Promoting Cardiac Rehabilitation in Acute Coronary Syndrome Patients: Quality Initiative Based on Education, Automated Referral, and Multidisciplinary Rounds

Cardiac rehabilitation is a class 1 recommendation for acute coronary syndrome (ACS) patients according to the American College of Cardiology/American Heart Association. However, only 1 in 5 ACS patients are referred for cardiac rehabilitation nationally, and even fewer at our institution. We sought to improve the number of referrals to cardiac rehabilitation for post-ACS patients admitted to our inpatient cardiology service, and ultimately their participation in the program. We designed a quality improvement initiative that included education of patients and house staff, automated referral order, and participation of cardiac rehabilitation staff members on multidisciplinary rounds. We compared the number of patients who received a referral to cardiac rehabilitation, had the first appointment scheduled before hospital discharge, and attended the program before and after our intervention. Six months after initiation of the project, the proportion of ACS patients referred to cardiac rehabilitation before hospital discharge increased from 10% to 43% (P < 0.001). The mean number of patients with a cardiac rehabilitation appointment scheduled before discharge was 2 before and 5 after the intervention (P < 0.001), and the mean number of patients who attended their scheduled appointment was 1 before and 3 after the intervention (P = 0.001). Run charts demonstrated that the number of referrals and the number of scheduled appointments remained above the median following the intervention. In conclusion, an initiative that included education, automated referrals, and direct one-on-one contact with cardiac rehabilitation staff before discharge increased the number of cardiac rehabilitation referrals, and appointments scheduled and attended in post-ACS patients.

Sex-Based Differences in Coronary and Structural Percutaneous Interventions

In the current state of interventional cardiology, the ability to offer advanced therapies to patients who historically were not surgical candidates has grown exponentially in the last few decades. As therapies have expanded in complex coronary and structural interventions, the nuances of treating certain populations have emerged. In particular, the role of sex-based anatomic and outcome differences has been increasingly recognized. As guidelines for cardiovascular prevention and treatment for certain conditions may vary by sex, therapeutic interventions in the structural and percutaneous coronary areas may also vary. In this review, we aim to discuss these differences, the current literature available on these topics, and areas of focus for the future.

Association of Vegetation Size With Embolic Risk in Patients With Infective Endocarditis: A Systematic Review and Meta-analysis

IMPORTANCE

Infective endocarditis is a life-threating condition with annual mortality of as much as 40% and is associated with embolic events in as many as 80% of cases. These embolic events have notable prognostic implications and have been linked to increased length of stay in intensive care units and mortality. A vegetation size greater than 10 mm has often been suggested as an optimal cutoff to estimate the risk of embolism, but the evidence is based largely on small observational studies.

OBJECTIVE

To study the association of vegetation size greater than 10 mm with embolic events using meta-analytic techniques.

DATA SOURCES

A computerized literature search of all publications in the PubMed and EMBASE databases from inception to May 1, 2017, was performed with search terms including varying combinations of infective endocarditis, emboli, vegetation size, pulmonary infarct, stroke, splenic emboli, renal emboli, retinal emboli, and mesenteric emboli. This search was last assessed as being up to date on May 1, 2017.

STUDY SELECTION

Observational studies or randomized clinical trials that evaluated the association of vegetation size greater than 10 mm with embolic events in adult patients with infective endocarditis were included. Conference abstracts and non-English language literature were excluded. The search was conducted by 2 independent reviewers blinded to the other's work.

DATA EXTRACTION AND SYNTHESIS

Following PRISMA guidelines, the 2 reviewers independently extracted data; disputes were resolved with consensus or by a third investigator. Categorical dichotomous data were summarized across treatment arms using Mantel-Haenszel odds ratios (ORs) with 95% CIs. Heterogeneity of effects was evaluated using the Higgins I2 statistic.

RESULTS

The search yielded 21 unique studies published from 1983 to 2016 with a total of 6646 unique patients with infective endocarditis and 5116 vegetations with available dimensions. Patients with a vegetation size greater than 10 mm had increased odds of embolic events (OR, 2.28; 95% CI, 1.71-3.05; P < .001) and mortality (OR, 1.63; 95% CI, 1.13-2.35; P = .009) compared with those with a vegetation size less than 10 mm.

CONCLUSIONS AND RELEVANCE

In this meta-analysis of 21 studies, patients with vegetation size greater than 10 mm had significantly increased odds of embolism and mortality. Understanding the risk of embolization will allow clinicians to adequately risk stratify patients and will also help facilitate discussions regarding surgery in patients with a vegetation size greater than 10 mm.

Intraoperative internal mammary artery transit-time flow measurements: comparative evaluation of two surgical pedicle preparation techniques

OBJECTS

Myocardial revascularization is performed preferentially with internal mammary artery grafts. Pedicle preparation and pharmacologic vasodilatory treatment vary greatly. Objective measurements are difficult since peripheral and later coronary vascular resistance and possible competitive flow of the native bypassed coronary artery will influence the results significantly. Our objectives were: (1) measurement of internal mammary artery graft flow with the transit-time flow technique; (2) comparison of two surgical take-down techniques (skeletonizing vs standard pedicle preparation); (3) quantitation of transit-time flow compared to the free pedicle flow and (4) the vasodilatory effect of papaverine on internal mammary artery flow.

METHOD

Consecutive elective cases of coronary artery bypass grafting, performed by two surgeons using routinely either skeletonizing of the internal mammary artery (group A, n = 10) or classical pedicle preparation technique (group B, n = 10), were studied prospectively. Anesthesia, cardiopulmonary bypass and operative data were otherwise comparable; likewise, hemodynamic parameters showed no statistical differences between the two groups. Transit-time flow (CardioMed, Medi-Stim, Norway) was measured at the following time points: beginning (1) and end of take-down (2); after papaverine soaking: before (3) and on cardiopulmonary bypass (4); free flow into a beaker (5); after anastomosis; on (6) and off cardiopulmonary bypass (7).

RESULTS

Measurement of mean flow showed the following results: (1) severe vasoconstruction of the internal mammary artery was detected in both groups regardless of the preparation technique (occurring earlier in group A); (2) papaverine soaking caused a moderate flow increase (up to 40%); (3) with corresponding cardiopulmonary bypass flow (4.4 vs. 4.1 l/min in group B) a higher free flow in group A was evident (67.7 vs. 50.7 ml/min); (4) after coronary grafting, transit-time flow showed no significant differences between the two groups and (5) using a 3 mm probe, a linear correlation was demonstrated between transit-time flow and simultaneously measured free flow (r = 0.89).

CONCLUSION

Intraoperative transit-time flow measurement is a reliable method for assessing internal mammary artery and coronary artery bypass flow; considering the simple technical application, the procedure may be regarded as a valuable instrument of quality control.

Surgery for acute ascending aortic dissection: closed versus open distal aortic repair

One hundred twelve consecutive patients with acute ascending aortic dissection and submitted to immediate surgery were retrospectively analyzed with regard to perioperative mortality and morbidity. The patients were divided into two groups according to whether distal aortic repair was carried out by the open procedure (using deep hypothermic circulatory arrest, group A: 68 patients) or by the closed technique (without circulatory arrest, group B: 44 patients). Patients' ages ranged from 24 to 78 years (mean 57.4 years). No significant difference was found between the two groups in terms of age and sex distribution. However, the prevalence in the extent of clinical and anatomical alterations was significantly higher in group A (hemodynamic instability, pericardial tamponade and neurological deficit). The duration of hypothermic circulatory arrest for group A patients averaged 25 min and ranged from 12 to 65 min. The overall perioperative mortality was 17% (19/112 patients); it was 20.6% (14/68) in group A and 11.4% (5/44) in group B; the difference was not statistically significant but consistent with a clear trend. The trend towards a higher mortality in group A mainly reflected the more severe and complex anatomical characteristics and could not be attributed to the circulatory arrest per se. The period of deep hypothermic circulatory arrest in the survivors (25 min) was similar to that of the group with lethal outcome (32 min). Among the non-lethal complications, however, group A patients more frequently showed clinical signs consistent with cerebral injury: apart from the transient symptoms suggestive in reversible diffuse cerebral damage, five patients in group A had a permanent focal neurological deficit (versus one patient in group B).(ABSTRACT TRUNCATED AT 250 WORDS)