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ObjectivesThere is sparse information on the safety of early primary discharge from the emergency department (ED) after rule-out of myocardial infarction in suspected acute coronary syndrome (ACS). This prospective registry aimed to confirm randomised study results in patients at low-to-intermediate risk, with a broader spectrum of symptoms, across different institutional standards and with a range of local troponin assays including high-sensitivity cTn (hs-cTn), cardiac troponin (cTn) and point-of-care troponin (POC Tn).DesignProspective, multicentre European registry.Setting18 emergency departments in nine European countries (Germany, Austria, Switzerland, France, Spain, UK, Turkey, Lithuania and Hungary)ParticipantsThe final study cohort consisted of 2294 patients (57.2% males, median age 57 years) with suspected ACS.InterventionsUsing the new dual markers strategy, 1477 patients were eligible for direct discharge, which was realised in 974 (42.5%) of patients.Main outcome measuresThe primary endpoint was all-cause mortality at 30 days.ResultsCompared with conventional workup after dual marker measurement, the median length of ED stay was 60 min shorter (228 min, 95% CI: 219 to 239 min vs 288 min, 95% CI: 279 to 300 min) in the primary dual marker strategy (DMS) discharge group. All-cause mortality was 0.1% (95% CI: 0% to 0.6%) in the primary DMS discharge group versus 1.1% (95% CI: 0.6% to 1.8%) in the conventional workup group after dual marker measurement. Conventional workup instead of discharge despite negative DMS biomarkers was observed in 503 patients (21.9%) and associated with higher prevalence of ACS (17.1% vs 0.9%, p<0.001), cardiac diagnoses (55.2% vs 23.5%, p<0.001) and risk factors (p<0.01), but with a similar all-cause mortality of 0.2% (95% CI: 0% to 1.1%) versus primary DMS discharge (p=0.64).ConclusionsCopeptin on top of cardiac troponin supports safe discharge in patients with chest pain or other symptoms suggestive of ACS under routine conditions with the use of a broad spectrum of local standard POC, conventional and high-sensitivity troponin assays.Trial registration number NCT02490969.

BackgroundHospitalisation with acute heart failure (AHF) carries a high risk of death, and those surviving to discharge remain at high risk of death or rehospitalisation with AHF. The impact of outpatient heart failure (HF) specialist care after discharge from AHF hospitalisation on longer-term outcomes is unclear in contemporary UK practice.MethodsA retrospective analysis of a cohort of 2104 patients admitted to hospital due to AHF between 2014–2022 in a single UK county was performed. Patient characteristics, left ventricular ejection fraction (EF) (LVEF) category (HF with reduced EF (LVEF ≤40%; HFrEF), HF with mildy reduced EF (LVEF 41%–49%; HFmrEF) and HF with preserved EF (LVEF ≥50%; HFpEF)) and survival free from a composite end point of AHF rehospitalisation or death are described. Cox regression survival analysis was performed to explore the impact of baseline patient characteristics and HF specialist care on long-term outcomes.ResultsThe median age of the cohort was 83 years. HFrEF was present in 36%, HFmrEF in 9% and HFpEF in 55%. 13% died during index AHF hospitalisation. Median follow-up for those surviving to discharge was 618 (IQR 264–1275) days. 21% were rehospitalised due to AHF, and 63% died during follow-up. On adjusted survival analysis of 1511 patients with echocardiogram data available, HF specialist care after discharge from hospital was independently associated with a significant reduction in the composite end point across all LVEF categories (HFrEF: HR 0.577, 95% CI 0.429 to 0.775, p<0.001; HFmrEF: HR 0.485, 0.281–0.834, p=0.009; HFpEF HR 0.762, 0.623–0.931, p=0.008).ConclusionsHF specialist care after discharge for patients hospitalised with AHF is associated with a significant reduction in the long-term risk of rehospitalisation and all-cause death. This association was present across the three LVEF categories (HFrEF, HFmrEF and HFpEF) and was independent of age and important comorbidities.

ObjectiveEbstein’s anomaly is a rare congenital cardiac condition and data regarding pregnancy outcomes in this patient group are scarce. We evaluated the maternal and perinatal risks of pregnancy in 81 women with Ebstein’s anomaly.MethodsThe Registry of Pregnancy and Cardiac disease is a prospective global registry of pregnancies in women with structural cardiac disease. Pregnancy outcomes in women with Ebstein’s anomaly were examined. The primary outcome was the occurrence of a major adverse cardiac event (MACE) defined as maternal mortality, heart failure, arrhythmia, thromboembolic event or endocarditis. Secondary endpoints were obstetric and perinatal outcomes and the influence of pregnancy on tricuspid valve regurgitation as well as right atrial and ventricular dimensions.ResultsIn the 81 women with Ebstein’s anomaly (mean age 29.7±6.1 years, 46.9% nulliparous), MACE occurred in 8 (9.9%) pregnancies, mostly heart failure (n=6). There were no maternal deaths. Prepregnancy signs of heart failure were predictive for MACE. Almost half of the women were delivered by caesarean section (45.7%) and preterm delivery occurred in 24.7%. Neonatal mortality was 2.5% and 4.9% of the infants had congenital heart disease. In the subgroup in which prepregnancy and postpregnancy data were available, there was no difference in tricuspid valve regurgitation grade or right atrial and ventricular dimensions before and after pregnancy.ConclusionsMost women with Ebstein’s anomaly tolerate pregnancy well, but women with prepregnancy signs of heart failure are at higher risk for MACE during pregnancy and should be counselled accordingly.

Background Buckinghamshire Healthcare NHS Trust (BHT) carried out a cardiac rehabilitation (CR) service redesign aimed at optimising patient recruitment and retention and decreasing readmissions. Methods A single centre observational study and local service evaluation were carried out to describe the impact of the novel technology-enabled CR model. Data were collected for adult patients referred for CR at BHT, retrospectively for patients referred during the 12-month pre-implementation period (Cohort 1) and prospectively for patients referred during the 12-month post-implementation period (Cohort 2). The observational study included 350 patients in each cohort, seasonally matched; the service evaluation included all eligible patients. No data imputation was performed. Results In the observational study, a higher proportion of referred patients entered CR in Cohort 2 (84.3%) than Cohort 1 (76.0%, P  = 0.006). Fewer patients in Cohort 2 had ≥1 cardiac-related emergency readmission within 6 months of discharge (4.3%) than Cohort 1 (8.9%, P  = 0.015); readmissions within 30 days and 12 months were not significantly different. Median time to CR entry from discharge was significantly shorter in Cohort 2 (35.0 days) than Cohort 1 (46.0 days, P  < 0.001). The CR completion rate was significantly higher in Cohort 2 (75.6%) than Cohort 1 (47.4%, P  < 0.001); median CR duration for completing patients was significantly longer in Cohort 2 (80.0 days) than Cohort 1 (49.0 days, P  < 0.001). Overall, similar results were observed in the service evaluation. Conclusions Introduction of the novel technology-enabled CR model was associated with short-term improvements in emergency readmissions and sustained increases in CR entry, duration and completion.

Background Renal denervation (RDN) may lower blood pressure (BP); however, it is unclear whether medication changes may be confounding results. Furthermore, limited data exist on pattern of ambulatory blood pressure (ABP) response—particularly in those prescribed aldosterone antagonists at the time of RDN. Methods We examined all patients treated with RDN for treatment-resistant hypertension in 18 UK centres. Results Results from 253 patients treated with five technologies are shown. Pre-procedural mean office BP (OBP) was 185/102 mmHg (SD 26/19; n  = 253) and mean daytime ABP was 170/98 mmHg (SD 22/16; n  = 186). Median number of antihypertensive drugs was 5.0: 96 % ACEi/ARB; 86 % thiazide/loop diuretic and 55 % aldosterone antagonist. OBP, available in 90 % at 11 months follow-up, was 163/93 mmHg (reduction of 22/9 mmHg). ABP, available in 70 % at 8.5 months follow-up, was 158/91 mmHg (fall of 12/7 mmHg). Mean drug changes post RDN were: 0.36 drugs added, 0.91 withdrawn. Dose changes appeared neutral. Quartile analysis by starting ABP showed mean reductions in systolic ABP after RDN of: 0.4; 6.5; 14.5 and 22.1 mmHg, respectively ( p  < 0.001 for trend). Use of aldosterone antagonist did not predict response ( p  > 0.2). Conclusion In 253 patients treated with RDN, office BP fell by 22/9 mmHg. Ambulatory BP fell by 12/7 mmHg, though little response was seen in the lowermost quartile of starting blood pressure. Fall in BP was not explained by medication changes and aldosterone antagonist use did not affect response.

Symptomatic relief is the primary goal of percutaneous coronary intervention (PCI) in stable angina and is commonly observed clinically. However, there is no evidence from blinded, placebo-controlled randomised trials to show its efficacy. ORBITA is a blinded, multicentre randomised trial of PCI versus a placebo procedure for angina relief that was done at five study sites in the UK. We enrolled patients with severe (≥70%) single-vessel stenoses. After enrolment, patients received 6 weeks of medication optimisation. Patients then had pre-randomisation assessments with cardiopulmonary exercise testing, symptom questionnaires, and dobutamine stress echocardiography. Patients were randomised 1:1 to undergo PCI or a placebo procedure by use of an automated online randomisation tool. After 6 weeks of follow-up, the assessments done before randomisation were repeated at the final assessment. The primary endpoint was difference in exercise time increment between groups. All analyses were based on the intention-to-treat principle and the study population contained all participants who underwent randomisation. This study is registered with ClinicalTrials.gov, number NCT02062593. ORBITA enrolled 230 patients with ischaemic symptoms. After the medication optimisation phase and between Jan 6, 2014, and Aug 11, 2017, 200 patients underwent randomisation, with 105 patients assigned PCI and 95 assigned the placebo procedure. Lesions had mean area stenosis of 84·4% (SD 10·2), fractional flow reserve of 0·69 (0·16), and instantaneous wave-free ratio of 0·76 (0·22). There was no significant difference in the primary endpoint of exercise time increment between groups (PCI minus placebo 16·6 s, 95% CI −8·9 to 42·0, p=0·200). There were no deaths. Serious adverse events included four pressure-wire related complications in the placebo group, which required PCI, and five major bleeding events, including two in the PCI group and three in the placebo group. In patients with medically treated angina and severe coronary stenosis, PCI did not increase exercise time by more than the effect of a placebo procedure. The efficacy of invasive procedures can be assessed with a placebo control, as is standard for pharmacotherapy. NIHR Imperial Biomedical Research Centre, Foundation for Circulatory Health, Imperial College Healthcare Charity, Philips Volcano, NIHR Barts Biomedical Research Centre.

IntroductionPatients with systolic heart failure are at high risk of admission to hospital and death. This can be reduced by ensuring that they are receiving all evidence-based heart failure medications and by detecting early signs of deterioration in their condition.MethodsPatients were enrolled from 2016 through 2017 at 12 GP practices across Buckinghamshire. Practices were selected if the used EMIS web as their electronic patient record and showed enthusiasm for participating in the study. At each practice, a senior heart failure nurse was deployed to identify patients with a REED code for heart failure and an echocardiographically determined ejection fraction (EF) of less than 40%. If no echocardiogram was available this was arranged. We recruited 209 primary care patients with echocardiographically proven left ventricular systolic dysfunction (ejection fraction<40%). 84 patients consented to be actively monitored by the heart failure team using telemedicine. It automatically uploaded any relevant data (weight, dyspnoea class, renal function, full blood count, urate, chest X-ray, repeat echocardiogram, hospital admissions, death) entered in the GP or hospital records. Patients were also encouraged to enter their own data (in particular weight and exercise tolerance). Clinicians were instructed to treat patients in accordance with national guidelines for the management of heart failure. 125 patients consented to receiving usual care but allowing access to their medical records. The primary end-point was cardiovascular death or admission to hospital for heart failure at 1 year. Secondary end-points included the prescription of evidence-based heart failure medications and patient satisfaction at the end of the study.ResultsThere was no difference in the mortality rate between the groups (6.02% in the active group and 5.56% in control). There was a significant difference in hospital admission (10.84% in the active group and 1.59% in control; p-value of 0.0078). At the end of the study, in the active group v control group, 92% v 52% of patients were on a beta-blocker, 92% v 48% on ACE-I/ARB, and 60% v 30% on an MRA. There were no differences in the final doses achieved.ConclusionsActive telemonitoring in an elderly population with systolic heart failure did not reduce cardiovascular mortality or admission to hospital for heart failure over the 1 year of the study. It did result in more patients receiving evidence-based heart failure medications. Overall satisfaction with active monitoring delivery a questionnaire was provided to all patients who opted to receive active monitoring. The purpose of the questionnaire was to determine overall satisfaction levels with the monitoring and identify areas for potential improvement. A questionnaire was circulated at the midpoint of the study (6 months) as well as at its conclusion (12 months). Of all patients in the active control group, a total of 27 completed both questionnaires (corresponding to 32.53% of all patients under active monitoring). The characteristics of this subset of the active cohort were consistent with the overall characteristics of all patients in the study; there was no significant differences in cardiovascular status (e.g., NYHA scores) or personal characteristics (e.g., gender, age).The questionnaire consisted of a eleven questions measuring the patient satisfaction on various aspects of the active monitoring treatment. The overall response from patients was positive, with an average satisfaction of 8.54 / 10. Furthermore, when asked how likely they would be recommend the active monitoring treatment, patients gave an average score of 8.34 / 10.Conflict of InterestNone

PurposeLow-density lipoprotein cholesterol (LDL-C) recommendations differ between the 2018 American College of Cardiology/American Heart Association (ACC/AHA) and 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for patients with atherosclerotic cardiovascular disease (ASCVD) (< 70 vs. < 55 mg/dl, respectively). In the DA VINCI study, residual cardiovascular risk was predicted in ASCVD patients. The extent to which relative and absolute risk might be lowered by achieving ACC/AHA versus ESC/EAS LDL-C recommended approaches was simulated.MethodsDA VINCI was a cross-sectional observational study of patients prescribed lipid-lowering therapy (LLT) across 18 European countries. Ten-year cardiovascular risk (CVR) was predicted among ASCVD patients receiving stabilized LLT. For patients with LDL-C ≥ 70 mg/dl, the absolute LDL-C reduction required to achieve an LDL-C of < 70 or < 55 mg/dl (LDL-C of 69 or 54 mg/dl, respectively) was calculated. Relative and absolute risk reductions (RRRs and ARRs) were simulated.ResultsOf the 2039 patients, 61% did not achieve LDL-C < 70 mg/dl. For patients with LDL-C ≥ 70 mg/dl, median (interquartile range) baseline LDL-C and 10-year CVR were 93 (81–115) mg/dl and 32% (25–43%), respectively. Median LDL-C reductions of 24 (12–46) and 39 (27–91) mg/dl were needed to achieve an LDL-C of 69 and 54 mg/dl, respectively. Attaining ACC/AHA or ESC/EAS goals resulted in simulated RRRs of 14% (7–25%) and 22% (15–32%), respectively, and ARRs of 4% (2–7%) and 6% (4–9%), respectively.ConclusionIn ASCVD patients, achieving ESC/EAS LDL-C goals could result in a 2% additional ARR over 10 years versus the ACC/AHA approach.

Introduction The ORBITA trial of percutaneous coronary intervention (PCI) versus a placebo procedure for patients with stable angina was conducted across six sites in the United Kingdom via home monitoring and telephone consultations. Patients underwent detailed assessment of medication adherence which allowed us to measure the efficacy of the implementation of the optimization protocol and interpretation of the main trial endpoints. Methods Prescribing data were collected throughout the trial. Self‐reported adherence was assessed, and urine samples collected at pre‐randomization and at follow‐up for direct assessment of adherence using high‐performance liquid chromatography with tandem mass spectrometry (HPLC MS/MS). Results Self‐reported adherence was >96% for all drugs in both treatment groups at both stages. The percentage of samples in which drug was detected at pre‐randomization and at follow‐up in the PCI versus placebo groups respectively was: clopidogrel, 96% versus 90% and 98% versus 94%; atorvastatin, 95% versus 92% and 92% versus 91%; perindopril, 95% versus 97% and 85% versus 100%; bisoprolol, 98% versus 99% and 96% versus 97%; amlodipine, 99% versus 99% and 94% versus 96%; nicorandil, 98% versus 96% and 94% versus 92%; ivabradine, 100% versus 100% and 100% versus 100%; and ranolazine, 100% versus 100% and 100% versus 100%. Conclusions Adherence levels were high throughout the study when quantified by self‐reporting methods and similarly high proportions of drug were detected by urinary assay. The results indicate successful implementation of the optimization protocol delivered by telephone, an approach that could serve as a model for treatment of chronic conditions, particularly as consultations are increasingly conducted online. Medical therapy for patients with stable angina optimised over 6 weeks of tele‐ health clinic visits. Treatment titrated to home blood pressure and heart rate measurements. Medication adherence confirmed using HPLC MS/MS and patient self‐reporting. Patients subsequently randomised to PCI or placebo procedure in the ORBITA trial. Adherence reassessed at final follow‐up. Self‐reported adherence was >96% for all drugs in both treatment groups at both stages. Proportion of expected drug detected was >90% for all first‐choice, protocol‐directed medicines at both stages. No significant between group differences at pre‐ randomisation or at follow‐up and medication taking patterns did not change following treatment with PCI. The study uses a simple model for optimisation of medical therapy in clinical practice using a telehealth approach with high levels of adherence.