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ObjectiveTo understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload.MethodsSingle centre prospective observational evaluation of 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. A proforma including frequency, nature, magnitude and level of procedural risk at the time of each distraction/interruption was completed for each case. The primary operator completed a National Aeronautical and Space Administration (NASA) task load questionnaire rating mental/physical effort, level of frustration, time-urgency, and overall effort and performance.Results264 distractions occurred in 106 (55%) out of 194 procedures observed; 80% were not relevant to the case being undertaken; 14% were urgent including discussions of potential ST-elevation myocardial infarction requiring emergency angioplasty. In procedures where distractions were observed, frequency per case ranged from 1 to 16 (mean 2.5, SD ±2.2); 43 were documented during high-risk stages of the procedure. Operator rating of NASA task load parameters demonstrated higher levels of mental and physical workload and effort during cases in which distractions occurred.ConclusionsIn this first description of HF in adult cardiac catheter laboratories, we found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. We propose the introduction of a ‘sterile cockpit’ environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.

For patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric carboxymaltose administration improves quality of life and exercise capacity in the short-term and reduces hospital admissions for heart failure up to 1 year. We aimed to evaluate the longer-term effects of intravenous ferric derisomaltose on cardiovascular events in patients with heart failure. IRONMAN was a prospective, randomised, open-label, blinded-endpoint trial done at 70 hospitals in the UK. Patients aged 18 years or older with heart failure (left ventricular ejection fraction ≤45%) and transferrin saturation less than 20% or serum ferritin less than 100 μg/L were eligible. Participants were randomly assigned (1:1) using a web-based system to intravenous ferric derisomaltose or usual care, stratified by recruitment context and trial site. The trial was open label, with masked adjudication of the outcomes. Intravenous ferric derisomaltose dose was determined by patient bodyweight and haemoglobin concentration. The primary outcome was recurrent hospital admissions for heart failure and cardiovascular death, assessed in all validly randomly assigned patients. Safety was assessed in all patients assigned to ferric derisomaltose who received at least one infusion and all patients assigned to usual care. A COVID-19 sensitivity analysis censoring follow-up on Sept 30, 2020, was prespecified. IRONMAN is registered with ClinicalTrials.gov, NCT02642562. Between Aug 25, 2016, and Oct 15, 2021, 1869 patients were screened for eligibility, of whom 1137 were randomly assigned to receive intravenous ferric derisomaltose (n=569) or usual care (n=568). Median follow-up was 2·7 years (IQR 1·8–3·6). 336 primary endpoints (22·4 per 100 patient-years) occurred in the ferric derisomaltose group and 411 (27·5 per 100 patient-years) occurred in the usual care group (rate ratio [RR] 0·82 [95% CI 0·66 to 1·02]; p=0·070). In the COVID-19 analysis, 210 primary endpoints (22·3 per 100 patient-years) occurred in the ferric derisomaltose group compared with 280 (29·3 per 100 patient-years) in the usual care group (RR 0·76 [95% CI 0·58 to 1·00]; p=0·047). No between-group differences in deaths or hospitalisations due to infections were observed. Fewer patients in the ferric derisomaltose group had cardiac serious adverse events (200 [36%]) than in the usual care group (243 [43%]; difference –7·00% [95% CI –12·69 to –1·32]; p=0·016). For a broad range of patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric derisomaltose administration was associated with a lower risk of hospital admissions for heart failure and cardiovascular death, further supporting the benefit of iron repletion in this population. British Heart Foundation and Pharmacosmos.

BackgroundInhibitors of the Renin-angiotensin-aldosterone-system (RAASi) offer prognostic advantages in heart failure with reduced ejection fraction (HFrEF), after myocardial infarction (MI) and for those with chronic kidney disease (CKD). Nevertheless, when patients develop hyperkalaemia RAASi dosage might be lowered or discontinued, potentially leading to unfavourable outcomes.PurposeA prospective observational study at a single center analysed real-world data of patient’s post-hospitalisation with a hyperkalaemia episode. The study focused on (i) the subsequent prescription patterns of renin-angiotensin-aldosterone system inhibitors (RAASi), particularly in HFrEF, (ii) the timing of follow-up blood tests after discharge, and (iii) one-year outcomes.MethodsPatients hospitalized in a major district hospital (Portsmouth Hospitals University NHS Trust, UK), who were on RAAS inhibitors (RAASi) with a potassium level of ≥5.5 mmol/l, capable of providing consent, were selected for inclusion. Exclusion criteria encompassed patients undergoing dialysis. Data regarding demographics, existing health conditions, medication history, RAASi prescriptions, scheduling of blood tests, and patient outcomes during the initial hospital stay and at follow-up intervals of 3 and 12 months were gathered and analysed.ResultsBetween July 2022 - November 2023, 100 patients with at least one episode of hyperkalaemia on RAASi were included. 55% of patients had history of hyperkalaemia in the preceding year. Mean age 75-years (SD +/-11), 26% women. Comorbidities were common (Fig 1A), 31% had 4 or more. HFrEF was the most common prognostic indication for RAASi (n=45), for these patients mean age was 76 years, 29% female. Contributory causes of hyperkalaemia are shown in figure 1B, the most common of which was acute kidney injury (AKI). Leading cause for AKI was infection (n=16), and dehydration (n=11). Survival to 1-year and re-hospitalisations for are shown in the figure 1C and 1D respectively. Of the 45 patients with HFrEF, 10 died by 3 months and 11 by 1 year.Renal function within 2 weeks post discharge was checked in 55% (51/92) of all patients, 48% (22/45) of HFrEF. This increased to 71% and 68% by 4 weeks, respectively. All patients had RAASi stopped during hospitalisation. All patients with HFrEF (n=41) who survived the index admission had at least one RAASi restarted, however, only 17 were receiving 2 RAASi at discharge. 63% (22/35) of those alive at 3 months, with HFrEF were on at least one RAASi, 67% (23/34) at 1 year.ConclusionHospitalized patients experiencing an episode of hyperkalaemia exhibit suboptimal one-year outcomes. Despite the complication of acute kidney injury (AKI) in numerous cases, consistent post-discharge renal function assessment is lacking. Additionally, renin-angiotensin-aldosterone system inhibitors (RAASi) are under prescribed during follow-up, even for patients with compelling indications like heart failure with reduced ejection fraction (HFrEF) and post MI. Enhancing patient care for this vulnerable group may require focused educational initiatives and the strategic use of potassium binders.Abstract 141 Table 1Use of RAASi following hyperkalaemia episode Number of hyperkalaemia episodes on 1 RAASi on 2 RAASi Index admission 100 100 27 Discharge 45 6 3 months 50 56 8 12 months 19 45 8 Abstract 141 Figure 1Conflict of InterestNo conflict of interest.

IntroductionRenin-angiotensin-aldosterone-system inhibitors (RAASi) are commonly used for a number of indications, including in the management of hypertension, proteinuric chronic kidney disease (CKD), post myocardial infarction and heart failure with reduced ejection fraction (HFrEF). Their use is often hindered by hyperkalaemia leading to underutilisation and/or underdosing.PurposeAssess perceptions of primary and secondary healthcare professionals regarding benefits of RAASi according to indication and in the context of developing hyperkalaemia, to identify barriers to optimal utilisation, and to explore options for improving management protocols, specifically in HFrEF.MethodsAn online survey was distributed in primary and secondary healthcare settings in Hampshire, UK, to evaluate: (i) understanding of benefit of the drugs according to indication, (ii) prescription of RAASi at various levels of potassium (K+) in patients with hypertension or HFrEF, (iii) educational needs. Hyperkalaemia was divided into mild (serum K+ 5.5 - 5.9 mmol/L), moderate (serum K+ 6.0 - 6.4 mmol/L), and severe (serum K+ ≥ 6.5 mmol/L).ResultsFrom November 2021 to January 2023, 300 questionnaires were completed by 274 (91%) doctors (123 juniors, 56 registrars, 54 consultants and 41 general practitioners), 22 (7%) non-medical prescribers, and 4 (1%) pharmacists. 80% were working in secondary care across a broad range of specialities (small numbers in cardiology n=31 and nephrology n=15). Whilst the majority of respondents were aware of prognostic benefit of angiotensin converting enzyme inhibitors (ACEi) for patients with HFrEF, 38% were unaware of symptom benefit. In contrast, 80% of respondents thought mineralocorticoid receptor antagonists (MRA) could improve symptoms for patients with HFrEF, but 26% were unaware of potential benefits on reducing heart failure hospitalisation and 35% unaware of mortality benefit. Figure 1 shows response to RAASI prescription according to different levels of hyperkalaemia. There were small differences in the willingness to continue ACEi (at same or reduced dose) according to indication in favour of HFrEF as compared to hypertension and MRA. When considering a clinical scenario for a patient with HFrEF whose ACEi treatment was interrupted due to hyperkalaemia (K+ 5.9 mmol/L), 77% of respondents would consider re-commencing the ACEi if the potassium levels < 5.5 mmol/L and only 1% would consider resuming therapy in the context of moderate or severe hyperkalaemia (Fig 2). Whilst 74% of the healthcare professionals were familiar with their local hyperkalaemia management protocol, the vast majority (93%) supported the need for dedicated training on RAASi dose adjustment and hyperkalaemia management.ConclusionThis survey, across a broad range of health care professionals, shows uncertainties around knowledge of benefits of RAASi in patients with HFrEF and there is sizeable variation in the prescribing response to degrees of hyperkalaemia. Given the voluntary nature of the survey, it is plausible that these data are biased towards individuals with greater understanding. Regardless, there is a need for continued education with a goal of improving patient-centred care.Abstract 150 Figure 1Healthcare professional responses to RAASi in patients with hypertension and HFrEF at varying levels of potassiumAbstract 150 Figure 2Potassium values at which respondents would consider recommencing ACEi in HFrEF, after temporary cessation of the drug due to potassium level of 5.9 mmol/LConflict of InterestNon

IntroductionAtrial fibrillation (AF) is a global public health priority. An unsolved problem is how to detect paroxysmal AF. Patients presenting with palpitations are usually monitored for a short period of time with conventional 24 hour Holter monitor or 72 hours cardiac memo. As a result, it is likely that AF is being routinely underdiagnosed and undertreated. This service evaluation reviewed the proportion of patients amongst those who are investigated for palpitations/pre-syncope/syncope by the Cardiology Department in Queen Alexandra hospital (CQAH) with a 24 hours Holter monitor or cardiac memo who have evidence of AF.MethodsRetrospective review of all patients who were investigated with either a 24 hours Holter monitor or 72 hours cardiac memo during August 2019. Clinic letters and discharge summaries were reviewed to assess reason for investigations, findings and outcomes. If a diagnosis of AF, paroxysmal AF or atrial flutter was made, management decision and subsequent anticoagulation was reviewed.ResultsA total of 232 patients were assessed with 24 hours Holter (n=122) monitor and Cardiac memo (n=108). Average age 65 years (5-94). In 5% of cases (12/232) no documentation of results was found. 5% (10/220) had new diagnosis of AF.60% (72/122) of patients investigated with a 24 hours Holter monitor for palpitation (18/122), pre-syncope (5/122) and syncope (15/122) were in sinus rhythm (SR) +/- ectopics. No patients with palpitation or pre-syncope had AF. 4/15 patients with syncope had a new diagnosis of AF (2) or supraventricular tachycardia (2). 34% (42/122) of Holter monitor were done as a result of a documented arrhythmia, 18/42 of which had known AF. 21% (26/122) of Holter monitor were used to investigate TIA/Stroke, 3/26 had new diagnosis of AF.70% (75/108) of patients investigated with a Cardiac Memo for palpitations (28/108), pre-syncope (13/108) and syncope (15/108) were in SR +/- ectopics. 3/28 with palpitations, 1/13 with pre-syncope, 1/15 with syncope group had new AF. 2/15 with syncope who were in SR had a reveal device implanted subsequently. 34% (37/108) were investigated due to TIA/Stroke, all of which were in SR.ConclusionThe number of patients diagnosed with significant cardiac arrhythmia, for example AF, as a result of conventional 24 hours tape and cardiac memo is low even if patients present with symptoms of palpitations, pre-syncope and syncope.As a result of this service evaluation we have applied for a £20.000 grant as part of a ‘NHS Joint Working Project’ to introduce novel, prolonged and home-based ECG monitoring to the department. Patients who are referred to CQAH and require investigation of symptoms of palpitation, pre-syncope and syncope will be offered ECG monitoring over up to 3 months with a KardiaMobile 6 lead ECG (by AliveCor) as an alternative to conventional methods described above. A comparison of identification of cardiac arrhythmia, in particularly AF and subsequent management change, will be made.Conflict of InterestNil

IntroductionPalpitations, pre-syncope and syncope is a common presentation to cardiology services. Short monitoring with conventional Holter monitor or cardiac memo is often not sufficient for the detection of paroxysmal cardiac arrhythmia. The aims of this project were: (i) to demonstrate symptom-rhythm correlation with novel ambulatory ECG devices, (ii) to demonstrate short time to diagnosis for patient presenting with palpitation, pre-syncope and syncope, (iii) to assess patient experience.Method: Patients referred to the local Cardiology Department with symptoms of palpitations were offered an Alivecor Kardiamobile 6L ECG for intermittent monitoring over a 3 months period. Patients with symptoms of pre-syncope or syncope were offered a Wellysis S-patch for continuous monitoring over 21 days. Both devices require connection of a smartphone for their use. ECGs recording were uploaded to a software and analysed by the project team. Patient demographics, diagnosis, time to diagnosis, symptom-rhythm correlation and patient experience were evaluated.ResultsOut of 86 patients 11 were excluded who did not have access to a smart phone to connect to monitoring devices. To date 62 out of 75 patients have completed the monitoring period with KardiaMobile (n=40, 64.5%) and S-patch (n=22, 35.5%). Participants’ mean age was 51 years (range 18–89), 70% women, mean ejection fraction 54%, 41% did not take any medication. 45% (28/62) experienced symptoms a couple of times per year. Symptom-rhythm-correlation was achieved in 75.8% (47/62). 66.7% (42/62) were in sinus rhythm, 7.9% (5/62) atrial fibrillation, 34% (21/62) had atrial or ventricular ectopics. Mean duration of symptom-rhythm correlation was 40 days (Kardiamobile) for intermittent palpitations, 12 days (S-patch) for evaluation of pre-syncope or syncope. A small number of patients reported issues with either of the devices: difficulty using software 13% (8/62), difficulty with connection 8% (5/62) and skin irritation from ECG patch 11% (7/62). Patient’s overall satisfaction was very good or excellent in 79% (49/62) of patients.Abstract 91 Figure 1Chart A showing number of diagnoses reached through the monitoring period Chart B second graph showing patients' feedback on the device use and their statisfactionAbstract 91 Table 1ConclusionThis project demonstrates the feasibility of using novel devices for the remote investigation of palpitations, pre-syncope and syncope. The short time to diagnosis and high patient satisfaction in patient who often repeatedly present to medical services with intermittent symptoms and subsequent negative conventional Holter monitoring highlights the potential in cost saving through reduction in health care utilization.In addition, the Covid pandemic has spotlighted benefits of remote, ambulatory ECG monitors which will become part of the digital future of cardiology. Competing interests: As part of a join working project Daiichi-Sankyo supported this project with £37,400 to purchase the devices and software license.Conflict of InterestNO

ObjectiveTo describe the population, heart failure (HF) diagnosis rate, and 1-year hospitalisation and mortality of patients with suspected HF and elevated N-terminal pro B-type natriuretic peptide (NTproBNP) investigated according to UK National Institute for Health and Care Excellence (NICE) guidelines.MethodsNICE recommends patients with suspected HF, based on clinical presentation and elevated NTproBNP, are referred for specialist assessment and echocardiography. Patients should be seen within 2 weeks when NTproBNP is >2000 pg/mL (2-week pathway: 2WP) or within 6 weeks when NTproBNP is 400–2000 pg/mL (6-week pathway: 6WP). This is a retrospective, multicentre, observational study of consecutive patients with suspected HF referred from primary care between 2014 and 2016 to dedicated secondary care HF clinics based on the NICE 2WP and 6WP. Data were obtained from hospital records and episode statistics. Mortality and hospitalisation rates were calculated 1 year from NTproBNP measurement.Results1271 patients (median age 80; IQR 73–85) were assessed, 680 (53%) of whom were female. 667 (53%) were referred on the 2WP and 604 (47%) on the 6WP. 698 (55%) were diagnosed with HF (369 HF with reduced ejection fraction) and 566 (45%) as not HF (NHF). 1-year mortality was 10% (n=129) and hospitalisation was 33% (n=413). Patients on the 2WP had higher mortality and hospitalisation rates than those on the 6WP, 14% vs 6% (p<0.001) and 38% vs 27% (p<0.001), respectively. All-cause mortality (11% vs 9%; p=0.306) and hospitalisation rates (35% vs 29%; p=0.128) did not differ between HF and NHF patients, respectively.ConclusionsOutcomes using the NICE approach of short waiting time targets for specialist assessment of patients with suspected HF and raised NTproBNP are not known. The model identifies an elderly population a high proportion of whom have HF. Irrespective of diagnosis, patients have high rates of adverse outcomes. These contemporary real-world data provide a platform for discussions with patients and shaping HF services.

PurposeTo understand factors contributing to disturbances during cardiac procedures, including frequency and nature of distractions, along with assessment of operator ‘work-load’ through NASA Task-load indices.MethodsA single centre prospective observational study was conducted on 194 consecutive patients undergoing cardiac procedures in 3 adult cardiac CL’s over a period of 4 weeks. A distraction pro-forma was completed for each case by CL team members (predominantly physiologists), documenting procedural logistics and referring both to the level of risk of the procedure at that time (table 1) and frequency, nature and magnitude of each distraction/interruption (table 2). The primary operator completed a NASA Task-load questionnaire rating parameters to include mental and physical effort, level of frustration, time–urgency, and overall effort and performance on a scale of 1 – 21.Abstract 54 Table 1Procedural risk categoryResults264 distractions occurred in 106 procedures (55% of total); 80% were not relevant to the case being undertaken; 13% were due to emergencies occurring in the ‘Hot- Lab’ predominantly to discuss potential ST-elevation myocardial infarction requiring emergency angioplasty. Frequency of distractions per case ranged from 1 to 16, with an average of 2.5; 16% (n=43) of these were documented to occur during high-risk stages (categories 3 or 4) of the procedure. Operator rating of NASA task-load parameters demonstrated higher levels of ‘mental’ and ‘physical’ workload and ‘effort’ when distractions occurred (figure 1).Abstract 54 Figure 1ConclusionIn this first description of human factors in the adult cardiac CL we have shown that less than half of all procedures are completed without interruption/distraction. The vast majority of these are unnecessary and without relation to the case or list. We therefore propose the introduction of a ‘sterile cockpit’ environment in the CL, as has been adapted from the aviation industry within surgical operating theatres, to minimise non-emergent interruptions and disturbances, in an attempt to improve operator conditions and overall patient safety.Conflict of InterestNil

IntroductionChronic heart failure (HF) represents a substantial and growing public health and financial burden and has a poor prognosis. National Institute for Health and Care Excellence (NICE) guidelines and quality standards recommend timely specialist assessment for patients with suspected HF and raised natriuretic peptides. However, data on the outpatient population assessed, diagnostic rates of HF and outcomes for patients on this pathway are not known. This is in contrast to patients hospitalised with acute HF who are well described in the UK. Our aim is to describe real world data from a large patient cohort with suspected HF investigated according to NICE protocols.MethodsAll patients with suspected HF and elevated NTproBNP referred to a dedicated HF clinic between January 2014 – December 2016 were included. Patients underwent specialist assessment, echocardiography and diagnosis in a one-stop clinic within 2 weeks (NTproBNP>2000pg/ml) or 6 weeks (NTproBNP 400–2000pg/ml) in accordance with NICE guidelines.Patient baseline characteristics and co-morbidities were recorded prospectively. 1 year all-cause hospitalisation (1 or more admissions) and mortality rates were retrospectively calculated from the date of NTproBNP measurement using hospital coding data and electronic patient records.Outcomes were compared between those referred on the 2 and 6 week pathways; and between those diagnosed with Heart Failure (HF) vs. Not Heart Failure (NHF) after specialist assessment.ResultsOut of 1042 consecutive patients referred, 1013 had NTproBNP measured and were included. 544 (54%) were on the 2-week and 469 (46%) on the 6-week pathway. 543 (54%) were diagnosed with HF; 300 (55%) with Heart Failure with reduced Ejection Fraction (HFrEF) and 243 (45%) with Heart Failure with preserved Ejection Fraction (HFpEF). 454 (45%) were diagnosed as NHF.A diagnosis of HF was made in 383 (70%) in the 2-week and 160 (34%) in the 6-week pathway (p<0.001). Of those with HF, HFrEF was diagnosed in 236 (62%) in the 2-week and 64 (40%) in the 6-week pathway (p<0.001). Patients characteristics comparing the 2 and 6-week pathways and the HF and NHF groups are shown in tables 1 & 2.For the entire population the 1-year hospitalisation rate was 324/1013 (32%) and mortality 112/1013 (11%).There were significantly higher rates of both mortality (88 [16%] vs 24 [5%] p <0.001) and hospitalisation (199 [37%] vs. 125 [27%] p=0.001) in the 2-week compared to the 6-week pathway. There was a significantly higher rate of hospitalisation in the HF group compared to the NHF group (189 [35%] vs 123 [27%]) p=0.009) but no difference in mortality (64 [12%] vs 39 [9%] p=0.099). Figures 1 & 2.Abstract 83 Figure 11 year All-cause mortality (%) comparing 2 vs. 6-week pathways and HF vs. NHF groupsAbstract 83 Figure 21 year All-cause hospitalisation (%) comparing 2 vs. 6-week pathways and HF vs. NHF groupsAbstract 83 Table 1Characteristics of patients on 2 and 6-week pathwaysAbstract 83 Table 2Characteristics of Heart Failure and Not Heart Failure groupsConclusionThe prognosis is relatively poor for outpatients with suspected chronic HF and raised natriuretic peptides, with high rates of adverse outcomes observed despite specialist investigation in accordance within NICE timeframes. This is regardless of the final diagnosis, as mortality is comparable between HF and NHF groups.The proportion of patients diagnosed with HF in the 2-week pathway was high. As expected, patients referred via the 2-week pathway had significantly higher rates of both mortality and hospitalisation.This study provides valuable real world data and insight into an important population, which will help inform discussions with patients and shape chronic HF services.Conflict of InterestNone