Background Natriuretic peptides are routinely quantified to diagnose heart failure (HF). Their concentrations are also elevated in atrial fibrillation (AF). To clarify their value in predicting future cardiovascular events, we measured natriuretic peptides in unselected patients with cardiovascular conditions and related their concentrations to AF and HF status and outcomes. Methods and Results Consecutive patients with cardiovascular conditions presenting to a large teaching hospital underwent clinical assessment, 7‐day ECG monitoring, and echocardiography to diagnose AF and HF. NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) was centrally quantified. Based on a literature review, four NT‐proBNP groups were defined (<300, 300–999, 1000–1999, and ≥2000 pg/mL). Clinical characteristics and NT‐proBNP concentrations were related to HF hospitalization or cardiovascular death. Follow‐up data were available in 1616 of 1621 patients (99.7%) and analysis performed at 2.5 years (median age, 70 [interquartile range, 60–78] years; 40% women). HF hospitalization or cardiovascular death increased from 36 of 488 (3.2/100 person‐years) in patients with neither AF nor HF, to 55 of 354 (7.1/100 person‐years) in patients with AF only, 92 of 369 (12.1/100 person‐years) in patients with HF only, and 128 of 405 (17.7/100 person‐years) in patients with AF plus HF ( P <0.001). Higher NT‐proBNP concentrations predicted the outcome in patients with AF only (C‐statistic, 0.82; 95% CI, 0.77–0.86; P <0.001) and in other phenotype groups (C‐statistic in AF plus HF, 0.66; [95% CI, 0.61–0.70]; P <0.001). Conclusions Elevated NT‐proBNP concentrations predict future HF events in patients with AF irrespective of the presence of HF, encouraging routine quantification of NT‐proBNP in the assessment of patients with AF.
Simulation-based learning (SBL) is well-established in medical education and has gained popularity, particularly during the COVID-19 pandemic when in-person teaching is infeasible. SBL replicates real-life scenarios and provides a fully immersive yet safe learning environment to develop clinical competency. Simulation via Instant Messaging – Birmingham Advance (SIMBA) is an exemplar of SBL, which we previously showed to be effective in endocrinology and diabetes. Previous studies reported the efficacy of SBL in acute medicine. We studied SIMBA as a learning intervention for healthcare professionals interested in acute medicine and defined our aims using the Kirkpatrick model: (i) develop an SBL tool to improve case management; (ii) evaluate experiences and confidence before and after; and (iii) compare efficacy across training levels.Three sessions were conducted, each representing a PDSA cycle (Plan-Do-Study-Act), consisting of four cases and advertised to healthcare professionals at our hospital and social media. Moderators facilitated progression through 25 min simulations and adopted patient and clinical roles as appropriate. Consultants chaired discussion sessions using relevant guidelines. Presimulation and postsimulation questionnaires evaluated self-reported confidence, feedback and intended changes to clinical practice.Improvements were observed in self-reported confidence managing simulated cases across all sessions. Of participants, 93.3% found SIMBA applicable to clinical practice, while 89.3% and 88.0% felt SIMBA aided personal and professional development, respectively. Interestingly, 68.0% preferred SIMBA to traditional teaching methods. Following participant feedback, more challenging cases were included, and we extended the time for simulation and discussion. The transcripts were amended to facilitate more participant-moderator interaction representing clinical practice. In addition, we refined participant recruitment over the three sessions. In cycle 1, we advertised incentives: participation counted towards teaching requirements, certificates and feedback. To rectify the reduction in participants in cycle 2, we implemented new advertisement methods in cycle 3, including on-site posters, reminder emails and recruitment of the defence deanery cohort.
Background/Introduction Cardiovascular (CV) diseases including atrial fibrillation and arteriosclerosis are associated with impaired cognitive function. Cognitive dysfunction can impact the process of shared clinical decision making, reduce adherence to polypharmacy, and decrease quality of life. The prevalence of cognitive dysfunction in contemporary patients with CV diseases and its implication on future CV events is not well known. Purpose We 1) quantified cognitive function in patients presenting to hospital with CV diseases, 2) identified clinical variables and blood biomarkers associated with cognitive dysfunction, and 3) quantified the hazard of abnormal cognitive function for predicting MACCE (major adverse CV and cerebrovascular events). Methods and results Of 1625 consecutive patients presenting acutely to a large teaching hospital with CV diseases, 614 patients (median age [Q1, Q3] 68 [58, 76] years; 66% male) who completed the Montreal Cognitive Assessment (MoCA) were analysed. The median [Q1, Q3] MoCA score was 25 points [21, 27]. 360 patients (59%) had an abnormal score (<26). At baseline, patients with abnormal scores were more likely to be female (odds ratio, OR [95% confidence intervals], 1.874 [1.287, 2.728]), have BMI<30 (OR 0.584 [0.410, 0.831]), heart failure (OR 1.492 [1.043, 2.135]), diabetes (OR 2.212 [1.529, 3.199]), chronic kidney disease (CKD-EPI<60 ml/min, OR 1.553 [1.021, 2.361]), and have more CV co-morbidities (OR per additional co-morbidity 1.415 [1.246, 1.605]). Amongst 12 CV biomarkers tested, elevated Bone Morphogenetic Protein 10 (OR 1.325 [1.022, 1.719]) and Growth Differentiation Factor 15 (OR 1.419 [1.054, 1.912]) increased odds of abnormal scores. Cox proportional hazards model adjusted for competing risk of non-CV death assessed the relationship between abnormal cognitive function and MACCE (stroke, TIA, myocardial infarction, hospitalisation for heart failure, CV death). Follow-up time ranged from 2.7 to 6.1 years. Patients were censored at 2.5 years for this analysis. 130 out of 614 patients experienced a MACCE (21%) and 71 had a non-CV death (12%). Patients with abnormal MoCA scores were at higher risk for MACCE (subhazard ratio, sHR [95% CI] 1.827 [1.253, 2.664]). The hazard remained significant after adjustment for age, sex, obesity, atrial fibrillation, stroke, heart failure, hypertension, coronary artery disease, diabetes, peripheral artery disease and renal dysfunction (sHR 1.367 [1.056, 2.326]; Figure). All-cause mortality was 1.785 times higher for those with abnormal MoCA scores [1.061, 3.002]. Conclusion In this study, 3 out of 5 patients with CV diseases had abnormal MoCA scores at baseline. Abnormal cognitive scores significantly predicted patients who went on to experience a MACCE within 2.5 years of follow-up. These observations call for further research and action to provide additional diagnostics, support and early intervention to address cognitive dysfunction in CV patients. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EU H2020 CATCH ME Cumulative incidence function
Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): West Midlands Academic Health Science Network. Background After an acute coronary syndrome (ACS), there is a persistent ~10% risk of recurrent ACS or death in the following year and a further ~10% risk between years 1-4. Several more recent guideline-recommended treatments that could reduce this risk (Knuuti et al 2019) and may be under-utilised. Some of these, such as long-term dual antithrombotic therapy, are recommended for patients with high cardiovascular risk. Others benefit patients with type 2 diabetes mellitus (SGLT2 inhibitors and GLP1 agonists), hypercholesterolaemia (ezetimibe and PCSK9 inhibitors) or heart failure (mineralocorticoid antagonists and sacubitril/valsartan in addition to ACE inhibitors and beta blockers). Methods We were recently awarded funding from the West Midlands Academic Health Science Network (UK) to introduce a new advanced secondary prevention clinic that focusses on more recent medications with recommendations from National Institute for Health and Care Excellence (NICE NG185 and relevant technology appraisals) and the ESC. In an audit we compared use of medications in the prevention clinic (n=57) with similar patients with prior ACS seen in standard cardiology clinics (n=109) between 2020-21 in our National Health Service (NHS) Trust (Fig 1.). Results Assessment of eligibility for medications was complex, but showed similar eligibility in prevention clinics and standard clinics. Patients were uniformly eligible for statins and ACE inhibitors, whereas NICE and ESC guidelines in some cases disagreed on eligibility of individual patients for dual antithrombotic therapy, beta blockers and ezetimibe. Use of treatments with definitive guideline recommendations from both NICE and ESC was determined for each patient (Fig 1). There was significantly higher adherence to these definitive recommendations in prevention vs. standard clinics (Fig 1), including SGLT2 inhibitors/GLP1 agonists (17/18 [94%] vs. 5/29 [17%]; P<0.001), PCSK9 inhibitors (3/3 [100%] vs. 0/6 [0%]; P=0.01), ezetimibe (23/25 [92%] vs. 11/48 [23%]; P<0.001], long-term dual antithrombotic therapy (22/23 [96%] vs. 3/31 [10%]; P<0.001]) and statins at a recommended dose (52/53 [98%] vs. 82/101 [81%]; P<0.001. Peer consultation identified several barriers to use of medications: complexity of treatment algorithms (which often differ between guidelines); need for personalisation (the audit identified >50 unique combinations of recommended treatments for individual patients); complex risk assessments; and time constraints in gathering data to assess eligibility the medications (often takes >5 min), exacerbated by high patient volume. Conclusions Several guideline-recommended medications with established cardiovascular benefit were under-utilised in standard clinics after ACS. Specialist preventative cardiology clinics can optimise utilisation of these medications, which has the potential to reduce the risk of further major adverse cardiovascular events. Innovative solutions are needed to scale this further.
Aims Natriuretic peptides are routinely quantified to diagnose heart failure (HF). Their concentrations are also elevated in atrial fibrillation (AF). To clarify their interpretation, we measured natriuretic peptides in unselected patients with cardiovascular conditions and related their concentrations to AF and HF status and to outcomes. Methods and results Consecutive patients with cardiovascular conditions presenting to a large teaching hospital (median age 70 [IQR 60–78] years, 40% women) underwent clinical assessment, 7-day ECG-monitoring, and echocardiography to diagnose AF and HF. N-terminal pro B-type natriuretic peptide (NT-proBNP) was centrally quantified. Clinical characteristics and NT-proBNP concentrations were related to HF hospitalization or cardiovascular death. Follow-up data was available in 1611/1616 patients (99.7%) and analysis performed at 2.5 years. Based on a literature review, four NT-proBNP groups were defined (<300pg/ml, 300–999pg/ml, 1000–1999pg/ml and ≥2000pg/ml). Multivariate Cox proportional hazards analysis of the composite outcome against AF and HF phenotype groups. This was adjusted for confounding factors including age, sex, race, body mass index, hypertension, diabetes, coronary artery disease, severe valvular heart disease, left bundle branch block, hyponatraemia, urea, haemoglobin, estimated glomerular filtration rate, NT-proBNP, medical treatment with ACE inhibitors or angiotensin receptor blockers, beta-blockers, diuretic (thiazide or loop diuretics), and anticoagulants (novel oral anticoagulant or vitamin K antagonist). Cox proportional hazards analysis adjusted for confounding variables for the composite outcome against baseline NT-proBNP concentration ranges was also performed in each patient group based on AF and HF status. HF hospitalization or cardiovascular death increased from patients with neither AF nor HF (36/488, 3.2/100 person-years), to 55/353 (7.1/100 person-years) in patients with AF only, 91/366 (12.1/100 person-years) in patients with HF only, and, 128/404 (17.7/100 person-years) in patients with AF plus HF (p<0.001). Higher NT-proBNP concentrations predicted the outcome in patients with AF only (C-statistic 0.82 [95% CI 0.77 to 0.86], p-value<0.001) and in other phenotype groups (C statistic in AF plus HF 0.66 [95% CI 0.61 to 0.70], p-value<0.001)). Sensitivity analyses confirmed these findings. Conclusion Elevated NT-proBNP concentrations predict future HF events in patients with AF irrespective of the presence of HF. In line with previous studies in HF, an NT-proBNP threshold of 1000 pg/ml is useful to identify high-risk patients with AF whether or not they are diagnosed with HF at the time of assessment. Pending external validation, these findings encourage the routine quantification of NT-proBNP in the initial assessment of patients with AF. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): 1) This study was partially supported by European Union BigData@Heart and 2) CATCH ME (Characterising Afib by Translating its Causes into Health Modifiers in the Elderly)
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