulmonary hypertension 6.41%). Of these, 5.2% of HD patients and 1.4% of No HD were readmitted. MACCE was higher in HD vs No HD (2.68% vs 0.17%, p <0.0001). Median time to MACCE was 5.6 days (interquartile range 3 to 15 days). CDM had >10% readmission at 42 days. Among HD patients, cardiovascular, infectious, hypertensive syndromes, and complications of pregnancy were the most common reasons for 42-day readmission. MACCE predictors in women with HD included HD subtype, age, insurance status, obesity, eclampsia, postpartum hemorrhage, MACCE during delivery, preterm delivery, and thrombotic complications. In conclusion, among a nationwide analysis, postpartum MACCE was more common among patients with HD especially within 1 week of discharge from delivery. Predictors can be easily screened for by clinicians, including presence of any HD, hypertensive syndromes, age, obesity, and obstetrical events during index hospitalization.

Management of Saphenous Vein Graft Disease in Patients with Prior Coronary Artery Bypass Surgery.

PURPOSE OF REVIEW: In this review, we summarize the pathogenesis of saphenous venous graft (SVG) failure in patients following coronary artery bypass graft (CABG) surgery. We also provide an update on various aspects of prevention and management of SVG failure. RECENT FINDINGS: Application of perioperative measures and medical therapies to promote SVG patency is crucial to optimize clinical outcomes in patients following CABG. Percutaneous coronary intervention (PCI) of SVG disease is fraught with complications, with the highest risk being no-reflow and periprocedural myocardial infarction due to distal embolization of microemboli. Minimizing this risk with use of distal embolic protection when feasible and understanding the role of adjunctive pharmacotherapies is critical in reducing the risk of adverse cardiac events. The long-term patency of SVGs remains a contemporary challenge and is adversely affected by thrombotic occlusion, intimal fibrosis, and accelerated atherosclerosis. Prevention of SVG failure is multifactorial. Use of perioperative measures, medical therapies, and PCI techniques to promote SVG patency is vital to optimize outcomes in patients following CABG. Further prospective trials are needed to define the optimal medical and surgical therapy to maintain short- and long term SVG patency.

Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials.

BACKGROUND: Telemedicine, the use of telecommunications to deliver health services, expertise and information, is a promising but unproven tool for improving the quality of diabetes care. We summarized the effectiveness of different methods of telemedicine for the management of diabetes compared with usual care. METHODS: We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials databases (to November 2015) and reference lists of existing systematic reviews for randomized controlled trials (RCTs) comparing telemedicine with usual care for adults with diabetes. Two independent reviewers selected the studies and assessed risk of bias in the studies. The primary outcome was glycated hemoglobin (HbA1C) reported at 3 time points (≤ 3 mo, 4-12 mo and > 12 mo). Other outcomes were quality of life, mortality and episodes of hypoglycemia. Trials were pooled using randomeffects meta-analysis, and heterogeneity was quantified using the I2 statistic. RESULTS: From 3688 citations, we identified 111 eligible RCTs (n = 23 648). Telemedicine achieved significant but modest reductions in HbA1C in all 3 follow-up periods (difference in mean at ≤ 3 mo: -0.57%, 95% confidence interval [CI] -0.74% to -0.40% [39 trials]; at 4-12 mo: -0.28%, 95% CI -0.37% to -0.20% [87 trials]; and at > 12 mo: -0.26%, 95% CI -0.46% to -0.06% [5 trials]). Quantified heterogeneity (I2 statistic) was 75%, 69% and 58%, respectively. In meta-regression analyses, the effect of telemedicine on HbA1C appeared greatest in trials with higher HbA1C concentrations at baseline, in trials where providers used Web portals or text messaging to communicate with patients and in trials where telemedicine facilitated medication adjustment. Telemedicine had no convincing effect on quality of life, mortality or hypoglycemia. INTERPRETATION: Compared with usual care, the addition of telemedicine, especially systems that allowed medication adjustments with or without text messaging or a Web portal, improved HbA1C but not other clinically relevant outcomes among patients with diabetes.

Infarct Size, Shock, and Heart Failure: Does Reperfusion Strategy Matter in Early Presenting Patients With ST-Segment Elevation Myocardial Infarction?

BACKGROUND: A pharmacoinvasive (PI) strategy for early presenting ST-segment elevation myocardial infarction nominally reduced 30-day cardiogenic shock and congestive heart failure compared with primary percutaneous coronary intervention (PPCI). We evaluated whether infarct size (IS) was related to this finding. METHODS AND RESULTS: Using the peak cardiac biomarker in patients randomized to PI versus PPCI within the Strategic Reperfusion Early After Myocardial Infarction (STREAM) trial, IS was divided into 3 groups: small (≤2 times the upper limit normal [ULN]), medium (>2 to ≤5 times the upper limit normal) and large (>5 times the upper limit normal). The association between IS and 30-day shock and congestive heart failure was subsequently examined. Data on 1701 of 1892 (89.9%) patients randomized to PI (n=853, 50.1%) versus PPCI (n=848, 49.9%) within STREAM were evaluated. A higher proportion of PPCI patients had a large IS (PI versus PPCI: small, 49.8% versus 50.2%; medium, 56.9% versus 43.1%; large, 48.4% versus 51.6%; P=0.035), despite comparable intergroup ischemic times for each reperfusion strategy. As IS increased, a parallel increment in shock and congestive heart failure occurred in both treatment arms, except for the small IS group. The difference in shock and congestive heart failure in the small IS group (4.4% versus 11.6%, P=0.026) in favor of PI likely relates to higher rates of aborted myocardial infarction with the PI strategy (72.7% versus 54.3%, P=0.005). After adjustment, a trend favoring PI persisted in this subgroup (relative risk 0.40, 95% CI 0.15 to 1.06, P=0.064); no difference in treatment-related outcomes was evident in the other 2 groups. CONCLUSION: A PI strategy appears to alter the pattern of IS after ST-segment elevation myocardial infarction, resulting in more medium and fewer large infarcts compared with PPCI. Despite a comparable number of small infarcts, PI patients in this group had more aborted myocardial infarctions and less 30-day shock and congestive heart failure. CLINICAL TRIAL REGISTRATION: URL: http://ClinicalTrials.gov. Unique identifier: NCT00623623.