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Angiodyplasia and aortic stenosis are both conditions that are highly prevalent in elderly people and can often co-exist. Recent studies suggest that this association is related to subtle alterations in plasma coagulation factors. The von Willebrand factor is the strongest link between aortic stenosis and bleeding associated with gastrointestinal angiodysplasia. With an ageing population, the disease burden of aortic stenosis and its association with angiodysplasia of the bowel makes this an incredibly underdiagnosed yet important condition. Clinicians should be aware of this association when dealing with elderly patients presenting either with unexplained anemia, gastrointestinal bleeding or with aortic stenosis. A high index of suspicion and appropriate diagnostic techniques followed by appropriate and prompt treatment could be life-saving. No clear guidelines exist on management but surgical aortic valve replacement is thought to offer the best hope for long-term resolution of bleeding. With a growing number of technological armamentarium in the management of such patients, especially with the advent of transcatheter aortic valve implantation, new options can be offered even to elderly patients with comorbidities for whom conventional surgery would have been impossible.

AimsHeart failure (HF) is associated with comorbidities which independently influence treatment response and outcomes. This retrospective observational study (January 2020–June 2021) analysed the impact of monthly HF multispecialty multidisciplinary team (MDT) meetings to address management of HF comorbidities and thereby on provision, cost of care and HF outcomes.MethodsPatients acted as their own controls, with outcomes compared for equal periods (for each patient) pre (HF MDT) versus post-MDT (multispecialty) meeting. The multispecialty MDT comprised HF cardiologists (primary, secondary, tertiary care), HF nurses, nephrologist, endocrinologist, palliative care, chest physician, pharmacist, clinical pharmacologist and geriatrician. Outcome measures were (1) all-cause hospitalisations, (2) outpatient clinic attendances and (3) cost.Results334 patients (mean age 72.5±11 years) were discussed virtually through MDT meetings and follow-up duration was 13.9±4 months. Mean age-adjusted Charlson Comorbidity Index was 7.6±2.1 and Rockwood Frailty Score 5.5±1.6. Multispecialty interventions included optimising diabetes therapy (haemoglobin A1c-HbA1c pre-MDT 68±11 mmol/mol vs post-MDT 61±9 mmol/mol; p<0.001), deprescribing to reduce anticholinergic burden (pre-MDT 1.85±0.4 vs 1.5±0.3 post-MDT; p<0.001), initiation of renin–angiotensin aldosterone system inhibitors in HF with reduced ejection fraction (HFrEF) with advanced chronic kidney disease (9% pre vs 71% post-MDT; p<0.001). Other interventions included potassium binders, treatment of anaemia, falls assessment, management of chest conditions, day-case ascitic, pleural drains and palliative support. Total cost of funding monthly multispecialty meetings was £32 400 and resultant 64 clinic appointments cost £9600. The post-MDT study period was associated with reduction in 481 clinic appointments (cost saving £72150) and reduced all-cause hospitalisations (pre-MDT 1.1±0.4 vs 0.6±0.1 post-MDT; p<0.001), reduction of 1586 hospital bed-days and cost savings of £634 400. Total cost saving to the healthcare system was £664 550.ConclusionHF multispecialty virtual MDT model provides integrated, holistic care across all healthcare tiers for management of HF and associated comorbidities. This approach is associated with reduced clinic attendances and all-cause hospitalisations, leading to significant cost savings.

Abstract Background Previous studies have shown that xanthine oxidase inhibitors (XOI) might improve outcome for patients with cardiovascular disease. However, more evidence is required. Methods and results We published a meta-analysis of trials conducted before 2014 examining the effects of XOI on mortality in patients with cardiovascular disease. At least two further trials (N = 323 patients) have since been published. Accordingly, we repeated our analysis after a further search for randomized controlled trials of XOI in PubMed/MEDLINE, EMBASE, and Cochrane Databases. We identified eight relevant trials with 1031 patients. The average age of the patients was 61 years and 68% were men (one study did not report gender). There were 57 deaths in these eight trials, 26 in those assigned to XOI, and 31 in those assigned to the control. The updated meta-analysis could not confirm a reduction in mortality for patients assigned to XOI compared with placebo (odds ratio 0.84) but 95% confidence intervals were wide (0.48–1.47). Conclusions This updated meta-analysis does not suggest that XOI exert a large reduction in mortality but also cannot exclude the possibility of substantial harm or benefit.

A 70-year-old gentleman previously fit and well referred by his general practitioner (GP) was admitted to our acute medical unit (AMU) with new shortness of breath, rapidly progressing paroxysmal nocturnal dyspnoea and orthopnoea over a 3-week period. While being assessed by the GP, an audible murmur was detected, hence the referral for further assessment. Upon initial assessment in the AMU, the patient was haemodynamically stable and comfortable at rest. Auscultation revealed a harsh holosystolic murmur radiating to the left axilla. A bedside point of care ultrasound (POCUS) demonstrated severe mitral regurgitation (MR) with a flail posterior mitral valve leaflet and a broad colour flow doppler jet extending to the back of the left atrium (Fig. 1). Visually, his left ventricle and atrium appeared dilated with preserved left ventricular systolic function. Lung POCUS showed a bilateral B-line profile, consistent with pulmonary oedema.

PurposeLeft main stem (LMS) disease is associated with significant morbidity and mortality, even more within an elderly population. Traditionally coronary artery bypass grafting (CABG) has been the gold standard for treatment of these lesions, however, percutaneous coronary intervention (PCI) in this geriatric cohort is expanding with the advent of newer drug-eluting stents (DES), better intravascular imaging modalities and careful patient selection. This study was to investigate the safety and efficacy of LMS treatment with PCI at a UK non-surgical centre.MethodsFrom January 2018 to December 2022, all patients who underwent PCI to LMS lesions in our cath-lab were enrolled. The relevant clinical and angiographic characteristics at the time of PCI, as well as the clinical follow-up outcomes, were retrieved and analysed.ResultsA total of 117 patients were analysed with a mean age 71.3 ± 11 years. Of these 86 (74%) were males, 29 (25%) were diabetic, 58 (50) hypertensive. There were 78(67%) who presented with acute coronary syndrome, 32(27%) were elective admission whilst 7(6%) presented with cardiogenic shock.Of these 117, 79(68%) underwent single stent strategy while 38(32%) had double stent strategy. IVUS was used in 48(41%) cases, 16(14%) also required rotational atherectomy.The clinical success rate was 94%. Intra-aortic balloon pump was used in 2 of the procedures. Six (6%) patients died during hospitalization, all due to presenting cardiogenic shock. No major complication occurred. Among 111(95%) hospital survivors, the major adverse cardiac events (MACE) rate was 5 (4%), all due to target lesion revascularization or target vessel revascularization while 18(15%) died of other causes of death.ConclusionsIn this elderly patient cohort, LMS treatment with PCI could be safely carried out with a minimal complication rate and low out-of-hospital MACE despite relatively low use of intracoronary imaging.Conflict of InterestNon

PurposeHeart failure (HF) has a prevalence of over 750,000 people in the UK and over 23 million worldwide. In response to the burden of hospital readmissions and post hospitalisation needs of HF patients, recent health policies stress the need to develop services that will cater for patients’ requirements and deliver these closer to their home. One such service is out of hospital parenteral diuretic treatment, which is supported by data from observation studies although there may be observation bias. We aimed at carrying out an online survey to evaluate use of outpatient acute HF management in the UK and assessing the feasibility of setting up a randomised control trial (RCT) comparing inpatient versus outpatient acute heart failure management in the UK.MethodWe developed a brief online survey by using SurveyMonkey® (Palo Alto, Calif) that was sent to 237 consultant cardiologists with an interest in heart failure in the UK identified from the Directory of Cardiology 2014. The survey was available from 26 February through 10 March 2015 and comprised questions regarding existence of an outpatient acute heart failure service (frusemide lounge) at the hospital where the consultant currently works, whether hospital/PCT currently support a community based acute heart failure management service including the use of parenteral frusemide, identity of person who delivers the community parenteral frusemide service, interest to take part in a multi-centre randomised controlled trial comparing outpatient acute heart failure management with standard inpatient care and if so the number of patients that can potentially be randomised over the next 2 years.ResultsThe survey was sent by direct e-mail invitation to 237 cardiologists; 55 (23%) took and completed the survey. 14 (25%) indicated existence of an outpatient acute heart failure service (frusemide lounge) at the hospital where they currently work and 14 (25%) mentioned that their hospital/PCT currently support a community based acute heart failure management service including the use of parenteral frusemide. Of these 14 (25%) centres, in 5 (9%) delivery of the community parenteral frusemide service was provided by district nurses, 2 (3.5%) by GP, 7 (12.5%) by heart failure nurse and 1 (1.7%) by an ambulatory care unit. Finally 21 (37.5%) expressed an interest in taking part in a multi-centre randomised controlled trial comparing outpatient acute heart failure management with standard inpatient care.ConclusionOur study shows that only a very small minority of hospitals in the UK offers an outpatient based acute heart failure management such as frusemide lounges. No RCT has investigated the clinical effectiveness and safety of outpatient IV diuretic therapy in patients with decompensated HF yet. Hence our aim is to carry out the first RCT looking at safety and effectiveness of Out-of-hospital Acute Heart failure Care compared with inpatient management in the UK.

IntroductionTo compare the impact of an e-learning package with theoretical teaching on the ability of both graduate and undergraduate medical students to learn the management of supraventricular tachycardia.MethodsWe conducted a randomised, controlled, study at two Welsh medical schools. Participants were graduate-entry and undergraduate medical students, who were randomised (in a 1:1 ratio) to either 1 hour of training using an e-learning package or an hour of lecture-based teaching. The outcome was a comparison, within each group and between groups, of median scores achieved in assessments of knowledge through completion of preintervention, immediate post intervention and 2 weeks postintervention questionnaires.ResultsOf the 97 participants available for randomisation, 47 underwent teaching using the e-learning package and 50 were taught in the lecture group. Median scores were higher in the e-learning package group than the lecture group, though this difference was not statistically significant (4.00 vs 3.00; p=0.08) immediately after intervention. At 2 weeks post intervention, median scores in the e-learning package group were significantly higher than the median scores in the lecture group (4.00 vs 3.00; p=0.002). This was despite a subanalysis of the results demonstrating that subjects in the lecture group reported having seen more cases compared with those in the e-learning group (32 vs 13; p=0.002). Further, there was a significant fall in score over 2 weeks in the group receiving lecture-based teaching, but no such decrease in those using the e-learning package.ConclusionE-learning seems to be the preferred method of learning and the method that confers longer retention time for both postgraduate and undergraduate medical students.

IntroductionTo compare the impact of e-learning package and theoretical teaching on the ability of both graduate and undergraduate medical students to learn the management of supraventricular tachycardia (SVT).MethodsWe conducted a randomized controlled blinded study at two medical schools in Wales, UK. Participants included graduate-entry medical students from Swansea University and undergraduate medical students from Cardiff University. The intervention consisted of one hour of training using an e-learning package versus an hour of lecture based teaching. The outcome was comparison within each groups and between groups of mean scores using a pre-intervention and immediate post-intervention questionnaire. Another questionnaire was e-mailed after 2 weeks and mean scores were again compared to baseline, immediate post intervention between each groups and within each groups. The hypothesis was an improved outcome in the intervention group. Randomization was 1 to 1.ResultsOf the 97 participants available for randomization, 46 underwent teaching using the e-learning package and 51 were taught in the lecture group. Mean scores were higher in the e-learning package group than the lecture group, though this difference was not statistically significant (3.63 vs. 3.37; P = 0.085) immediately after intervention. At 2-weeks post intervention, mean scores in the e-learning package group was significantly higher than the mean scores in the lecture group (3.59 vs. 2.86; P = 0.002). This was despite a sub-analysis of the results demonstrating that subjects in the lecture group had seen more cases which was statistically significant compared to those in the e-learning group (32 vs. 13; P = 0.002).ConclusionE-learning seems to be the preferred method of learning and the method that confers longer retention time for both post-graduate and undergraduate medical students.Conflict of InterestNone

Doc number: P195

BackgroundHeart failure (HF) is a complex clinical syndrome associated with high mortality and high rate of hospital readmissions. Telehealth (TH) is a promising strategy for improving HF outcomes but there is an urgent need to properly identify those patients in whom a TH approach would provide benefit. The purpose of this study was to determine if TH in patients with recently diagnosed HF and ejection fraction <45%, reduces the risk of re-admission from any cause or death from any cause.MethodsA retrospective study of 124 patients (78.2% male; 68.6 ± 12.6 years; 56.5% ischaemic aetiology) who underwent TH and 345 patients (68.5% male; 70.2 ± 10.7 years; 56.3% ischaemic aetiology) who underwent the usual-care (UC), between 2009–12. All patients had a recent diagnosis of HF, NHYA class II-III and ejection fraction < 45%. The TH group were assessed by body weight, blood pressure and heart rate on a daily basis using electronic devices with automatic transfer of measured data to an online database. The follow-up period was 12 months.ResultsDeath from any cause occurred in 8.1% of the TH group and 19% of the UC group, p = 0.002. Readmissions for any cause occurred in 63.7% of patients in the TH group and 62.5% of patients in the UC group, p = 0.8. The number of readmissions/patients was also similar in the two groups, 1.3 ± 1.7 in the TH group and 1.4 ± 1.7 in the UC group (p = 0.9). A difference in the number of days in hospital was noted (8.1 ± 12.8 days in TH group and 9.5 ± 17.3 in UC group) but this was not statistically significant (p = 0.4). There was significant difference in the days alive and away from the hospital in the two groups: 348.3 ± 5.5 days in the TH group and 329.9 ± 4.6 days in the UC group (p = 0.008).ConclusionsIn patients with a recent diagnosis of HF and reduced left ventricle systolic function, TH is associated with lower any-cause mortality. Furthermore TH has the potential to reduce number of days lost to hospitalisation and death.