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Coviello A, Cirillo D, Vargas M, de Siena AU, Barone MS, Esposito F, Izzo A, Buonanno P, Volpe S, Stingone AG, Iacovazzo C. Preoperative Echocardiographic Unknown Valvopathy Evaluation in Elderly Patients Undergoing Neuraxial Anesthesia during Major Orthopedic Surgery: A Mono-Centric Retrospective Study. J Clin Med 2024; 13:3511. [PMID: 38930041 PMCID: PMC11204530 DOI: 10.3390/jcm13123511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/31/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Background: The assessment of cardiac risk is challenging for elderly patients undergoing major orthopedic surgery with preoperative functional limitations. Currently, no specific cardiac risk scores are available for these critical patients. Echocardiography may be a reliable and safe instrument for assessing cardiac risks in this population. This study aims to evaluate the potential benefits of echocardiography in elderly orthopedic patients, its impact on anesthesiologic management, and postoperative Major Adverse Cardiac Events (MACEs). Methods: This is a retrospective, one-arm, monocentric study conducted at ''Federico II'' Hospital-University of Naples-from January to December 2023, where 59 patients undergoing hip or knee revision surgery under neuraxial anesthesia were selected. The demographic data, the clinical history, and the results of preoperative Echocardiography screening (pEco-s) were collected. After extensive descriptive statistics, the χ2 test was used to compare the valvopathies and impaired Left Ventricular Function (iLVEF) prevalence before and after echocardiography screening and the incidence of postoperative MACE; a p-value < 0.05 was considered statistically significant. Results: The mean age was 72.5 ± 6.9, and the prevalence of cardiac risk factors was about 90%. The cumulative prevalence of iLVEF and valvopathy was higher after the screening (p < 0.001). The pEco-s diagnosed 25 new valvopathies: three of them were moderate-severe. No patients had MACE. Conclusions: pEco-s evaluation could discover unknown heart valve pathology; more studies are needed to understand if pEco-s could affect the anesthetic management of patients with functional limitations, preventing the incidence of MACE, and assessing its cost-effectiveness.
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Affiliation(s)
- Antonio Coviello
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II”—University of Naples, 80100 Naples, Italy; (A.C.); (M.V.); (A.U.d.S.); (M.S.B.); (F.E.); (P.B.); (S.V.); (A.G.S.); (C.I.)
| | - Dario Cirillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II”—University of Naples, 80100 Naples, Italy; (A.C.); (M.V.); (A.U.d.S.); (M.S.B.); (F.E.); (P.B.); (S.V.); (A.G.S.); (C.I.)
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II”—University of Naples, 80100 Naples, Italy; (A.C.); (M.V.); (A.U.d.S.); (M.S.B.); (F.E.); (P.B.); (S.V.); (A.G.S.); (C.I.)
| | - Andrea Uriel de Siena
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II”—University of Naples, 80100 Naples, Italy; (A.C.); (M.V.); (A.U.d.S.); (M.S.B.); (F.E.); (P.B.); (S.V.); (A.G.S.); (C.I.)
| | - Maria Silvia Barone
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II”—University of Naples, 80100 Naples, Italy; (A.C.); (M.V.); (A.U.d.S.); (M.S.B.); (F.E.); (P.B.); (S.V.); (A.G.S.); (C.I.)
| | - Francesco Esposito
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II”—University of Naples, 80100 Naples, Italy; (A.C.); (M.V.); (A.U.d.S.); (M.S.B.); (F.E.); (P.B.); (S.V.); (A.G.S.); (C.I.)
| | - Antonio Izzo
- Unit of Orthopedics and Traumatology, Department of Public Health, School of Medicine, “Federico II”—University of Naples, 80100 Naples, Italy;
| | - Pasquale Buonanno
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II”—University of Naples, 80100 Naples, Italy; (A.C.); (M.V.); (A.U.d.S.); (M.S.B.); (F.E.); (P.B.); (S.V.); (A.G.S.); (C.I.)
| | - Serena Volpe
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II”—University of Naples, 80100 Naples, Italy; (A.C.); (M.V.); (A.U.d.S.); (M.S.B.); (F.E.); (P.B.); (S.V.); (A.G.S.); (C.I.)
| | - Andrea Gabriele Stingone
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II”—University of Naples, 80100 Naples, Italy; (A.C.); (M.V.); (A.U.d.S.); (M.S.B.); (F.E.); (P.B.); (S.V.); (A.G.S.); (C.I.)
| | - Carmine Iacovazzo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II”—University of Naples, 80100 Naples, Italy; (A.C.); (M.V.); (A.U.d.S.); (M.S.B.); (F.E.); (P.B.); (S.V.); (A.G.S.); (C.I.)
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Elias M, Tateosian VS, Richman DC. What's New in Preoperative Cardiac Testing. Anesthesiol Clin 2024; 42:9-25. [PMID: 38278596 DOI: 10.1016/j.anclin.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
More than 300 million surgeries are performed annually worldwide. Patients are progressively aging and often have multiple comorbidities that put them at increased cardiovascular risk in the perioperative period. The United States published latest guidelines regarding preoperative cardiac evaluation and risk stratification for patients undergoing non-cardiac surgery in 2014. There are multiple risk stratification tools available that can help guide management. Furthermore, newer laboratory tests, such as preoperative NT-proBNP and high-sensitivity troponin assays, may aid in preventing and diagnosing perioperative myocardial injury.
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Affiliation(s)
- Murad Elias
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Health Sciences Center, Level 4, 101 Nicolls Road, Stony Brook, NY 11794-8480, USA.
| | - Vahé S Tateosian
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Health Sciences Center, Level 4, 101 Nicolls Road, Stony Brook, NY 11794-8480, USA
| | - Deborah C Richman
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Health Sciences Center, Level 4, 101 Nicolls Road, Stony Brook, NY 11794-8480, USA
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3
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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4
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Garbi M. Improving access to echocardiography for the detection and follow-up of heart valve disease in the UK. THE BRITISH JOURNAL OF CARDIOLOGY 2023; 30:10. [PMID: 38911691 PMCID: PMC11189158 DOI: 10.5837/bjc.2023.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Affiliation(s)
- Madalina Garbi
- President, British Heart Valve Society, and Consultant Cardiologist, Royal Papworth Hospital Royal Papworth Hospital NHS Foundation Trust, Papworth Road, Cambridge Biomedical Campus, Cambridge, CB2 0AY
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5
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Davidsen AH, Andersen S, Halvorsen PA, Schirmer H, Reierth E, Melbye H. Diagnostic accuracy of heart auscultation for detecting valve disease: a systematic review. BMJ Open 2023; 13:e068121. [PMID: 36963797 PMCID: PMC10040065 DOI: 10.1136/bmjopen-2022-068121] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
OBJECTIVE The objective of this study was to determine the diagnostic accuracy in detecting valvular heart disease (VHD) by heart auscultation, performed by medical doctors. DESIGN/METHODS A systematic literature search for diagnostic studies comparing heart auscultation to echocardiography or angiography, to evaluate VHD in adults, was performed in MEDLINE (1947-November 2021) and EMBASE (1947-November 2021). Two reviewers screened all references by title and abstract, to select studies to be included. Disagreements were resolved by consensus meetings. Reference lists of included studies were also screened. The results are presented as a narrative synthesis, and risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. MAIN OUTCOME MEASURES Sensitivity, specificity and likelihood ratios (LRs). RESULTS We found 23 articles meeting the inclusion criteria. Auscultation was compared with full echocardiography in 15 of the articles; pulsed Doppler was used as reference standard in 2 articles, while aortography and ventriculography was used in 5 articles. One article used point-of-care ultrasound. The articles were published from year 1967 to 2021. Sensitivity of auscultation ranged from 30% to 100%, and specificity ranged from 28% to 100%. LRs ranged from 1.35 to 26. Most of the included studies used cardiologists or internal medicine residents or specialists as auscultators, whereas two used general practitioners and two studied several different auscultators. CONCLUSION Sensitivity, specificity and LRs of auscultation varied considerably across the different studies. There is a sparsity of data from general practice, where auscultation of the heart is usually one of the main methods for detecting VHD. Based on this review, the diagnostic utility of auscultation is unclear and medical doctors should not rely too much on auscultation alone. More research is needed on how auscultation, together with other clinical findings and history, can be used to distinguish patients with VHD. PROSPERO REGISTRATION NUMBER CRD42018091675.
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Affiliation(s)
- Anne Herefoss Davidsen
- General Practice Research Unit, Department of Community Medicine, UiT The Arctic University, Tromso, Norway
| | - Stian Andersen
- General Practice Research Unit, Department of Community Medicine, UiT The Arctic University, Tromso, Norway
| | - Peder Andreas Halvorsen
- General Practice Research Unit, Department of Community Medicine, UiT The Arctic University, Tromso, Norway
| | - Henrik Schirmer
- Department of Clinical Medicine, University of Oslo Faculty of Medicine, Lørenskog, Norway
- Department of Cardiology, Akershus University Hospital, Lorenskog, Norway
| | - Eirik Reierth
- Science and Health Library, UiT The Arctic University, Tromso, Troms, Norway
| | - Hasse Melbye
- General Practice Research Unit, Department of Community Medicine, UiT The Arctic University, Tromso, Norway
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Saeed S, Mohamed Ali A, Wasim D, Risnes I, Urheim S. Correlation between Murmurs and Echocardiographic Findings; From an Imaging Cardiologist Point of View. Curr Probl Cardiol 2023; 48:101479. [PMID: 36336114 DOI: 10.1016/j.cpcardiol.2022.101479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
A heart murmur in adults is a common reason for referral for echocardiography at most general cardiology clinics in Europe. A murmur may indicate either a mild age-related valvular calcification or regurgitation, or represent a significant heart valve disease requiring valvular intervention. Generally, the correlation between murmurs by auscultation and severity of heart valve disease by echocardiography is poor. Particularly, the severity and characterization of diastolic murmurs by auscultation may poorly correlate with echocardiographic findings. This narrative review aims to summarize the differential diagnoses of physiological and pathological murmurs, describes the current referral practice of murmur patients for echocardiography, and presents a single-center experience on the correlation of auscultation and echocardiographic findings with a particular focus on aortic and mitral valve diseases. A careful auscultation of the heart prior to the echocardiogram is mandatory and may help to predict the echocardiographic findings and their interpretation in view of the clinical information. The correlation between clinical examination, point of care ultrasound and standard echocardiography is a matter of continued exploration.
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Affiliation(s)
- Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
| | - Abukar Mohamed Ali
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Daanyaal Wasim
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Ivar Risnes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Stig Urheim
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
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7
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Phelan A, Broughan J, McCombe G, Collins C, Fawsitt R, O’Callaghan M, Quinlan D, Stanley F, Cullen W. Impact of enhancing GP access to diagnostic imaging: A scoping review. PLoS One 2023; 18:e0281461. [PMID: 36897853 PMCID: PMC10004541 DOI: 10.1371/journal.pone.0281461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/24/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Direct access to diagnostic imaging in General Practice provides an avenue to reduce referrals to hospital-based specialities and emergency departments, and to ensure timely diagnosis. Enhanced GP access to radiology imaging could potentially reduce hospital referrals, hospital admissions, enhance patient care, and improve disease outcomes. This scoping review aims to demonstrate the value of direct access to diagnostic imaging in General Practice and how it has impacted on healthcare delivery and patient care. METHODS A search was conducted of 'PubMed', 'Cochrane Library', 'Embase' and 'Google Scholar' for papers published between 2012-2022 using Arksey and O'Malley's scoping review framework. The search process was guided by the PRISMA extension for Scoping Reviews checklist (PRISMA-ScR). RESULTS Twenty-three papers were included. The studies spanned numerous geographical locations (most commonly UK, Denmark, and Netherlands), encompassing several study designs (most commonly cohort studies, randomised controlled trials and observational studies), and a range of populations and sample sizes. Key outcomes reported included the level of access to imaging serves, the feasibility and cost effectiveness of direct access interventions, GP and patient satisfaction with direct access initiatives, and intervention related scan waiting times and referral process. CONCLUSION Direct access to imaging for GPs can have many benefits for healthcare service delivery, patient care, and the wider healthcare ecosystem. GP focused direct access initiatives should therefore be considered as a desirable and viable health policy directive. Further research is needed to more closely examine the impacts that access to imaging studies have on health system operations, especially those in General Practice. Research examining the impacts of access to multiple imaging modalities is also warranted.
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Affiliation(s)
- Amy Phelan
- School of Medicine, University College Dublin, Dublin, Ireland
| | - John Broughan
- Clinical Research Centre, School of Medicine, University College Dublin, Dublin, Ireland
- * E-mail:
| | - Geoff McCombe
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Claire Collins
- Research, Policy and Information, Irish College of General Practitioners, Dublin, Ireland
| | - Ronan Fawsitt
- General Practice, Castle Gardens Medical Centre, Kilkenny, Ireland
- Primary Care Advisor, Ireland East Hospital Group, Dublin, Ireland
| | - Mike O’Callaghan
- Irish College of General Practitioners, ICGP, Dublin, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
| | | | - Fintan Stanley
- Irish College of General Practitioners, ICGP, Dublin, Ireland
| | - Walter Cullen
- School of Medicine, University College Dublin, Dublin, Ireland
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Chai J, Mohiaddin H, Mandal AKJ, Gan J, Hirani T, Sholapurkar R, Missouris CG. Role of open access echocardiography in detection of cardiac structural and functional abnormalities. Postgrad Med J 2022; 99:postgradmedj-2021-141195. [PMID: 35027469 DOI: 10.1136/postgradmedj-2021-141195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 01/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To evaluate the prevalence and incidence of significant structural heart disease in targeted patients with cardiac symptoms referred by general practitioners (GPs) using open access echocardiography, without prior clinical evaluation by a cardiologist. DESIGN Data were derived from 488 subjects who underwent transthoracic echocardiography between January and April 2018. Patients were referred directly by GPs in East Berkshire, South England, through an online platform. Echocardiography was performed within 4-6 weeks of referral and all reports were assessed by a consultant cardiologist with expedited follow-up facilitated pro re nata. Results were analysed to determine the frequency of detection of structural abnormalities, particularly of the left ventricle and cardiac valves. RESULTS Echocardiography was prospectively performed in consecutive subjects (50% male, mean (±SD) age 68.5±22 years; 50% female; mean (±SD) 64.6 (±19.1)). At least one abnormality likely to change management was found in 133 (27.3%) of all open access echocardiograms. Clinical heart failure with left ventricular systolic dysfunction (LVSD) and diastolic dysfunction was confirmed in 46 (9%) and 69 (14%), respectively. Of the 46 patients with LVSD, 33 were new diagnoses. Significant cardiac valve disease was found in 42 (8.6%) patients. 12 of these had known valvular disease or previous valvular surgery, and 30 were new diagnoses. CONCLUSION Major structural and functional cardiac abnormalities are common in late middle-aged patients who present to GPs with cardiac symptoms and signs. Reported, unrestricted open access echocardiography enables early detection of significant cardiac pathology and timely intervention may improve cardiovascular outcomes.
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Affiliation(s)
- Jason Chai
- Department of Medicine and Cardiology, Wexham Park Hospital, Slough, UK
| | - Hasan Mohiaddin
- Department of Medicine and Cardiology, Wexham Park Hospital, Slough, UK
| | - Amit K J Mandal
- Department of Medicine and Cardiology, Wexham Park Hospital, Slough, UK
| | - Jasmine Gan
- Department of Medicine and Cardiology, Wexham Park Hospital, Slough, UK
| | - Trisha Hirani
- Department of Medicine and Cardiology, Wexham Park Hospital, Slough, UK
| | | | - Constantinos G Missouris
- Department of Medicine and Cardiology, Wexham Park Hospital, Slough, UK .,Department of Cardiology, University of Nicosia Medical School, Nicosia, Cyprus
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Steeds RP, Potter A, Mangat N, Fröhlich M, Deutsch C, Bramlage P, Thoenes M. Community-based aortic stenosis detection: clinical and echocardiographic screening during influenza vaccination. Open Heart 2021; 8:openhrt-2021-001640. [PMID: 34021069 PMCID: PMC8144056 DOI: 10.1136/openhrt-2021-001640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/14/2021] [Indexed: 11/25/2022] Open
Abstract
Background Degenerative aortic stenosis (AS), the most common valvular heart disease in the Western world, is often diagnosed late when the mortality risk becomes substantial. We determined the feasibility of AS screening during influenza vaccination at general practitioner (GP) surgeries in the UK. Methods Consecutive subjects aged >65 years presenting to a GP for influenza vaccination underwent heart auscultation and 2D echocardiography (V-scan). Based on these findings, a patient management strategy was determined (referral to cardiologist, review within own practice or no follow-up measures) and status at 3 months was determined. Results 167 patients were enrolled with a mean age of 75 years. On auscultation, a heart murmur was detected in 30 of 167 (18%) patients (6 subjects with an AS-specific and 24 with a non-specific murmur). 75.2% of those with no murmur had a negative V-scan finding. Conversely, 16 of 30 (53%) patients with any murmur had an abnormal V-scan finding that was largely related to the aortic valve. Using clinical auscultation and V-scan screening, a decision not to pursue follow-up measures was taken in 147 (88%) cases, whereas 18 (10.8%) subjects were referred onward; with 5 of 18 (27.8%) and 3 of 18 (16.7%) being diagnosed with mild and moderate AS. Conclusions Our pilot study confirms feasibility of valvular heart disease screening in the elderly in a primary care setting. Using simple and inexpensive diagnostic measures and 7.3 million UK inhabitants undergoing influenza vaccination, nationwide screening could potentially identify 130 000 patients with moderate AS and a significant number of patients with severe AS.
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Affiliation(s)
- Richard Paul Steeds
- Queen Elizabeth Hospital & Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | | | | | - Maren Fröhlich
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Cornelia Deutsch
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Martin Thoenes
- Leman Research Institute, Schaffhausen, Switzerland.,Medical Department, Edwards Lifesciences, Nyon, Switzerland
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Chambers JB. EDUCATIONAL SERIES ON THE SPECIALIST VALVE CLINIC: How to run a specialist valve clinic: the history, examination and exercise test. Echo Res Pract 2019; 6:T23-T28. [PMID: 31096187 PMCID: PMC6865356 DOI: 10.1530/erp-19-0003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/14/2019] [Indexed: 01/03/2023] Open
Abstract
Echocardiography is the key to the detection and initial assessment of valve disease. The examination helps differentiate severe from moderate disease if this is unclear from the echocardiogram, but is less useful than echocardiography for surveillance. However, the history is extremely important because symptoms are an indication for surgery in all types of valve disease. In aortic stenosis, the mortality rises soon after the onset of exertional breathlessness or chest tightness. Exercise testing is an extension of the history and may reveal symptoms in apparently asymptomatic patients. This article discusses the history, examination and exercise testing in patients either newly referred or under routine follow-up in a specialist valve clinic.
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Affiliation(s)
- John B Chambers
- Cardiothoracic Centre, Guy’s and St Thomas’ Hospitals, London, UK
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11
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Abstract
There is consensus on important aspects of managing heart valve disease. Despite this, many patients are managed by general physicians or cardiologists without specialist competencies in valve disease, which leads to suboptimal outcomes. Multidisciplinary heart valve clinics bring together cardiologists, surgeons, nurses, and in some countries scientists to deliver expert guidelines and experience-driven optimal care. Patients are referred at the optimal time for interventions at heart valve centers, defined by strict standards of facilities and processes. Valve networks link valve clinic, heart valve center, and the community to improve the passage of patients at every level of care.
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Affiliation(s)
- John B Chambers
- Cardiothoracic Center, Guy's and St Thomas' Hospitals, Westminster Bridge Road, London SE1 7EH, UK.
| | - Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Rue de l'hôpital 1, 4000 Liège, Belgium
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12
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Melero-Alegria JI, Cascon M, Romero A, Vara PP, Barreiro-Perez M, Vicente-Palacios V, Perez-Escanilla F, Hernandez-Hernandez J, Garde B, Cascon S, Martin-Garcia A, Diaz-Pelaez E, de Dios JM, Uribarri A, Jimenez-Candil J, Cruz-Gonzalez I, Blazquez B, Hernandez JM, Sanchez-Pablo C, Santolino I, Ledesma MC, Muriel P, Dorado-Diaz PI, Sanchez PL. SALMANTICOR study. Rationale and design of a population-based study to identify structural heart disease abnormalities: a spatial and machine learning analysis. BMJ Open 2019; 9:e024605. [PMID: 30765403 PMCID: PMC6398793 DOI: 10.1136/bmjopen-2018-024605] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/06/2018] [Accepted: 12/18/2018] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION This study aims to obtain data on the prevalence and incidence of structural heart disease in a population setting and, to analyse and present those data on the application of spatial and machine learning methods that, although known to geography and statistics, need to become used for healthcare research and for political commitment to obtain resources and support effective public health programme implementation. METHODS AND ANALYSIS We will perform a cross-sectional survey of randomly selected residents of Salamanca (Spain). 2400 individuals stratified by age and sex and by place of residence (rural and urban) will be studied. The variables to analyse will be obtained from the clinical history, different surveys including social status, Mediterranean diet, functional capacity, ECG, echocardiogram, VASERA and biochemical as well as genetic analysis. ETHICS AND DISSEMINATION The study has been approved by the ethical committee of the healthcare community. All study participants will sign an informed consent for participation in the study. The results of this study will allow the understanding of the relationship between the different influencing factors and their relative importance weights in the development of structural heart disease. For the first time, a detailed cardiovascular map showing the spatial distribution and a predictive machine learning system of different structural heart diseases and associated risk factors will be created and will be used as a regional policy to establish effective public health programmes to fight heart disease. At least 10 publications in the first-quartile scientific journals are planned. TRIAL REGISTRATION NUMBER NCT03429452.
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Affiliation(s)
- Jose Ignacio Melero-Alegria
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | - Manuel Cascon
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | | | - Pedro Pablo Vara
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | - Manuel Barreiro-Perez
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | - Victor Vicente-Palacios
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | | | - Jesus Hernandez-Hernandez
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | - Beatriz Garde
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | - Sara Cascon
- Robleda Primary Care Center, Salamanca, Spain
| | - Ana Martin-Garcia
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | - Elena Diaz-Pelaez
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | | | - Aitor Uribarri
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | - Javier Jimenez-Candil
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | - Ignacio Cruz-Gonzalez
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | | | | | - Clara Sanchez-Pablo
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | | | | | - Paz Muriel
- Miguel Armijo Primary Care Centre, Salamanca, Spain
| | - P Ignacio Dorado-Diaz
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
| | - Pedro L Sanchez
- Department of Cardiology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Facultad de Medicina, Universidad de Salamanca, and CIBERCV, Salamanca, Spain
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Galusko V, Bodger O, Ionescu A. A systematic review of pocket-sized imaging devices: small and mighty? Echo Res Pract 2018; 5:113-138. [PMID: 30304538 PMCID: PMC6198255 DOI: 10.1530/erp-18-0030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction Hand-held imaging devices are widely used in clinical practice and are a useful tool. There is no published review examining the diagnostic parameters achieved with these devices in clinical practice. Methods We searched three online medical literature databases (PubMed, EMBASE and MEDLINE) for all literature published up until January 2018. We selected studies that (1) were conducted in the adult population; (2) used a truly hand-held device; (3) featured sensitivities and/or specificities on the use of the hand-held scanner. We extracted and summarised the diagnostic metrics from the literature. Results Twenty-seven articles were excluded from the initial 56 relevant articles, as the device featured was not truly hand-held. Ultimately a total of 25 studies were analysed. Sixteen studies were carried out by experienced users, seven by users with little previous experience and two studies by nurses. High diagnostic parameters were achieved by all three groups when scanning cardiac pathology and intra-abdominal structures. Training of non-expert users varied, taking a mean of 21.6 h. These hand-held devices can change diagnoses at the bedside and be used as gate-keepers to formal echocardiography. Individual studies show them to be cost-effective. Conclusion Hand-held echocardiography is a useful tool in the hands of experts and novices alike. Studies conducted are highly heterogeneous making it difficult to pool data for the diagnostic metrics. Further studies with rigorous methodology are needed to evaluate the true diagnostic potential in the hands of non-experts and in the community as well as to validate training protocols.
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Affiliation(s)
- Victor Galusko
- Swansea University Medical School, Swansea University, Singleton Park, Swansea, UK
| | - Owen Bodger
- Swansea University Medical School, Swansea University, Singleton Park, Swansea, UK
| | - Adrian Ionescu
- Morriston Cardiac Regional Centre, ABMU LHB, Swansea, UK
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Draper J, Subbiah S, Bailey R, Chambers JB. Murmur clinic: validation of a new model for detecting heart valve disease. Heart 2018; 105:56-59. [PMID: 30049836 PMCID: PMC6317436 DOI: 10.1136/heartjnl-2018-313393] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/01/2018] [Accepted: 07/02/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We aimed to determine if auscultation or a point-of-care scan could reduce the need for standard echocardiography (transthoracic echocardiogram (TTE)) in community patients with asymptomatic murmurs. METHODS Requests from general practitioners were directed to a new murmur clinic. Auscultation and a point-of-care scan were performed by a cardiologist between 1 October 2013 and 31 December 2014 and by a scientist between 21 July 2015 and 9 May 2017. RESULTS In the first phase (cardiologist), there were 75 patients, mean age 54 (56 women), and in the second phase there were 100 patients, mean age 60 (76 women). In the total population of 175, abnormalities were shown on TTE in 52 (30%), on point-of-care scan in 52 (30%) and predicted on auscultation in 45 (26%) (p=0.125; 95% CI -0.02 to 0.29). The sensitivity of auscultation was not significantly different for the cardiologist (91%) as for the scientist (83%) (p=0.18; 95% CI -0.22 to 0.175) and the specificity was 100% for both. Accuracy was 97% for the cardiologist and 95% for the scientist. For the point-of-care scan, the sensitivity, specificity, positive and negative predictive values and accuracy were 100% for both cardiologist and scientist. CONCLUSION Most patients in a specialist murmur clinic had normal auscultation and point-of-care scans and no additional valve disease was detected by standard echocardiography. This suggests that a murmur clinic is a valid model for reducing demand on hospital echocardiography services.
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Affiliation(s)
- Jane Draper
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals, London, UK
| | - Sheila Subbiah
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals, London, UK
| | - Rikki Bailey
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals, London, UK
| | - John B Chambers
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals, London, UK
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15
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Affiliation(s)
- John B Chambers
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
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16
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Gardezi SKM, Myerson SG, Chambers J, Coffey S, d’Arcy J, Hobbs FDR, Holt J, Kennedy A, Loudon M, Prendergast A, Prothero A, Wilson J, Prendergast BD. Cardiac auscultation poorly predicts the presence of valvular heart disease in asymptomatic primary care patients. Heart 2018; 104:1832-1835. [DOI: 10.1136/heartjnl-2018-313082] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 12/13/2022] Open
Abstract
ObjectiveCardiac auscultation is a key clinical skill, particularly for the diagnosis of valvular heart disease (VHD). However, its utility has declined due to the widespread availability of echocardiography and diminishing emphasis on the importance of clinical examination. We aim to determine the contemporary accuracy of auscultation for diagnosing VHD in primary care.MethodsCardiac auscultation was undertaken by one of two experienced general practitioners (primary care/family doctors) in a subset of 251 asymptomatic participants aged >65 years undergoing echocardiography within a large community-based screening study of subjects with no known VHD. Investigators were blinded to the echocardiographic findings. Newly detected VHD was classified as mild (mild regurgitation of any valve or aortic sclerosis) or significant (at least moderate regurgitation or mild stenosis of any valve).ResultsNewly identified VHD was common, with mild disease in 170/251 participants (68%) and significant disease in 36/251 (14%). The sensitivity of auscultation was low for the diagnosis of mild VHD (32%) but slightly higher for significant VHD (44%), with specificities of 67% and 69%, respectively. Likelihood ratios were not statistically significant for the diagnosis of either mild or significant VHD in the overall cohort, but showed possible value for auscultation in non-overweight subjects (body mass index <25 kg/m2).ConclusionCardiac auscultation has limited accuracy for the detection of VHD in asymptomatic patients and is a poor diagnostic screening tool in primary care, particularly for overweight subjects. Ensuring easy access to echocardiography in patients with symptoms suggesting VHD is likely to represent a better diagnostic strategy.
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18
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Muñoz MA, Mundet-Tuduri X, Real J, Del Val JL, Domingo M, Vinyoles E, Calero E, Checa C, Soldevila-Bacardit N, Verdú-Rotellar JM. Heart failure labelled patients with missing ejection fraction in primary care: prognosis and determinants. BMC FAMILY PRACTICE 2017; 18:38. [PMID: 28302060 PMCID: PMC5356293 DOI: 10.1186/s12875-017-0612-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 03/02/2017] [Indexed: 11/16/2022]
Abstract
Background It is common to find a high variability in the accuracy of heart failure (HF) diagnosis in electronic primary care medical records (EMR). Our aims were to ascertain (i) whether the prognosis of HF labelled patients whose ejection fraction (EF) was missing in their EMR differed from those that had it registered, and (ii) the causes contributing to the differences in the availability of EF in EMR. Methods Retrospective cohort analyses based on clinical records of HF and attended at 52 primary healthcare centres of Barcelona (Spain). Information of 8376 HF patients aged > 40 years followed during five years was analyzed. Results EF was available only in 8.5% of primary care medical records. Cumulate incidence for mortality and hospitalization from 1st January 2009 to 31th December 2012 was 37.6%. The highest rate was found in patients with missing EF (HR 1.84, 95% CI 1.68 -1.95) compared to those with preserved EF. Patients hospitalized the previous year and those requiring home healthcare (HR 1.81, 95% Confidence Interval 1.68-1.95 and HR 1.58, 95% CI 1.46-1.71, respectively) presented a higher risk of having an adverse outcome. Older patients, those more socio-economically disadvantaged, obese, requiring home healthcare, and taking loop diuretics were less likely to have an EF registered. Conclusions EF is poorly recorded in primary care. HF patients with EF missing at medical records had the worst prognosis. They tended to be older, socio-economically disadvantaged, and more fragile.
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Affiliation(s)
- Miguel-Angel Muñoz
- Institut Català de la Salut, Barcelona, Spain.,Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Xavier Mundet-Tuduri
- Institut Català de la Salut, Barcelona, Spain. .,Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain. .,Universitat Autònoma de Barcelona, Bellaterra, Spain.
| | - Jordi Real
- Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain.,Epidemiologia i Salut Pública, Universitat Internacional de Catalunya, Sant Cugat, Spain
| | - José-Luis Del Val
- Institut Català de la Salut, Barcelona, Spain.,Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Mar Domingo
- Institut Català de la Salut, Barcelona, Spain.,Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Ernest Vinyoles
- Institut Català de la Salut, Barcelona, Spain.,Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
| | - Ester Calero
- Institut Català de la Salut, Barcelona, Spain.,Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Caterina Checa
- Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain.,EAP Dreta de l'Eixample, Barcelona, Spain
| | - Nuria Soldevila-Bacardit
- Institut Català de la Salut, Barcelona, Spain.,Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - José-María Verdú-Rotellar
- Institut Català de la Salut, Barcelona, Spain.,Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra, Spain
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Chambers JB, Garbi M, Nieman K, Myerson S, Pierard LA, Habib G, Zamorano JL, Edvardsen T, Lancellotti P, Delgado V, Cosyns B, Donal E, Dulgheru R, Galderisi M, Lombardi M, Muraru D, Kauffmann P, Cardim N, Haugaa K, Rosenhek R. Appropriateness criteria for the use of cardiovascular imaging in heart valve disease in adults: a European Association of Cardiovascular Imaging report of literature review and current practice. Eur Heart J Cardiovasc Imaging 2017; 18:489-498. [DOI: 10.1093/ehjci/jew309] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 11/17/2016] [Indexed: 01/16/2023] Open
Affiliation(s)
- John B. Chambers
- Cardiothoracic Centre, Guy’s and St Thomas Hospitals, London, UK
| | - Madalina Garbi
- King's Health Partners, King's College Hospital NHS Foundation Trust, London, UK
| | - Koen Nieman
- Departments of Cardiology and Radiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Gilbert Habib
- Aix-Marseille University, URMITE, Marseille, France
- Department of Cardiology, APHM, La Timone Hospital, Marseille, France
| | | | - Thor Edvardsen
- Department of Cardiology and Centre of Cardiological Innovation, Oslo University Hospital, Rikshospitalet and University of Oslo, Oslo, Norway
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, GIGA Cardiovascular Sciences, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium
- Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
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Yates J, Royse CF, Royse C, Royse AG, Canty DJ. Focused cardiac ultrasound is feasible in the general practice setting and alters diagnosis and management of cardiac disease. Echo Res Pract 2016; 3:63-9. [PMID: 27457967 PMCID: PMC5045516 DOI: 10.1530/erp-16-0026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 07/22/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Ultrasound-assisted examination of the cardiovascular system with focused cardiac ultrasound by the treating physician is non-invasive and changes diagnosis and management of patient's with suspected cardiac disease. This has not been reported in a general practice setting. AIM To determine whether focused cardiac ultrasound performed on patients aged over 50 years changes the diagnosis and management of cardiac disease by a general practitioner. DESIGN AND SETTING A prospective observational study of 80 patients aged over 50years and who had not received echocardiography or chest CT within 12months presenting to a general practice. METHOD Clinical assessment and management of significant cardiac disorders in patients presenting to general practitioners were recorded before and after focused cardiac ultrasound. Echocardiography was performed by a medical student with sufficient training, which was verified by an expert. Differences in diagnosis and management between conventional and ultrasound-assisted assessment were recorded. RESULTS AND CONCLUSION Echocardiography and interpretation were acceptable in all patients. Significant cardiac disease was detected in 16 (20%) patients, including aortic stenosis in 9 (11%) and cardiac failure in 7 (9%), which were missed by clinical examination in 10 (62.5%) of these patients. Changes in management occurred in 12 patients (15% overall and 75% of those found to have significant cardiac disease) including referral for diagnostic echocardiography in 8 (10%), commencement of heart failure treatment in 3 (4%) and referral to a cardiologist in 1 patient (1%).Routine focused cardiac ultrasound is feasible and frequently alters the diagnosis and management of cardiac disease in patients aged over 50years presenting to a general practice.
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Affiliation(s)
- James Yates
- The University of Melbourne, Parkville, Victoria, Australia
| | - Colin Forbes Royse
- Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Carolyn Royse
- Nillumbik and Research Medical Centre, Eltham, Victoria, Australia
| | - Alistair George Royse
- Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia Department of Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - David Jeffrey Canty
- Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia Department of Medicine, Monash University, Clayton, Victoria, Australia Department of Anaesthesia and Perioperative Medicine, Clayton, Victoria, Australia
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Asthana S, Gibson A, Bailey T, Moon G, Hewson P, Dibben C. Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BackgroundA strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.ObjectivesTo generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.DesignCross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).ResultsThe utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.ConclusionsWe found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- College of Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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