EDUCATE: An international, randomized controlled trial for teaching electrocardiography

INTRODUCTION

Despite the critical role of electrocardiograms (ECGs) in patient care, evident gaps exist in ECG interpretation competency among healthcare professionals across various medical disciplines and training levels. Currently, no practical, evidence-based, and easily accessible ECG learning solution is available for healthcare professionals. The aim of this study was to assess the effectiveness of web-based, learner-directed interventions in improving ECG interpretation skills in a diverse group of healthcare professionals.

METHODS

In an international, prospective, randomized controlled trial, 1206 healthcare professionals from various disciplines and training levels were enrolled. They underwent a pre-intervention test featuring 30 12-lead ECGs with common urgent and non-urgent findings. Participants were randomly assigned to four groups: (i) practice ECG interpretation question bank (question bank), (ii) lecture-based learning resource (lectures), (iii) hybrid question- and lecture-based learning resource (hybrid), or (iv) no ECG learning resources (control). After four months, a post-intervention test was administered. The primary outcome was the overall change in ECG interpretation performance, with secondary outcomes including changes in interpretation time, self-reported confidence, and accuracy for specific ECG findings. Both unadjusted and adjusted scores were used for performance assessment.

RESULTS

Among 1206 participants, 863 (72 %) completed the trial. Following the intervention, the question bank, lectures, and hybrid intervention groups each exhibited significant improvements, with average unadjusted score increases of 11.4 % (95 % CI, 9.1 to 13.7; P<0.01), 9.8 % (95 % CI, 7.8 to 11.9; P<0.01), and 11.0 % (95 % CI, 9.2 to 12.9; P<0.01), respectively. In contrast, the control group demonstrated a non-significant improvement of 0.8 % (95 % CI, -1.2 to 2.8; P=0.54). While no differences were observed among intervention groups, all outperformed the control group significantly (P<0.01). Intervention groups also excelled in adjusted scores, confidence, and proficiency for specific ECG findings.

CONCLUSION

Web-based, self-directed interventions markedly enhanced ECG interpretation skills across a diverse range of healthcare professionals, providing an accessible and evidence-based solution.

Predictors of ECG Interpretation Proficiency in Healthcare Professionals

Accurate ECG interpretation is vital, but variations in skills exist among healthcare professionals. This study aims to identify factors contributing to ECG interpretation proficiency. Survey data and ECG interpretation test scores from participants in the EDUCATE Trial were analyzed to identify predictors of performance for 30 sequential 12-lead ECGs. Nonmodifiable factors (being a physician, clinical experience, patient care impact) and modifiable factors (weekly interpretation volume, training hours, expert supervision frequency) were analyzed. Bivariate and multivariate analyses were used to generate a Comprehensive Model (incorporating all factors) and Actionable Model (incorporating modifiable factors only). Among 1206 participants analyzed, there were 72 (6.0%) primary care physicians, 146 (12.1%) cardiology fellows-in-training, 353 (29.3%) resident physicians, 182 (15.1%) medical students, 84 (7.0%) advanced practice providers, 120 (9.9%) nurses, and 249 (20.7%) allied health professionals. Among them, 571 (47.3%) were physicians and 453 (37.6%) were nonphysicians. The average test score was 56.4% ± 17.2%. Bivariate analysis demonstrated significant associations between test scores and >10 weekly ECG interpretations, being a physician, >5 training hours, patient care impact, and expert supervision but not clinical experience. In the Comprehensive Model, independent associations were found with weekly interpretation volume (9.9 score increase; 95% CI, 7.9-11.8; P < 0.001), being a physician (9.0 score increase; 95% CI, 7.2-10.8; P < 0.001), and training hours (5.7 score increase; 95% CI, 3.7-7.6; P < 0.001). In the Actionable Model, scores were independently associated with weekly interpretation volume (12.0 score increase; 95% CI, 10.0-14.0; P < 0.001) and training hours (4.7 score increase; 95% CI, 2.6-6.7; P < 0.001). The Comprehensive and Actionable Models explained 18.7% and 12.3% of the variance in test scores, respectively. Predictors of ECG interpretation proficiency include nonmodifiable factors like physician status and modifiable factors such as training hours and weekly ECG interpretation volume.

Impact of Computer-Interpreted ECGs on the Accuracy of Healthcare Professionals

The interpretation of electrocardiograms (ECGs) involves a dynamic interplay between computerized ECG interpretation (CEI) software and human overread. However, the impact of computer ECG interpretation on the performance of healthcare professionals remains largely unexplored. The aim of this study was to evaluate the interpretation proficiency of various medical professional groups, with and without access to the CEI report. Healthcare professionals from diverse disciplines, training levels, and countries sequentially interpreted 60 standard 12-lead ECGs, demonstrating both urgent and nonurgent findings. The interpretation process consisted of 2 phases. In the first phase, participants interpreted 30 ECGs with clinical statements. In the second phase, the same 30 ECGs and clinical statements were randomized and accompanied by a CEI report. Diagnostic performance was evaluated based on interpretation accuracy, time per ECG (in seconds [s]), and self-reported confidence (rated 0 [not confident], 1 [somewhat confident], or 2 [confident]). A total of 892 participants from various medical professional groups participated in the study. This cohort included 44 (4.9%) primary care physicians, 123 (13.8%) cardiology fellows-in-training, 259 (29.0%) resident physicians, 137 (15.4%) medical students, 56 (6.3%) advanced practice providers, 82 (9.2%) nurses, and 191 (21.4%) allied health professionals. The inclusion of the CEI was associated with a significant improvement in interpretation accuracy by 15.1% (95% confidence interval, 14.3-16.0; P < 0.001), decrease in interpretation time by 52 s (-56 to -48; P < 0.001), and increase in confidence by 0.06 (0.03-0.09; P = 0.003). Improvement in interpretation accuracy was seen across all professional subgroups, including primary care physicians by 12.9% (9.4-16.3; P = 0.003), cardiology fellows-in-training by 10.9% (9.1-12.7; P < 0.001), resident physicians by 14.4% (13.0-15.8; P < 0.001), medical students by 19.9% (16.8-23.0; P < 0.001), advanced practice providers by 17.1% (13.3-21.0; P < 0.001), nurses by 16.2% (13.4-18.9; P < 0.001), allied health professionals by 15% (13.4-16.6; P < 0.001), physicians by 13.2% (12.2-14.3; P < 0.001), and nonphysicians by 15.6% (14.3-17.0; P < 0.001).CEI integration improves ECG interpretation accuracy, efficiency, and confidence among healthcare professionals.

Exploring Factors Influencing ECG Interpretation Proficiency of Medical Professionals

The electrocardiogram (ECG) is a crucial diagnostic tool in medicine with concerns about its interpretation proficiency across various medical disciplines. Our study aimed to explore potential causes of these issues and identify areas requiring improvement. A survey was conducted among medical professionals to understand their experiences with ECG interpretation and education. A total of 2515 participants from diverse medical backgrounds were surveyed. A total of 1989 (79%) participants reported ECG interpretation as part of their practice. However, 45% expressed discomfort with independent interpretation. A significant 73% received less than 5 hours of ECG-specific education, with 45% reporting no education at all. Also, 87% reported limited or no expert supervision. Nearly all medical professionals (2461, 98%) expressed a desire for more ECG education. These findings were consistent across all groups and did not vary between primary care physicians, cardiology FIT, resident physicians, medical students, APPs, nurses, physicians, and nonphysicians. This study reveals substantial deficiencies in ECG interpretation training, supervision, and confidence among medical professionals, despite a strong interest in increased ECG education.

ECG Interpretation Proficiency of Healthcare Professionals

ECG interpretation is essential in modern medicine, yet achieving and maintaining competency can be challenging for healthcare professionals. Quantifying proficiency gaps can inform educational interventions for addressing these challenges. Medical professionals from diverse disciplines and training levels interpreted 30 12-lead ECGs with common urgent and nonurgent findings. Average accuracy (percentage of correctly identified findings), interpretation time per ECG, and self-reported confidence (rated on a scale of 0 [not confident], 1 [somewhat confident], or 2 [confident]) were evaluated. Among the 1206 participants, there were 72 (6%) primary care physicians (PCPs), 146 (12%) cardiology fellows-in-training (FITs), 353 (29%) resident physicians, 182 (15%) medical students, 84 (7%) advanced practice providers (APPs), 120 (10%) nurses, and 249 (21%) allied health professionals (AHPs). Overall, participants achieved an average overall accuracy of 56.4% ± 17.2%, interpretation time of 142 ± 67 seconds, and confidence of 0.83 ± 0.53. Cardiology FITs demonstrated superior performance across all metrics. PCPs had a higher accuracy compared to nurses and APPs (58.1% vs 46.8% and 50.6%; P < 0.01), but a lower accuracy than resident physicians (58.1% vs 59.7%; P < 0.01). AHPs outperformed nurses and APPs in every metric and showed comparable performance to resident physicians and PCPs. Our findings highlight significant gaps in the ECG interpretation proficiency among healthcare professionals.

Education curriculum assessment for teaching electrocardiography: Rationale and design for the prospective, international, randomized controlled EDUCATE trial

BACKGROUND

Electrocardiogram (ECG) interpretation training is a fundamental component of medical education across disciplines. However, the skill of interpreting ECGs is not universal among medical graduates, and numerous barriers and challenges exist in medical training and clinical practice. An evidence-based and widely accessible learning solution is needed.

DESIGN

The EDUcation Curriculum Assessment for Teaching Electrocardiography (EDUCATE) Trial is a prospective, international, investigator-initiated, open-label, randomized controlled trial designed to determine the efficacy of self-directed and active-learning approaches of a web-based educational platform for improving ECG interpretation proficiency. Target enrollment is 1000 medical professionals from a variety of medical disciplines and training levels. Participants will complete a pre-intervention baseline survey and an ECG interpretation proficiency test. After completion, participants will be randomized into one of four groups in a 1:1:1:1 fashion: (i) an online, question-based learning resource, (ii) an online, lecture-based learning resource, (iii) an online, hybrid question- and lecture-based learning resource, or (iv) a control group with no ECG learning resources. The primary endpoint will be the change in overall ECG interpretation performance according to pre- and post-intervention tests, and it will be measured within and compared between medical professional groups. Secondary endpoints will include changes in ECG interpretation time, self-reported confidence, and interpretation accuracy for specific ECG findings.

CONCLUSIONS

The EDUCATE Trial is a pioneering initiative aiming to establish a practical, widely available, evidence-based solution to enhance ECG interpretation proficiency among medical professionals. Through its innovative study design, it tackles the currently unaddressed challenges of ECG interpretation education in the modern era. The trial seeks to pinpoint performance gaps across medical professions, compare the effectiveness of different web-based ECG content delivery methods, and create initial evidence for competency-based standards. If successful, the EDUCATE Trial will represent a significant stride towards data-driven solutions for improving ECG interpretation skills in the medical community.

Paroxysmal supine hypoxaemia with hyperthyroidism and atrial fibrillation: a case report of a diagnostic challenge

Background

A patent foramen ovale (PFO) is a persistent embryonic defect in the interatrial septum. Platypnoea-orthodeoxia syndrome is characterized by positional hypoxaemia that is most commonly due to right-to-left shunting through a PFO. Dynamic right-to-left shunting through a PFO can also exacerbate positional hypoxaemia without platypnea-orthodeoxia syndrome.

Case summary

A 78-year-old woman with hyperthyroidism and paroxysmal atrial fibrillation (AF) presented with positional hypoxaemia exacerbated by supine positioning. Diagnostic testing revealed intermittent right-to-left shunting through a PFO triggered by worsening atrial functional tricuspid regurgitation and elevated right atrial pressures. Diuresis, rate control, and thyroidectomy initially led to resolution of positional hypoxaemia, but recurrent AF episodes triggered right-to-left shunting with recurrent desaturation. Left atrial and cavo-tricuspid isthmus ablation led to restoration of normal sinus rhythm and resolution of positional hypoxaemia without PFO closure.

Discussion

The clinical presentation of intermittent intracardiac right-to-left shunting can mimic decompensated heart failure with pulmonary oedema. Persistent hypoxaemia out of proportion to the degree of pulmonary oedema and minimally responsive to supplemental O₂ should raise suspicion for right-to-left shunt aetiology. Positional arterial blood gases can facilitate the diagnostic evaluation of refractory hypoxaemia in cases of suspected shunting. Diagnostic imaging for PFO detection includes both transthoracic and transesophageal echocardiography with Valsalva manoeuver and agitated saline injection. Closure of a PFO for management of arterial deoxygenation syndromes should not be performed before treating other causes of arterial deoxygenation and optimizing factors that may exacerbate shunting across the PFO.

Validity of a cardiology fellow performance assessment: reliability and associations with standardized examinations and awards

BACKGROUND

Most work on the validity of clinical assessments for measuring learner performance in graduate medical education has occurred at the residency level. Minimal research exists on the validity of clinical assessments for measuring learner performance in advanced subspecialties. We sought to determine validity characteristics of cardiology fellows' assessment scores during subspecialty training, which represents the largest subspecialty of internal medicine. Validity evidence included item content, internal consistency reliability, and associations between faculty-of-fellow clinical assessments and other pertinent variables.

METHODS

This was a retrospective validation study exploring the domains of content, internal structure, and relations to other variables validity evidence for scores on faculty-of-fellow clinical assessments that include the 10-item Mayo Cardiology Fellows Assessment (MCFA-10). Participants included 7 cardiology fellowship classes. The MCFA-10 item content included questions previously validated in the assessment of internal medicine residents. Internal structure evidence was assessed through Cronbach's α. The outcome for relations to other variables evidence was overall mean of faculty-of-fellow assessment score (scale 1-5). Independent variables included common measures of fellow performance.

FINDINGS

Participants included 65 cardiology fellows. The overall mean ± standard deviation faculty-of-fellow assessment score was 4.07 ± 0.18. Content evidence for the MCFA-10 scores was based on published literature and core competencies. Cronbach's α was 0.98, suggesting high internal consistency reliability and offering evidence for internal structure validity. In multivariable analysis to provide relations to other variables evidence, mean assessment scores were independently associated with in-training examination scores (beta = 0.088 per 10-point increase; p = 0.05) and receiving a departmental or institutional award (beta = 0.152; p = 0.001). Assessment scores were not associated with educational conference attendance, compliance with completion of required evaluations, faculty appointment upon completion of training, or performance on the board certification exam. R² for the multivariable model was 0.25.

CONCLUSIONS

These findings provide sound validity evidence establishing item content, internal consistency reliability, and associations with other variables for faculty-of-fellow clinical assessment scores that include MCFA-10 items during cardiology fellowship. Relations to other variables evidence included associations of assessment scores with performance on the in-training examination and receipt of competitive awards. These data support the utility of the MCFA-10 as a measure of performance during cardiology training and could serve as the foundation for future research on the assessment of subspecialty learners.

Burnout and Well-Being Among Cardiology Fellowship Program Directors

OBJECTIVES

The third annual Cardiovascular Diseases (CV) Fellowship Program Directors (PDs) Survey sought to understand burnout and well-being among CV fellowship PDs.

BACKGROUND

Physician burnout is a common phenomenon. Data on burnout among cardiologists, specifically CV PDs, remain limited.

METHODS

The survey contained 8 questions examining satisfaction, stress, and burnout among CV fellowship PDs. Burnout was defined based on the self-reported presence of ≥1 symptom of burnout, constant feelings of burnout, or complete burnout.

RESULTS

Survey response rate was 57%. Most respondents were men (78%) and 54% represented university-based programs. Eighty percent reported satisfaction with their current job as PD, and 96% identified interactions with fellows as a driver of their satisfaction. Forty-five percent reported feeling a great deal of stress from their job. Stress was higher among women PDs, early-career PDs, and PDs of larger and university-based programs. Twenty-one percent reported some symptoms of burnout, and only 36% reported enjoyment without stress or burnout. Rates of enjoyment without stress or burnout were higher among men and late-career PDs, PDs of smaller programs, and PDs of community-based programs. Seventeen percent of PDs reported a high likelihood of resigning in the next year, of which the most common reason was the tasks of PDs were becoming overwhelming.

CONCLUSIONS

Most CV fellowship PDs are satisfied with their position, but stress and burnout remain common. Women PDs, early-career PDs, and PDs of larger, university-based programs demonstrate more adverse markers of well-being. Opportunities exist to support CV fellowship PDs in their critical role.

Program Directors Survey on Diversity in Cardiovascular Training Programs

BACKGROUND

Women and minorities are under-represented in cardiovascular disease (CVD) specialties. It remains unknown how characteristics of the CVD learning environment affect diversity and how program directors (PDs) approach these critical issues.

OBJECTIVES

The second annual Cardiovascular PD Survey aimed to investigate characteristics of the CVD learning environment that may affect diversity and strategies PDs use to approach these issues.

METHODS

The survey contained 20 questions examining U.S.-based CVD PD perceptions of diversity in CVD and related characteristics of the CVD fellowship learning environment.

RESULTS

In total, 58% of PDs completed the survey. Responding programs demonstrated geographic diversity. The majority were university-based or -affiliated. A total of 86% of PDs felt diversity in CVD as a field needs to increase, and 70% agreed that training programs could play a significant role in this. In total, 89% of PDs have attempted to increase diversity in fellowship recruitment. The specific strategies used were associated with PD sex and the presence of under-represented minority trainees in the program. PDs identified lack of qualified candidates and overall culture of cardiology as the 2 most significant barriers to augmenting diversity. A majority of programs have support systems in place for minority fellows or specific gender groups, including procedures to report issues of harassment or an unsafe learning environment. PDs identified shared best practices for recruitment and implicit bias training, among others, as important resources in their efforts to support diversity in CVD training.

CONCLUSIONS

Diversity is important to CVD PDs. They are striving to increase it in their programs through recruitment and strategies directed toward the fellowship learning environment. The CVD community has opportunities to standardize strategies and provide national resources to support PDs in these critical efforts.

Medical Education Interest, Exposure, and Career Planning in Subspecialty Trainees

We conducted a survey of subspecialty fellows at a three-site academic institution and characterized fellows' perception of, interest, and training in medical education. One hundred sixty-nine of 530 (31.9%) fellows responded. Most (78.2%) planned careers in academic medicine. Fellows' conception of medical education involved supervising trainees clinically (93.5%), classroom teaching (89.3%), and providing mentorship (87.6%). While only 30.2% had received formal training in medical education, 61.5% felt it should be required for careers with strong educational components. This study provides evidence for the creation and promotion of educational training programs for trainees interested in careers involving medical education.

Predicting Quality of Clinical Performance From Cardiology Fellowship Applications

Variables in cardiology fellowship applications have not been objectively analyzed against applicants' subsequent clinical performance. We investigated possible correlations in a retrospective cohort study of 65 cardiology fellows at the Mayo Clinic (Rochester, Minn) who began 2 years of clinical training from July 2007 through July 2013. Application variables included the strength of comparative statements in recommendation letters and the authors' academic ranks, membership status in the Alpha Omega Alpha Honor Medical Society, awards earned, volunteer activities, United States Medical Licensing Examination (USMLE) scores, advanced degrees, publications, and completion of a residency program ranked in the top 6 in the United States. The outcome was clinical performance as measured by a mean of faculty evaluation scores during clinical training. The overall mean evaluation score was 4.07 ± 0.18 (scale, 1-5). After multivariable analysis, evaluation scores were associated with Alpha Omega Alpha designation (β=0.13; 95% CI, 0.01-0.25; P=0.03), residency program reputation (β=0.13; 95% CI, 0.05-0.21; P=0.004), and strength of comparative statements in recommendation letters (β=0.08; 95% CI, 0.01-0.15; P=0.02), particularly in letters from residency program directors (β=0.05; 95% CI, 0.01-0.08; P=0.009). Objective factors to consider in the cardiology fellowship application include Alpha Omega Alpha membership, residency program reputation, and comparative statements from residency program directors.

Characteristics of internal medicine residents who successfully match into cardiology fellowships

BACKGROUND

The unique traits of residents who matriculate into subspecialty fellowships are poorly understood. We sought to identify characteristics of internal medicine (IM) residents who match into cardiovascular (CV) fellowships.

METHODS

We conducted a retrospective cohort study of 8 classes of IM residents who matriculated into residency from 2007 to 2014. The primary outcome was successful match to a CV fellowship within 1 year of completing IM residency. Independent variables included residents' licensing exam scores, research publications, medical school reputation, Alpha Omega Alpha (AOA) membership, declaration of intent to pursue CV in the residency application personal statement, clinical evaluation scores, mini-clinical evaluation exercise scores, in-training examination (ITE) performance, and exposure to CV during residency.

RESULTS

Of the 339 included residents (59% male; mean age 27) from 120 medical schools, 73 (22%) matched to CV fellowship. At the time of residency application, 104 (31%) had ≥1 publication, 38 (11%) declared intention to pursue CV in their residency application personal statement, and 104 (31%) were members of AOA. Prior to fellowship application, 111 (33%) completed a CV elective rotation. At the completion of residency training, 108 (32%) had ≥3 publications. In an adjusted logistic regression analysis, declaration of intention to pursue CV (OR 6.4, 99% CI 1.7-23.4; p < 0.001), completion of a CV elective (OR 7.3, 99% CI 2.8-19.0; p < 0.001), score on the CV portion of the PGY-2 ITE (OR 1.05, 99% CI 1.02-1.08; p < 0.001), and publication of ≥3 manuscripts (OR 4.7, 99% CI 1.1-20.5; p = 0.007) were positively associated with matching to a CV fellowship. Overall PGY-2 ITE score was negatively associated (OR 0.93, 99% CI 0.90-0.97; p < 0.001) with matching to a CV fellowship.

CONCLUSIONS

Residents' matriculation into CV fellowships was associated with declaration of CV career intent, completion of a CV elective rotation, CV medical knowledge, and research publications during residency. These findings may be useful when advising residents about pursuing careers in CV. They may also help residents understand factors associated with a successful match to a CV fellowship. The negative association between matching into CV fellowship and overall ITE score may indicate excessive subspecialty focus during IM residency.

Preoperative Dobutamine Stress Echocardiography and Clinical Factors for Assessment of Cardiac Risk after Noncardiac Surgery

BACKGROUND

The role of dobutamine stress echocardiography (DSE) in the risk stratification of patients undergoing noncardiac surgery in the current era is unclear. The aim of this study was to evaluate the yield of DSE and the additive role of DSE to clinical criteria for preoperative risk stratification of patients undergoing noncardiac surgery.

METHODS

The study included 4,494 patients undergoing DSE ≤90 days before noncardiac surgery. The primary outcome was a composite of postoperative myocardial infarction, cardiac arrest, and all-cause mortality ≤30 days after noncardiac surgery.

RESULTS

The overall 30-day postoperative cardiac event rate was 2.3%. The mortality rate was 0.9% overall and 0.7% and 1.3% after normal and abnormal results on DSE, respectively. Among clinical variables, the modified Revised Cardiac Risk Index score demonstrated the strongest association with postoperative risk (P < .001). Patients with Revised Cardiac Risk Index scores of ≥3 had an event rate of 7.5%. The event rates for patients with wall motion score index ≥1.7 at baseline, left ventricular ejection fractions <40% at peak stress, or ischemic thresholds <70% of age-predicted maximal heart rate were 7.1%, 8.6%, and 7.9%, respectively. After adjusting for clinical variables, the overall result of DSE (P < .001), baseline and peak-stress wall motion score index (P < .001 and P = .014, respectively), peak-stress left ventricular ejection fraction (P < .001), and the number of ischemic segments (P = .027) were all associated with postoperative cardiac events. Incremental multivariate analysis demonstrated that an overall abnormal result on DSE, added to clinical variables, was associated with an increased risk for postoperative cardiac events (odds ratio, 2.07; 95% CI, 1.35-3.17; P < .001).

CONCLUSIONS

Baseline and peak-stress findings on preoperative DSE add to the prognostic utility of clinical variables for stratifying cardiac risk after noncardiac surgery.

Reinvigorating Continuing Medical Education: Meeting the Challenges of the Digital Age

Clinicians in today's health care environment face an overwhelming quantity of knowledge that requires continued education and lifelong learning. However, traditional continuing medical education (CME) courses cannot meet these educational needs, particularly given the proliferation of knowledge and increasing demands on clinicians' time and resources. CME courses that previously offered only in-person, face-to-face education must evolve in a learner-centric manner founded on principles of adult learning theory to remain relevant in the current era. In this article, we describe the transition of the Mayo Clinic Cardiovascular Review for Cardiology Boards and Recertification (CVBR) from a traditional course with only live content to a course integrating live, online, and enduring materials. This evolution has required leveraging technology to maximize learner engagement, offering faculty development to ensure content alignment with learner needs, and strong leadership dedicated to providing learners an unparalleled educational experience. Despite stagnation in growth of the traditional live course, these changes have increased the overall reach of the Mayo Clinic CVBR. Learners engaging with digital content have demonstrated larger increases in knowledge with less educational time commitment. Courses seeking to implement similar changes must develop formal learning objectives focused on learner needs, build an online presence that includes an assessment of learner knowledge, enlist a cohort of dedicated faculty who teach based on principles of adult learning theory, and perpetually refresh educational content based on learner feedback and performance. Following these principles will allow traditional CME courses to thrive despite learners' resource constraints and alternative means to access information.

QT prolongation in patients with acute leukemia or high-risk myelodysplastic syndrome prescribed antifungal prophylaxis during chemotherapy-induced neutropenia

Benefits of serial electrocardiographic (ECG) monitoring to detect QT prolongation in patients with hematological malignancies remain unclear. This retrospective, single-center, study evaluated 316 adult acute leukemia and high-risk MDS patients who received 11,775 patient-days of voriconazole prophylaxis during induction chemotherapy. Of these, 37 patients (16.2%) experienced QTc prolongation. Medications associated with QTc prolongation included furosemide, haloperidol, metronidazole, mirtazapine, prochlorperazine, and venlafaxine. Hypokalemia and hypomagnesemia were also significantly associated with QTc prolongation (HR 3.15; p = .003 and HR 6.47, p = .007, respectively). Management modifications due to QTc prolongation included discontinuation of QT prolonging medications (n = 25), more aggressive electrolyte repletion (n = 5), and enhanced ECG monitoring (n = 3). One patient with multiple QT prolonging factors experienced possible Torsades de Pointes. Overall mortality was 15% with no cardiac-related deaths. Serial ECG monitoring during induction chemotherapy can be tailored proportionally to QT-prolonging risk factors. Management should include aggressive electrolyte repletion and avoidance of concurrent QT prolonging medications.

Multimodal Imaging of Anomalous Left Coronary Artery from the Pulmonary Artery in a 75-Year-Old Woman

Anomalous origin of the left coronary artery from the pulmonary artery is rare and typically results in mitral regurgitation, ventricular arrhythmias, heart failure, and sudden death. The condition most often manifests itself in early childhood, but some individuals are diagnosed much later. We describe the case of a 75-year-old woman with heart failure in whom stepwise multimodal imaging revealed anomalous origin of the left coronary artery from the pulmonary artery.

Handheld echocardiography during hospitalization for acute myocardial infarction

BACKGROUND

Handheld echocardiography (HHE) is concordant with standard transthoracic echocardiography (TTE) in a variety of settings but has not been thoroughly compared to traditional TTE in patients with acute myocardial infarction (AMI).

HYPOTHESIS

Completed by experienced operators, HHE provides accurate diagnostic capabilities compared with standard TTE in AMI patients.

METHODS

This study prospectively enrolled patients admitted to the coronary care unit with AMI. Experienced sonographers performed HHE with a V-scan. All patients underwent clinical TTE. Each HHE was interpreted by 2 experts blinded to standard TTE. Agreement was assessed with κ statistics and concordance correlation coefficients.

RESULTS

Analysis included 82 patients (mean age, 66 years; 74% male). On standard TTE, mean left ventricular (LV) ejection fraction was 46%. Correlation coefficients between HHE and TTE were 0.75 (95% confidence interval: 0.66 to 0.82) for LV ejection fraction and 0.69 (95% confidence interval: 0.58 to 0.77) for wall motion score index. The κ statistics ranged from 0.47 to 0.56 for LV enlargement, 0.55 to 0.79 for mitral regurgitation, and 0.44 to 0.57 for inferior vena cava dilatation. The κ statistics were highest for the anterior (0.81) and septal (0.71) apex and lowest for the mid inferolateral (0.36) and basal inferoseptal (0.36) walls.

CONCLUSIONS

In patients with AMI, HHE and standard TTE demonstrate good correlation for LV function and wall motion. Agreement was less robust for structural abnormalities and specific wall segments. In experienced hands, HHE can provide a focused assessment of LV function in patients hospitalized with AMI; however, HHE should not substitute for comprehensive TTE.

The Supply and Demand of the Cardiovascular Workforce: Striking the Right Balance

As the burden of cardiovascular disease in the United States continues to increase, uncertainty remains on how well-equipped the cardiovascular workforce is to meet the challenges that lie ahead. In a time when health care is rapidly shifting, numerous factors affect the supply and demand of the cardiovascular workforce. This Council Commentary critically examines several factors that influence the cardiovascular workforce. These include current workforce demographics and projections, evolving health care and practice environments, and the increasing burden of cardiovascular disease. Finally, we propose 3 strategies to optimize the workforce. These focus on cardiovascular disease prevention, the effective utilization of the cardiovascular care team, and alterations to the training pathway for cardiologists.

Side Effects of CV Medications Following Hospitalization for ACS Are Associated With More Frequent Health-Care Contacts

Background:

Patients hospitalized for first acute coronary syndrome (ACS) are frequently discharged on multiple new medications. The short-term tolerability of these medications is unknown.

Methods:

This single-center cohort study assessed 30-day health-care utilization and how it may be impacted by medication prescribing trends. We included Olmsted County patients presenting with ACS and previously undiagnosed coronary artery disease in 2008 to 2009. All health-care contacts were reviewed 30 days after index hospital discharge for potential adverse medication effects including documented hypotension or bradycardia, or symptoms likely attributed to the medications.

Results:

The study included 86 patients; their mean age was 63 (standard deviation: 15.5 years). Antianginal or antihypertensive cardiovascular (CV) medications were prescribed to 98% of patients at discharge; 76% were prescribed 2 or more. There were 233 health-care contacts in 30 days; 90 (39%) of these contacts were unscheduled. More CV medications tended to be prescribed to patients with unscheduled contacts, both pre-ACS ( P = .045) and upon hospital discharge ( P = .051). Hypotension and/or bradycardia at follow-up occurred in 52 patients (60%). Surprisingly, there was no association between hypotension and/or bradycardia at follow-up and increased health-care utilization ( P = .12). Potential adverse drug effects were reported in 34 (40%) patients. These patients had significantly more total health-care contacts ( P < .001) and unscheduled health-care contacts (median 0 vs 1.5; P < .001).

Conclusions:

Symptoms of adverse drug effects were associated with more frequent health-care utilization after ACS. Clinicians need to consider this while striving to increase patient compliance with post-ACS medications and optimize care transitions.

Platypnea-Orthodeoxia Syndrome: Diagnostic Challenge and the Importance of Heightened Clinical Suspicion

Platypnea-orthodeoxia syndrome is an uncommon condition of positional dyspnea and hypoxemia; symptoms occur when the patient is upright and resolve with recumbency. Causes can be broadly categorized into 4 groups: intracardiac shunting, pulmonary shunting, ventilation-perfusion mismatch, or a combination of these. Platypnea-orthodeoxia syndrome should be suspected when normal arterial oxygen saturations are recorded while an individual is supine, followed by abrupt declines in those saturations when upright. Further investigations with use of imaging and cardiac catheterization aid in the evaluation. When platypnea-orthodeoxia syndrome is due to intracardiac shunting without pulmonary hypertension, intracardiac shunt closure can be curative. In this article, we report a case of platypnea-orthodeoxia syndrome in an 83-year-old woman who was successfully treated by means of percutaneous transcatheter closure of an atrial septal defect.

COCATS 4: Securing the Future of Cardiovascular Medicine

The latest iteration of the Core Cardiology Training Statement (COCATS 4) [Corrected] provides a potentially transformative advancement in cardiovascular fellowship training intended, ultimately, to improve patient care. This review addressed 3 primary themes of COCATS 4 from the perspective of fellows-in-training: 1) the evolution of training requirements culminating in a competency-based curriculum; 2) the development of novel learning paradigms; and 3) the establishment of task forces in emerging areas of multimodality imaging and critical care cardiology. This document also examined several important challenges presented by COCATS 4. The proposed changes in COCATS 4 should not only enhance the training experience but also improve trainee satisfaction. Because it embraces continual transformation of training requirements to meet evolving clinical needs and public expectations, COCATS 4 will enrich the cardiovascular fellowship training experience for patients, programs, and fellows-in-training.

Transesophageal echocardiography-guided cardioversion after cardiac operations

BACKGROUND

Transesophageal echocardiography (TEE) is often performed during cardiac operations. The need to repeat TEE to exclude left atrial or left atrial appendage thrombus before direct current cardioversion (DCCV) in patients with a recent intraoperative TEE showing no thrombus is unclear. We sought to determine the incidence of and risk factors for new thrombus in patients undergoing TEE-guided DCCV after cardiac operations.

METHODS

We reviewed 817 patients referred for TEE-guided DCCV within 30 days of a cardiac operation and an intraoperative TEE. Patients were excluded if the intraoperative TEE showed thrombus or a surgical left atrial appendage intervention was performed. Univariate logistic regression identified risk factors for thrombus.

RESULTS

The study included 362 patients (71% male) with a mean age of 69 years. Median time from the operation to DCCV was 6 days. Thrombus was present in 13 patients (3.6%) on TEE before cardioversion; DCCV was cancelled in these patients. Heart failure was associated with a significantly higher risk of new thrombus formation (7% vs 2%; odds ratio, 3.26; 95% confidence interval, 1.07 to 9.95). Preoperative atrial arrhythmias, duration of perioperative arrhythmias, level of anticoagulation, and time from operation to DCCV were not significantly associated with thrombus. Thrombus was not associated with 30-day mortality.

CONCLUSIONS

Development of new thrombus in patients with atrial arrhythmias early after cardiac operations is not uncommon, especially in patients with heart failure. Patients at high risk for thromboembolic events should undergo TEE before DCCV, even if a recent intraoperative TEE showed no thrombus.

Diagnostic capability of comprehensive handheld vs transthoracic echocardiography

OBJECTIVE

To assess the diagnostic capability of handheld echocardiography (HHE) compared with transthoracic echocardiography (TTE) performed and evaluated by experienced sonographers and expert echocardiographers.

PATIENTS AND METHODS

We conducted a prospective study of adult outpatients undergoing comprehensive TTE between July 9, 2012, and April 3, 2013. Experienced sonographers performed a detailed, standardized examination using a handheld ultrasound device that included 2-dimensional and color Doppler images from standard imaging windows. Images from TTE and HHE were independently interpreted by expert echocardiographers to whom the other study was masked. Agreement between the standard TTE and the HHE reports was analyzed.

RESULTS

The study group contained 190 patients (mean ± SD age, 62 ± 17 years; 49% male [n=93]). The κ values were 0.52 for left ventricular (LV) enlargement, 0.52 for right ventricular enlargement, 0.62 for regional wall motion abnormalities, 0.73 for aortic stenosis, and 0.61 for mitral regurgitation. Lin concordance correlation coefficients ranged from 0.89 for LV end-systolic diameter to 0.78 for LV end-diastolic diameter. In 51 patients (27%), echocardiographic findings were discordant between HHE and standard TTE. The most common discordant finding was the presence vs absence of any regional wall motion abnormalities. In discordant cases, HHE tended to underestimate, rather than overestimate, the severity of abnormal findings.

CONCLUSION

In experienced hands, HHE shows moderate correlation with standard TTE, but discordant findings were present in 27% of patients. Even when performed and interpreted by experienced operators, HHE should not be used as a surrogate for standard TTE.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01558518.

Weight change after a one-time preventive cardiology clinic visit

AIM

The effect of a one-time visit to a cardiovascular health clinic (CVHC) on weight change remains unknown. Our study examined the effects of such a visit for subjects undergoing medical and preventive evaluations.

METHODS

The study screened 836 subjects with a baseline BMI>25 kg/m2 and a follow-up weight at least 6 months from the initial visit. Patients with active cardiac disease were excluded. Data were obtained through a medical record review. The study included 342 patients with a mean baseline weight of 93.1 kg and BMI of 31.0 kg/m2.

RESULTS AND CONCLUSION

Mean subsequent weight was 92.4 kg, representing a weight loss of 0.76 kg (P=0.005). Subjects with a previously documented weight showed a trend toward weight gain before the baseline visit. Mean weight loss was higher when the referring provider documented a weight-related diagnosis or plan (-1.63 vs. -0.23 kg, P=0.01), when the CVHC encounter occurred with an MD rather than a PhD-level exercise physiologist (-1.50 vs. 0.03 kg, P=0.004), and when the CVHC provider documented a weight-related diagnosis (-1.39 vs. -0.18 kg, P=0.02) or recommended diet changes (-1.09 vs. 0.75 kg, P=0.01). Individuals undergoing a preventive evaluation had lower mean weight loss (-0.13 vs. -1.49 kg, P=0.02). A single encounter in the CVHC reversed the trend toward weight gain. Characteristics associated with weight loss were referral for weight issues, encounter with an MD provider, and provision of diet recommendations. Patients undergoing medical evaluation had more weight loss than participants in a preventive health program.

Risks and Benefits of Anticoagulation in Atrial Fibrillation

Background—

Patients with atrial fibrillation (AF) at the highest stroke risk derive the largest benefit from oral anticoagulation (OAC). Those with the highest stroke risk have been paradoxically less likely to receive OAC. This study assessed the association between stroke and bleeding risk on rates of OAC.

Methods and Results—

We analyzed OAC use among 10 098 patients with AF from 174 community-based outpatient practices enrolled in 2010–2011 in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). OAC was defined as warfarin or dabigatran use at study enrollment. Stroke and bleeding risk were calculated using congestive heart failure, hypertension, age, diabetes mellitus, prior stroke (CHADS 2 ), and anticoagulation and risk factors in AF (ATRIA) scores, respectively. The mean subject age was 73 years; 58% were men. Overall, 76% of patients received OAC (71% warfarin and 5% dabigatran). The use of OAC increased among those with higher CHADS 2 scores, from 53% for CHADS 2 =0 to 80% for CHADS 2 ≥2 ( P <0.001). OAC use fell slightly with increasing ATRIA bleeding risk score, from 81% for ATRIA=3 to 73% for ATRIA≥5 ( P <0.001). A significant interaction existed between ATRIA and CHADS 2 scores ( P =0.021). Among those with low bleeding risk, use of OAC increased significantly with increasing stroke risk. Among those with high bleeding risk, CHADS 2 stroke risk had a smaller impact on use of OAC.

Conclusions—

In community-based outpatients with AF, use of OAC was high and driven by not only predominantly stroke but also bleeding risk. Stroke risk significantly affects OAC use among those with low bleeding risk, whereas those with high bleeding risk demonstrate consistently lower use of OAC regardless of stroke risk.

Transvenous, antegrade Melody valve-in-valve implantation for bioprosthetic mitral and tricuspid valve dysfunction: a case series in children and adults

OBJECTIVES

The purpose of this study was to report the results of percutaneous valve-in-valve therapy using the Melody valve (Medtronic, Minneapolis, Minnesota) for patients with degenerated mitral and tricuspid bioprosthetic valves.

BACKGROUND

Open surgery for replacement of degenerated bioprosthetic valves is associated with morbidity and mortality.

METHODS

Nineteen patients (median age 65 years, range 10 to 88 years; 7 males) with degenerated mitral (n = 9) or tricuspid (n = 10) bioprosthetic valves underwent transvenous valve-in-valve implantation of the Melody valve.

RESULTS

In the mitral patients, the mean Society of Thoracic Surgeons mortality score was 13.3 ± 5.6%. All patients had a prosthetic valve mean diastolic inflow gradient ≥5 mm Hg. Moderate or worse regurgitation was present in 7 of 9 mitral and 7 of 10 tricuspid patients. Implantation of a Melody valve was successful in all. Among the mitral patients, mean diastolic gradient decreased from 12.3 ± 4.6 mm Hg to 5.2 ± 2 mm Hg (p < 0.01). Residual regurgitation was trivial to mild in 6, mild to moderate in 2, and moderate in 1 patient. Among the tricuspid patients, mean diastolic gradient decreased from 10.0 ± 4.3 mm Hg to 5.6 ± 2.5 mm Hg (p < 0.01). Residual regurgitation was trivial to mild in 9 and mild to moderate in 1 patient. New York Heart Association functional class improved in 17 of 19 patients (p < 0.01). No periprocedural deaths, myocardial infarctions, strokes, or valve embolizations occurred. Vascular access site complications occurred in 4 patients.

CONCLUSIONS

Percutaneous valve-in-valve implantation of the Melody valve in the mitral or tricuspid position for treatment of bioprosthetic valve dysfunction is feasible and can lead to significant symptomatic improvement in carefully selected high-risk patients.

Trends in low-density lipoprotein cholesterol goal achievement in high risk United States adults: longitudinal findings from the 1999-2008 National Health and Nutrition Examination Surveys

BACKGROUND

Previous studies have demonstrated gaps in achievement of low-density lipoprotein-cholesterol (LDL-C) goals among U.S. individuals at high cardiovascular disease risk; however, recent studies in selected populations indicate improvements.

OBJECTIVE

We sought to define the longitudinal trends in achieving LDL-C goals among high-risk United States adults from 1999-2008.

METHODS

We analyzed five sequential population-based cross-sectional National Health and Nutrition Examination Surveys 1999-2008, which included 18,656 participants aged 20-79 years. We calculated rates of LDL-C goal achievement and treatment in the high-risk population.

RESULTS

The prevalence of high-risk individuals increased from 13% to 15.5% (p = 0.046). Achievement of LDL-C <100 mg/dL increased from 24% to 50.4% (p<0.0001) in the high-risk population with similar findings in subgroups with (27% to 64.8% p<0.0001) and without (21.8% to 43.7%, p<0.0001) coronary heart disease (CHD). Achievement of LDL-C <70 mg/dL improved from 2.4% to 17% (p<0.0001) in high-risk individuals and subgroups with (3.4% to 21.4%, p<0.0001) and without (1.7% to 14.9%, p<0.0001) CHD. The proportion with LDL-C ≥130 mg/dL and not on lipid medications decreased from 29.4% to 18% (p = 0.0002), with similar findings among CHD (25% to 11.9% p = 0.0013) and non-CHD (35.8% to 20.8% p<0.0001) subgroups.

CONCLUSION

The proportions of the U.S. high-risk population achieving LDL-C <100 mg/dL and <70 mg/dL increased over the last decade. With 65% of the CHD subpopulation achieving an LDL-C <100 mg/dL in the most recent survey, U.S. LDL-C goal achievement exceeds previous reports and approximates rates achieved in highly selected patient cohorts.