This study demonstrates that a six-month, multidisciplinary approach to CHF management can improve important clinical outcomes at a similar cost in recently hospitalized high-risk patients with CHF.

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Purpose: To compare the effectiveness of an algorithm created for use in a nurse‐managed outpatient anticoagulation clinic with the use of clinical judgment without formalized guidelines. Data source: A search of the databases in Pub Med and the Cumulative Index to Nursing of articles published through November 2009 yielded 19 articles concerning warfarin, practice guidelines, and use of algorithms. Methods: A retrospective study was conducted comparing 179 consecutive patient visits in September 2007 with 206 consecutive patient visits in 2009 at the Johns Hopkins Outpatient Anticoagulation Clinic. An algorithm was created that incorporated “removeable causes” to aid nurses in decision making when, for example, additions and deletions of new medications are added that interact with warfarin (Coumadin). Results: In both years, there was a greater percentage of no change versus change in warfarin dose reflecting stable dosage patterns in both years. Chi‐square analysis showed no statistical significance in the relationship between dosing changes and year. A significant relationship was found, however, between removeable causes and year, suggesting improved documentation of removable causes in 2009. Implications for practice: Further study with a larger prospective randomized sample population is needed to more accurately assess the algorithm's effect on time in therapeutic range (TTR).

Background: Echocardiographic (EC) indices of mechanical dyssynchrony (MD) are based largely upon longitudinal strain, whereas magnetic resonance imaging myocardial tissue tagging (MRI-MT) assessment is based on circumferential strain, the latter being the primary direction of myocardial contraction. Methods: We sought to compare cardiac MRI studies with an EC protocol using 2D imaging, tissue Doppler imaging (TDI), and M-mode in 32 subjects. Absolute strain, time to peak strain in 6 segments, TDI septal-to-lateral delay (SLD; MD if ≥ 70 ms), and M-mode septal-to-posterior wall motion delay (SPWMD; MD if ≥ 130 ms) were measured and compared to the MRI-MT-based CURE (circumferential uniformity ratio estimate, CURE; 0 –1, 0 = asynchrony, 1 = perfect synchrony; MD if < 0.75), which recently has been shown to predict clinical CRT response. Results: The 8 control subjects (normal QRSd; CURE 0.975 ± 0.01; SLD 26 ± 27 ms) had less MD by MRI-MT (p = 0.0001) and TDI (p = 0.04) as compared to 24 subjects with ejection fraction ≤ 35% (QRSd 135 ≤ 35 ms; CURE 0.695 ± 0.17; SLD 59 ± 39 ms). There was a moderate correlation between TDI and MRI-MT (R = 0.62), with a discordance rate of 22% overall and 25% in cardiomyopathy subjects, in some cases due to abnormal CURE with normal SLD and, in others, normal CURE with abnormal SLD. The M-mode assay (SPWMD) could not be assessed in 10 patients with septal akinesis (AK), although there was MD by TDI and MRI-MT in most of these subjects. In the patients without AK, the discordance rate between TDI and M-mode was 33%. Conclusions: MRI-MT assessment of circumferential strain and MD is complementary to TDI with a good correlation, but also a significant discordance rate.

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