Electronic consultations (e-consultations) have been shown to improve timely access to specialty care, particularly in resource-constrained systems (1). ...from the health care delivery system’s goal ...of ensuring patient access, electronic consultation will play a very important role. ...e-consultations have the risk of presenting an “EMR-centric” view of the patient versus a patient-centric view of their medical illness. ...the loss of direct human contact by the cardiologist in delivering the care plan may have an impact on diagnostic accuracy, patient understanding, and future adherence to the care plan.
The coronavirus disease 2019 (COVID-19) pandemic has resulted in severe psychological, social, and economic stress in people's lives. It is not known whether the stress of the pandemic is associated ...with an increase in the incidence of stress cardiomyopathy.
To determine the incidence and outcomes of stress cardiomyopathy during the COVID-19 pandemic compared with before the pandemic.
This retrospective cohort study at cardiac catheterization laboratories with primary percutaneous coronary intervention capability at 2 hospitals in the Cleveland Clinic health system in Northeast Ohio examined the incidence of stress cardiomyopathy (also known as Takotsubo syndrome) in patients presenting with acute coronary syndrome who underwent coronary arteriography. Patients presenting during the COVID-19 pandemic, between March 1 and April 30, 2020, were compared with 4 control groups of patients with acute coronary syndrome presenting prior to the pandemic across 4 distinct timelines: March to April 2018, January to February 2019, March to April 2019, and January to February 2020. Data were analyzed in May 2020.
Patients were divided into 5 groups based on the date of their clinical presentation in relation to the COVID-19 pandemic.
Incidence of stress cardiomyopathy.
Among 1914 patient presenting with acute coronary syndrome, 1656 patients (median interquartile range age, 67 59-74; 1094 66.1% men) presented during the pre-COVID-19 period (390 patients in March-April 2018, 309 patients in January-February 2019, 679 patients in March-April 2019, and 278 patients in January-February 2020), and 258 patients (median interquartile range age, 67 57-75; 175 67.8% men) presented during the COVID-19 pandemic period (ie, March-April 2020). There was a significant increase in the incidence of stress cardiomyopathy during the COVID-19 period, with a total of 20 patients with stress cardiomyopathy (incidence proportion, 7.8%), compared with prepandemic timelines, which ranged from 5 to 12 patients with stress cardiomyopathy (incidence proportion range, 1.5%-1.8%). The rate ratio comparing the COVID-19 pandemic period to the combined prepandemic period was 4.58 (95% CI, 4.11-5.11; P < .001). All patients during the COVID-19 pandemic had negative reverse transcription-polymerase chain reaction test results for COVID-19. Patients with stress cardiomyopathy during the COVID-19 pandemic had a longer median (interquartile range) hospital length of stay compared with those hospitalized in the prepandemic period (COVID-19 period: 8 6-9 days; March-April 2018: 4 3-4 days; January-February 2019: 5 3-6 days; March-April 2019: 4 4-8 days; January-February: 5 4-5 days; P = .006). There were no significant differences between the COVID-19 period and the overall pre-COVID-19 period in mortality (1 patient 5.0% vs 1 patient 3.6%, respectively; P = .81) or 30-day rehospitalization (4 patients 22.2% vs 6 patients 21.4%, respectively; P = .90).
This study found that there was a significant increase in the incidence of stress cardiomyopathy during the COVID-19 pandemic when compared with prepandemic periods.
An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for ...an individual patient. ...clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C.\n ACS = acute coronary syndromes AKI = acute kidney injury BMS = bare-metal stent(s) CABG = coronary artery bypass graft surgery CAD = coronary artery disease CKD = chronic kidney disease CTO = chronic total occlusion DAPT = dual antiplatelet therapy DES = drug-eluting stent(s) ECG = electrocardiogram EF = ejection fraction EPD = embolic protection device FDA = U.S. Food and Drug Administration FFR = fractional flow reserve GDMT = guideline-directed medical therapy GI = gastrointestinal GP = glycoprotein IABP = intra-aortic balloon pump IV = intravenous IVUS = intravascular ultrasound LAD = left anterior descending LIMA = left internal mammary artery LV = left ventricular LVEF = left ventricular ejection fraction MACE = major adverse cardiac event MI = myocardial infarction MRI = magnetic resonance imaging NCDR = National Cardiovascular Data Registry PCI = percutaneous coronary intervention PPI = proton pump inhibitor RCT = randomized controlled trial SIHD = stable ischemic heart disease STEMI = ST-elevation myocardial infarction SVG = saphenous vein graft TIMI = Thrombolysis In Myocardial Infarction TMR = transmyocardial laser revascularization UA/NSTEMI = unstable angina/non-ST-elevation myocardial infarction UFH = unfractionated heparin * This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant.
This single-center, observational study assessed the impact of age, gender, and body mass index (BMI) in patients with cardiogenic shock (CS) on temporary mechanical circulatory support.
All adult ...patients admitted to the Cleveland Clinic main campus Cardiac Intensive Care Unit (CICU) between December 1, 2015, to December 31, 2019, CICU with CS necessitating mechanical circulatory support (MCS) with intra-aortic balloon pump, Impella, or venous arterial-extra corporeal membrane oxygenation were retrospectively analyzed for this study. Baseline characteristics and 30-day outcomes were collected through physician-directed chart review. The impact of age, gender, and BMI on 30-day mortality was assessed using multivariable logistic regression. Kaplan-Meier survival curves were used to analyze the survival difference in specific subsets.
A total of 393 patients with CS on temporary MCS were admitted to our CICU during the study period. The median age of our cohort was 63 years (interquartile range 54 to 70 years), median BMI was 28.50 kg/m2 (interquartile range 24.62 to 29.72) and 70% (n = 276) were men. In total, 22 patients >80 years had received MCS compared with 372 patients <80 years.
Patients >80 years on MCS had significantly higher 30-day mortality compared with those <80 years (81.8% vs 49.3%, p = 0.006). Upon stratifying patients by BMI, 161 (41%) patients were found to have BMI ≥30 kg/m2 whereas 232 (59%) patients had BMI <30 kg/m2. Comparison of 30-day mortality revealed that patients with BMI ≥30 did significantly worse than patients with BMI <30 (59.6% vs 45.3%, p = 0.007). There was no difference in 30-day mortality between men and women. On multivariable logistic regression, both age and BMI had a positive linear relation with adjusted 30-day mortality whereas gender did not have a major effect.
Advanced age and higher BMI are independently associated with worse outcomes in patients with CS on MCS. Utilizing a strict selection criterion for patients in CS is pertinent to derive the maximum benefit from advanced mechanical support.
Consensus guidelines and hospital quality-of-care programs recommend that ST-elevation myocardial infarction patients achieve a door-to-balloon time of < or = 90 minutes. However, there are limited ...prospective data on specific measures to significantly reduce door-to-balloon time.
We prospectively determined the impact on median door-to-balloon time of a protocol mandating (1) emergency department physician activation of the catheterization laboratory and (2) immediate transfer of the patient to an immediately available catheterization laboratory by an in-house transfer team consisting of an emergency department nurse, a critical care unit nurse, and a chest pain unit nurse. We collected door-to-balloon time for 60 consecutive ST-elevation myocardial infarction patients undergoing emergency percutaneous intervention within 24 hours of presentation from October 1, 2004, through August 31, 2005, and compared this group with 86 consecutive ST-elevation myocardial infarction patients from September 1, 2005, through June 26, 2006, after protocol implementation. Median door-to-balloon time decreased overall (113.5 versus 75.5 minutes; P<0.0001), during regular hours (83.5 versus 64.5 minutes; P=0.005), during off-hours (123.5 versus 77.5 minutes; P<0.0001), and with transfer from an outside affiliated emergency department (147 versus 85 minutes; P=0.0006). Treatment within 90 minutes increased from 28% to 71% (P<0.0001). Mean infarct size decreased (peak creatinine kinase, 2623+/-3329 versus 1517+/-1556 IU/L; P=0.0089), as did hospital length of stay (5+/-7 versus 3+/-2 days; P=0.0097) and total hospital costs per admission ($26,826+/-29,497 versus $18,280+/-8943; P=0.0125).
Emergency department physician activation of the catheterization laboratory and immediate transfer of the patient to an immediately available catheterization laboratory reduce door-to-balloon time, leading to a reduction in myocardial infarct size, hospital length of stay, and total hospital costs.
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