Cardiology

Mack, M. and H. Baumgarten (2016). “Just because you get on a scale doesn’t mean you lose weight: Is meetbaar beter really measurably better?” Eur J Cardiothorac Surg 49(6): 1669-1670.

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The article by van Veghel et al. [1] describes a national initiative in the Netherlands termed ‘Meetbaar Beter’ or in English ‘Measurably Better’. The stated goal of this multicentre effort according to its website ‘aims to improve quality and transparency of care for patients with heart diseases by measuring limited patient-relevant outcome measures’. Those outcomes include survival, degree of health/recovery, time to recovery and return to normal activity, disutility of the care of treatment process, sustainability of health/recovery and nature of recurrences and long-term consequences of the therapy. By doing this, they are proposing to implement a ‘Value Based Healthcare Theory’ by ‘measuring patient relevant outcomes and sharing and adopting each others best practices’.

McCabe, J. M., P. H. Huang, D. J. Cohen, E. H. Blackstone, F. G. Welt, M. J. Davidson, T. Kaneko, M. H. Eng, K. B. Allen, K. Xu, A. M. Lowry, Y. Lei, J. Rajeswaran, D. L. Brown, M. J. Mack, J. G. Webb, C. R. Smith, M. B. Leon and A. C. Eisenhauer (2016). “Surgical versus percutaneous femoral access for delivery of large-bore cardiovascular devices (from the partner trial).” Am J Cardiol 117(10): 1643-1650.

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It is unclear if surgical exposure confers a risk advantage compared with a percutaneous approach for patients undergoing endovascular procedures requiring large-bore femoral artery access. From the randomized controlled Placement of Aortic Transcatheter Valve trials A and B and the continued access registries, a total of 1,416 patients received transfemoral transcatheter aortic valve replacement, of which 857 underwent surgical, and 559 underwent percutaneous access. Thirty-day rates of major vascular complications and quality of life scores were assessed. Propensity matching was used to adjust for unmeasured confounders. Overall, there were 116 major vascular complications (8.2%). Complication rates decreased dramatically during the study period. In unadjusted analysis, major vascular complications were significantly less common in the percutaneous access group (35 [6.3%] vs 81 [9.5%] p = 0.032). However, among 292 propensity-matched pairs, there was no difference in major vascular complications (22 [7.5%] vs 28 [9.6%], p = 0.37). Percutaneous access was associated with fewer total in-hospital vascular complications (46 [16%] vs 66 [23%], p = 0.036), shorter median procedural duration (97 interquartile range [IQR 68 to 166] vs 121 [IQR 78 to 194] minutes, p <0.0001), and median length of stay (4 [IQR 2 to 8] vs 6 [IQR 3 to 10] days, p <0.0001). There were no significant differences in quality of life scores at 30 days. Surgical access for large-bore femoral access does not appear to confer any advantages over percutaneous access and may be associated with more minor vascular complications.

Cochran, G., C. Field, M. Foreman, T. Ylioja and C. V. Brown (2016). “Effects of brief intervention on subgroups of injured patients who drink at risk levels.” Inj Prev 22(3): 221-225.

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Alcohol-related injuries are a major source of admission for trauma care. Screening and brief intervention (SBI) for injured patients can result in decreased drinking and risk behaviors. It is not clear SBI is equally beneficial for all injured patients. A secondary data analysis of 553 patients admitted to two Level-1 trauma centers was conducted. Latent class analysis was used to identify patient subgroups based on injury-related risks and consequences of alcohol use. Intervention effects on drinking were examined among subgroups. Five subgroups were identified. Drinking improved in patients reporting multiple risks and injuries/accidents and drinking and driving. Patients that reported drinking and driving and taking foolish risks or fighting while drinking and taking foolish risks did not show improvements. Trauma centers may benefit from targeting interventions based on injury-related risks and consequences of alcohol use. Further research is needed to test bedside approaches for tailored interventions.

Gonzalez-Stawinski, G. V. (2016). “Donor hearts: Time to look at them in a different light?” J Card Fail 22(5): 383-384.

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In this edition of The Journal of Cardiac Heart Failure, 2 papers aim to inform readers of donor groups that could be considered at the time of cardiac donation in the hope of expanding the stagnant donor pool.

Charytan, D. M., R. Foley, P. A. McCullough, J. D. Rogers, P. Zimetbaum, C. A. Herzog, J. A. Tumlin, D. I. Mi and Comm (2016). “Arrhythmia and sudden death in hemodialysis patients: Protocol and baseline characteristics of the monitoring in dialysis study.” Clinical Journal of the American Society of Nephrology 11(4): 721-734.

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Background Dialysis patients have high rates of cardiovascular morbidity and mortality, but data on arrhythmia burden, arrhythmia type, arrhythmia triggers, and the identity of terminal arrhythmias have historically been limited by an inability to monitor heart rhythm for prolonged periods. Objectives To investigate arrhythmia and its association with sudden death in dialysis-dependent ESRD, describe the potential for implantable devices to advance study of dialysis physiology, review the ethical implications of using implantable devices in clinical studies, and report on the protocol and baseline results of the Monitoring in Dialysis Study (MiD). Design, setting, participants, & measurements In this multicenter, interventional-observational, prospective cohort study, we placed implantable loop recorders in patients undergoing long-term hemodialysis. The proportion of patients experiencing clinically significant arrhythmias was the primary endpoint. For 6 months, we captured detailed data on the primary endpoint, symptomatic arrhythmias, other electrocardiographic variables, dialysis prescription, electrolytes, dialysis-related variables, and vital signs. We collected additional electrocardiographic data for up to 1 year. Results Overall, 66 patients underwent implantation in sites in the United States and India. Diabetes was present in 63.6% of patients, 12.1% were age >= 70 years, 69.7% were men, and 53.0% were black. Primary and secondary endpoint data are expected in 2016. Conclusions Cardiac arrhythmia is an important contributor to cardiovascular morbidity and mortality in dialysis patients, but available technology has previously limited the ability to estimate its true burden and triggers and to define terminal rhythms in sudden death. Use of implantable technology in observational studies raises complex issues but may greatly expand understanding of dialysis physiology. The use of implantable loop recorders in MiD is among the first examples of such a trial, and the results are expected to provide novel insights into the nature of arrhythmia in hemodialysis patients.