Do you hear what you see? Utilizing phonocardiography to enhance proficiency in cardiac auscultation

INTRODUCTION

Cardiac auscultation skills have proven difficult to train and maintain. The authors investigated whether using phonocardiograms as visual adjuncts to audio cases improved first-year medical students' cardiac auscultation performance.

METHODS

The authors randomized 135 first-year medical students using an email referral link in 2018 and 2019 to train using audio-only cases (audio group) or audio with phonocardiogram tracings (combined group). Training included 7 cases with normal and abnormal auscultation findings. The assessment included feature identification and diagnostic accuracy using 14 audio-only cases, 7 presented during training, and 7 alternate versions of the same diagnoses. The assessment-administered immediately after training and repeated 7 days later-prompted participants to identify the key features and diagnoses for 14 audio-only cases. Key feature scores and diagnostic accuracy were compared between groups using repeated measures ANOVA.

RESULTS

Mean key feature scores were statistically significantly higher in the combined group (70%, 95% CI 67-75%) compared to the audio group (61%, 95% CI 56-66%) (F(1,116) = 6.144, p = 0.015, d_s = 0.45). Similarly, mean diagnostic accuracy in the combined group (68%, 95% CI 62-73%) was significantly higher than the audio group, although with small effect size (59%, 95% CI 54-65%) (F(1,116) = 4.548, p = 0.035, d_s = 0.40). Time on task for the assessment and prior auscultation experience did not significantly impact performance on either measure.

DISCUSSION

The addition of phonocardiograms to supplement cardiac auscultation training improves diagnostic accuracy and heart sound feature identification amongst novice students compared to training with audio alone.

Treatment and outcomes of first troponin-negative non-ST-segment elevation myocardial infarction

Little is known about non-ST-segment elevation myocardial infarction (MI) in patients with an initial negative troponin finding. The aim of this study was to determine in post hoc analysis of a large regional medical center presenting clinical characteristics, treatment differences, and in-hospital and 6-month outcomes of first troponin-negative MI (FTNMI). In this study, 659 of 1,855 consecutive patients with non-ST-segment elevation MI (35.5%) were classified as having FTNMI. In-hospital cardiac catheterization rates were similar between the 2 groups (70.1% vs 71.5%, p = 0.53) In hospital, patients with FTNMI were less likely to receive statins (48.9% vs 59.9%, p <0.001). On discharge, patients with FTNMI were less likely to be on clopidogrel (53.1% vs 59.0%, p = 0.019) and statins (67.7% vs 75.2%, p <0.001). At 6-month follow-up, patients with FTNMI were less likely to be on clopidogrel (43.5% vs 55.2%, p = 0.01) In-hospital recurrent ischemia was 2 times as common in FTNMI (20.1% vs 11.5%, p <0.001). There were no differences, however, in congestive heart failure, cardiogenic shock, cardiac arrest, stroke, or death in hospital. At 6 months, patients with FTNMI were 2 times as likely to have had recurrent MI (12.0% vs 6.6%, p <0.001). Combined end points of death at 6 months, MI, stroke, and rehospitalization were higher for FTNMI (47.7% vs 40.9%, p = 0.017); however, this was due to higher rates of recurrent MI. In conclusion, patients with FTNMI received less aggressive pharmacotherapy and were 2 times as likely to have recurrent MI at 6 months. FTNMI is common and represents a clinical entity that should be treated more aggressively.

Abstract 322: Duration of Resuscitation Efforts for In-Hospital Cardiac Arrest by Predicted Survival Outcomes: Insights from Get With The Guidelines - Resuscitation

Background. The duration of cardiopulmonary resuscitation has implications for patient survival of in-hospital cardiac arrest (IHCA). However, the duration of resuscitation efforts should be balanced against the probability of patient survival. It is unknown whether the duration of attempted resuscitation for IHCA is associated with the predicted probability of patient survival.

Methods. We identified 40,563 non-survivors of resuscitation efforts for IHCA within the Get With The Guidelines [[Unable to Display Character: &#8211;]] Resuscitation Registry between 2000 and 2012. In these patients, we determined the pre-arrest predicted probability of survival to discharge with good neurologic status using the previously validated GO-FAR score. Using this tool, predicted survival was categorized into very low (<1%), low (1-3%), average (>3% to 15%), and above average (>15%). Duration of resuscitation efforts were measured in minutes from the onset of cardiac arrest to termination of resuscitation efforts. We then compared the duration of resuscitation efforts by predicted survival categories.

Results. Among 40,563 non-survivors of IHCA, the predicted survival to discharge was very low in 4801 (11.8%) patients, low in 8889 (21.9%), average in 19910 (49.1%) patients, and above average in 6963 (17.2%) patients. The median duration of attempted resuscitation was 19 minutes and the duration of attempted resuscitation was longer in non-survivors with a higher predicted probability of survival (median duration in minutes from very low to above average categories of predicted survival, 16 vs 17 vs 20 vs 23, P<.001). However, the duration of attempted resuscitation was often discordant with predicted survival (Figure), including shorter than median duration of attempted resuscitation in 31.9% of patients with above average predicted survival.

Conclusions. In a national cohort of non-survivors of IHCA, the duration of attempted resuscitation correlated overall with predicted arrest survival. However, nearly a third of patients with above average predicted survival received shorter than average attempted resuscitation efforts. Emphasis on an adequate duration of attempted resuscitation, particularly among patients with better than average predicted outcomes, may have implications for improving in-hospital cardiac arrest outcomes.

Trends in syncope testing and admissions in the USA from 2006 through 2019

INTRODUCTION

Syncope is common, with bimodal distribution through life, peaking in adolescence and in the elderly, and overall increases in incidence with age among both men and women. In this context, syncope-related visits to emergency departments (ED), hospitalizations, and testing are a significant healthcare cost burden. Ultimately, understanding the volume of testing types and settings of syncope encounters may aid in more effective healthcare utilization and high value care for this patient population.

METHODS

Data for this study were collected from the Truven Health Analytics MarketScan Database from 2006 to 2019. This database contains both commercially insured patients and those with Medicare coverage. Patients with the diagnosis of syncope were identified using International Classification of Diseases (ICD)-9 and -10 codes. We assessed the incidence of various tests for syncope evaluation and ED disposition for the study period.

RESULTS

The incidence of syncope among the study cohort rose from nine per 1000 patients to 13 per 1000 patients during the study period. The incidence of testing for syncope among multiple domains (neurologic, cardiac, blood testing) decreased in some categories, but routine testing remained prevalent. Women had a significantly lower incidence of testing in most testing domains. Discharge rate from the ED for patients presenting with syncope remained stable during the study period. However, admission rate to the hospital for those aged > 65 years increased during the study time.

CONCLUSION

Testing and admissions for syncope remain prevalent and are drivers of healthcare-associated costs. There is a clear need for further work in developing a focused approach in the evaluation of syncope patients in order to mitigate healthcare costs and improve outcomes.