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. 2016 Mar 16. [Epub ahead of print]

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The article by van Veghel et al.[First results of a national initiative to enable quality improvement of cardiovascular care by transparently reporting on patient-relevant outcomes; Eur J Cardiothorac Surg., first published online March 16, 2016] 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’ (http://www.meetbaarbeter.com/). 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.’ This programme that began in 2012, termed the Netherlands Joint Outcomes and Transparency Initiative is a voluntary cooperative of 14 of the 16 heart centres in the country. The initial results of that effort in 86 000 patients treated at 12 of those hospitals with one of three diseases are reported in the accompanying article. The conclusion of this study is that ‘annual data collection of patient relevant outcomes appears to be feasible’. Furthermore, the authors conclude that transparency drives quality improvement and that using a limited set of outcomes measures enables comparisons and ‘exposes the quality of decision-making’. Lastly, they conclude that transparent communication is feasible, safe, cost-effective and stimulates professional decision-making and disease management . . . While this is an ambitious national multicentre initiative that is based on achieving patient-centred healthcare value, it is not clear from this study exactly how much the ‘needle has moved’. It is also not apparent how much of any change that may have occurred is truly causation and not merely association. Don Berwick, former administrator of the Center for Medicare and Medicaid in the USA, has recently stated as the first of nine steps to improve healthcare that we must stop excessive measurement. Stated another way, just because you step on a scale does not mean you lose weight. While the goals of this programme are laudable and beyond reproach, the evidence that change is actually occurring is not evident from this report. We would encourage the leaders of this national initiative to make efforts to provide greater clarity of results actually achieved and quality improvement in patient-relevant outcomes that they can directly credit to the programme. They are stepping on the scales and weighing a lot but is any weight really being lost? (Excerpts from text; no abstract.)

Kodali, S., M. R. Williams, D. Doshi, R. T. Hahn, K. H. Humphries, V. T. Nkomo, D. J. Cohen, P. S. Douglas, M. Mack, K. Xu, L. Svensson, V. H. Thourani, E. M. Tuzcu, N. J. Weissman, M. Leon and A. J. Kirtane (2016). “Sex-Specific Differences at Presentation and Outcomes Among Patients Undergoing Transcatheter Aortic Valve Replacement: A Cohort Study.” Ann Intern Med 164(6): 377-384.

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BACKGROUND: Female sex is associated with poorer outcomes after surgical aortic valve replacement (SAVR). Data on sex-specific differences after transcatheter aortic valve replacement (TAVR) are conflicting. OBJECTIVE: To examine sex-specific differences in patients undergoing TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) trial. DESIGN: Secondary analysis of the randomized and nonrandomized portions of the PARTNER trial. (ClinicalTrials.gov: NCT00530894). SETTING: 25 hospitals in the United States, Canada, and Germany. PATIENTS: High-risk and inoperable patients (1220 women and 1339 men). INTERVENTION: TAVR. MEASUREMENTS: Demographic characteristics, cardiac and noncardiac comorbidities, mortality, stroke, rehospitalization, vascular complications, bleeding complications, and echocardiographic valve parameters. RESULTS: At baseline, women had lower rates of hyperlipidemia, diabetes, smoking, and renal disease but higher Society of Thoracic Surgeons Predicted Risk of Mortality scores (11.9% vs. 11.1%; P < 0.001). After TAVR, women had more vascular complications (17.3% vs. 10.0%; difference, 7.29 percentage points [95% CI, 4.63 to 9.95 percentage points]; P < 0.001) and major bleeding (10.5% vs. 7.7%; difference, 2.8 percentage points [CI, 0.57 to 5.04 percentage points]; P = 0.012) but less frequent moderate and severe paravalvular regurgitation (6.0% vs. 14.3%; difference, -8.3 percentage points [CI, -11.7 to -5.0 percentage points]; P < 0.001). At 30 days, the unadjusted all-cause mortality rate (6.5% vs. 5.9%; difference, 0.6 percentage point [CI, -1.29 to 2.45 percentage points]; P = 0.52) and stroke incidence (3.8% vs. 3.0%; difference, 0.8 percentage point [CI, -0.62 to 2.19 percentage points]; P = 0.28) were similar. At 1 year, all-cause mortality was significantly lower in women than in men (19.0% vs. 25.9%; hazard ratio, 0.72 [CI, 0.61 to 0.85]; P < 0.001). LIMITATION: Secondary analysis that included nonrandomized trial data. CONCLUSION: Despite a higher incidence of vascular and bleeding complications, women having TAVR had lower mortality than men at 1 year. Thus, sex-specific risk in TAVR is the opposite of that in SAVR, for which female sex has been shown to be independently associated with an adverse prognosis. PRIMARY FUNDING SOURCE: Edwards Lifesciences.

Roberts, W. C., S. A. Hall, J. M. Ko, P. A. McCullough and B. Lima (2016). “Atrophy of the Heart After Insertion of a Left Ventricular Assist Device and Closure of the Aortic Valve.” Am J Cardiol 117(5): 878-879.

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Described are findings in a 70-year-old man who had heart transplantation 4 years after treatment with a left ventricular assist device, and surgical closure of his previously replaced aortic valve. The result was a totally nonfunctioning left ventricle resulting in severe atrophy.

Roberts, W. C. (2016). “Proliferation of Online Medical Journals.” Am J Cardiol 117(4): 699-700.

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Almost daily on my emails there is a new open access (online) medical journal requesting a manuscript from me, or asking that I review a manuscript received by them. During a recent 2-month period, I counted at least 26 heart-related journals (Table 1) and at least 75 non-heart related journals (Table 2). Most do not have a physician as editor and few are included on PubMed. Medicine went from a physician editor of international distinction to a non-physician editor of unknown qualifications. Most of the online journals charge authors to publish their manuscripts and not the readers for reading them, the reverse of hundreds of years of publishing. Some of these online journals not only request reviews from physicians of the submitted manuscripts but also request that physicians recommend names of appropriate reviewers, and some request that physicians actually manage groups of manuscripts as visiting editors. A young investigator might be tempted to submit his/her manuscript to one of the open-access journals after receiving a gracious invitation to do so rather than submit the manuscript to an established journal. I realize that online publishing without print publishing will probably be the future for most present-day print journals but that change has not occurred yet so I recommend staying with the print journals as long as they use that medium. Academic careers will not be built by publishing in the open access journals with non-physician editors.

Wang, A., P. Grayburn, J. A. Foster, M. L. McCulloch, V. Badhwar, J. S. Gammie, S. P. Costa, R. M. Benitez, M. J. Rinaldi, V. H. Thourani and R. P. Martin (2016). “Practice gaps in the care of mitral valve regurgitation: Insights from the American College of Cardiology mitral regurgitation gap analysis and advisory panel.” Am Heart J 172: 70-79.

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BACKGROUND: The revised 2014 American College of Cardiology (ACC)/American Heart Association valvular heart disease guidelines provide evidenced-based recommendations for the management of mitral regurgitation (MR). However, knowledge gaps related to our evolving understanding of critical MR concepts may impede their implementation. METHODS: The ACC conducted a multifaceted needs assessment to characterize gaps, practice patterns, and perceptions related to the diagnosis and treatment of MR. A key project element was a set of surveys distributed to primary care and cardiovascular physicians (cardiologists and cardiothoracic surgeons). Survey and other gap analysis findings were presented to a panel of 10 expert advisors from specialties of general cardiology, cardiac imaging, interventional cardiology, and cardiac surgeons with expertise in valvular heart disease, especially MR, and cardiovascular education. The panel was charged with assessing the relative importance and potential means of remedying identified gaps to improve care for patients with MR. RESULTS: The survey results identified several knowledge and practice gaps that may limit implementation of evidence-based recommendations for MR care. Specifically, half of primary care physicians reported uncertainty regarding timing of intervention for patients with severe primary or functional MR. Physicians in all groups reported that quantitative indices of MR severity were frequently not reported in clinical echocardiographic interpretations, and that these measurements were not consistently reviewed when provided in reports. In the treatment of MR, nearly 30% of primary care physician and general cardiologists did not know the volume of mitral valve repair surgeries by their reference cardiac surgeons and did not have a standard source to obtain this information. After review of the survey results, the expert panel summarized practice gaps into 4 thematic areas and offered proposals to address deficiencies and promote better alignment with the 2014 ACC/American Heart Association valvular disease guidelines. CONCLUSION: Important knowledge and skill gaps exist that may impede optimal care of the patient with MR. Focused educational and practice interventions should be developed to reduce these gaps.