Cardiac screening in the noncardiac surgery patient.

This article will address common cardiac conditions that require evaluation prior to noncardiac surgery, characterization of urgency and the risk associated with surgical procedures, calculation of preoperative risk assessment, indications for diagnostic testing to quantify cardiac risk, and perioperative strategies to minimize the risk of cardiac complications

Pulmonary hypertension subjects exhibit right ventricular transient exertional dilation during supine exercise stress echocardiography.

Pulmonary hypertension is a condition with high morbidity and mortality. Resting transthoracic echocardiography is a pivotal diagnostic and screening test for pulmonary hypertension. The role of exercise stress echocardiography in the diagnosis of pulmonary hypertension is not well-established. We studied right ventricular size changes during exercise using exercise stress echocardiography to assess differences between normal and pulmonary hypertension patients and evaluate test safety, feasibility, and reproducibility. Healthy control and pulmonary hypertension patients performed recumbent exercise using a bicycle ergometer. Experienced echocardiography sonographers recorded the following resting and peak exercise right ventricular parameters using the apical four chamber view: end-diastolic area; end-systolic area; mid-diameter; basal diameter; and longitudinal diameter. Two cardiologists masked to clinical information subsequently analyzed the recordings. Parameters with acceptable inter-rater reliability were analyzed for statistical differences between the normal and pulmonary hypertension patient groups and their association with pulmonary hypertension. We enrolled 38 healthy controls and 40 pulmonary hypertension patients. Exercise stress echocardiography testing was found to be safe and feasible. Right ventricular size parameters were all readily obtainable and all had acceptable inter-observer reliability except for right ventricular longitudinal diameter. During exercise, healthy controls demonstrated a decrease in right ventricular end-systolic area, end-diastolic area, mid-diameter, and basal diameter ( P \u3c 0.05). Conversely, pulmonary hypertension patients demonstrated an increase in right ventricular end-systolic area, end-diastolic area, and mid-diameter ( P \u3c 0.05). These changes were unaffected by multivariate corrections. The sensitivity for pulmonary hypertension of an increase in right ventricular size was 97.2% with a negative predictive value of 95.2%. The ROC C-statistic for increase in right ventricular size was 0.93. This transient exertional dilation (TED) of the right ventricle is observed in pulmonary hypertension patients but not in healthy controls. Recumbent right ventricular exercise stress echocardiography is a feasible and safe diagnostic test for pulmonary hypertension which warrants additional study

Variation in additional testing and patient outcomes after stress echocardiography or myocardial perfusion imaging, according to accreditation status of testing site.

BACKGROUND: The purpose of the present study was to determine whether patients receiving a stress echocardiogram or myocardial perfusion imaging (MPI) test have differences in subsequent testing and outcomes according to accreditation status of the original testing facility. METHODS AND RESULTS: An all-payer claims dataset from Maine Health Data Organization from 2012 to 2014 was utilized to define two cohorts defined by an initial stress echocardiogram or MPI test. The accreditation status (Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) or none) of the facility performing the index test was known. Descriptive statistics and multivariate regression were used to examine differences in subsequent diagnostic testing and cardiac outcomes. We observed 4603 index stress echocardiograms and 8449 MPI tests. Multivariate models showed higher odds of subsequent MPI testing and hospitalization for angina if the index test was performed at a non-accredited facility in both the stress echocardiogram cohort and the MPI cohort. We also observed higher odds of percutaneous coronary interventions (PCI) performed (OR 1.68, 95% CI 1.13-2.50), if the initial MPI test was done in a non-accredited facility. CONCLUSION: Cardiac testing completed in non-accredited facilities were associated with higher odds of subsequent MPI testing, hospitalization for angina, and PCI

Healthy Links: Bridging the Social Determinants of Health Safety Net for At Risk Patients with Heart Failure

Purpose/Motivation: Our primary goals of “Bridging to the SoDH Safety Net for At Risk Patients with Heart Failure” are to reduce the rate of admissions, readmissions and unnecessary ED visits for high risk heart failure patients by addressing social determinants of health risk factors. Additionally, we aim to provide evidence in support of creating a third-party reimbursement code for services addressing social determinants screening. Background: Social determinants of health are defined by the World Health Organization as “the conditions in which people are born, grow, live, work and age”. In many ways these factors impact health literacy, morbidity, mortality and quality of life in the face of a chronic health condition such as heart failure. More specifically, our project is focusing on meeting the needs of high risk patients with food insecurities. Approach/Methods: MaineHealth Cardiology and Southern Maine Agency on Aging have partnered as a project team with support of a Harvard Pilgrim HealthCare grant for 80 patients. Patients were selected based on meeting criteria of having either two ED visits or hospitalizations for heart failure, and showing risk factors in social determinants of health. A primary heart failure nurse navigator has led patient outreach and recruitment through informational mailings and phone calls using the EPIC IT-generated patient list. Once patients have been enrolled, the SMAA outreach team conducted home visits and SDoH assessments, and established a baseline wellbeing score. Healthy Links “Simply Delivered” meals were then delivered to the patients. At the conclusion of the program, patients were re-assessed and given a follow-up wellbeing score. At this juncture, we have enrolled nearly 70 of the 80 patients and are still gathering data on ED visits, hospitalizations and wellbeing scores. Results: To date, we have reached out to over 153 patients and enrolled nearly 73 patients with SMAA community outreach. After completing the first phase of the program, 16 of the enrolled patients have chosen to continue receiving Simply Delivered meals by private pay, or qualified for Meals on Wheels. We did not anticipate that a high proportion of patients would fail to respond to initial contact in the recruitment process, nor did we foresee that many patients would no longer need this intervention due to transition to skilled nursing facilities, or unfortunately death. Conclusions: The project has made a positive impact from a subjective standpoint as a high percentage of patients in the first phase have requested to continue services and meal delivery. We anticipate that the project will also reduce unnecessary ED visits, hospitalizations, morbidity, mortality and ultimately enhance quality of life

Neural Network Assessment of Perioperative Cardiac Risk in Vascular Surgery Patients

Neural networks were developed to predict perioperative cardiac complications with data from 567 vascular surgery patients. Neural network scores were based on cardiac risk factors and dipyridamole thallium results. These scores were converted into like lihood ratios that predicted cardiac risk. The prognostic accuracy of the neural networks was similar to that of logistic regression models (ROC areas 76.0% vs 75.8%), but their calibration was better. Logistic regression overestimated event rates in a group of high-risk patients (predicted event rate, 64%; observed rate 30%; n = 50, p < 0.001). On a validation set of 514 patients, the neural networks still had ROC similar areas to those of logistic regression (68.3% vs 67.5%), but logistic regression again overesti mated event rates for a group of high-risk patients. The calibration difference was reflected in the Hosmer-Lemeshow chi-square statistic (18.6 for the neural networks, 45.0 for logistic regression). The neural networks successfully estimated perioperative cardiac risk with better calibration than comparable logistic regression models. Key words. neural networks; logistic regression; likelihood ratio; Bayes' theorem; cardiac risk. (Med Decis Making 1998;18:70-75

Behavioral Risk Factors and Regional Variation in Cardiovascular Health Care and Death.

INTRODUCTION: Reducing the burden of death from cardiovascular disease includes risk factor reduction and medical interventions. METHODS: This was an observational analysis at the hospital service area (HSA) level, to examine regional variation and relationships between behavioral risks, health services utilization, and cardiovascular disease mortality (the outcome of interest). HSA-level prevalence of cardiovascular disease behavioral risks (smoking, poor diet, physical inactivity) were calculated from the Behavioral Risk Factor Surveillance System; HSA-level rates of stress tests, diagnostic cardiac catheterization, and revascularization from a statewide multi-payer claims data set from Maine in 2013 (with 606,260 patients aged ≥35 years), and deaths from state death certificate data. Analyses were done in 2016. RESULTS: There were marked differences across 32 Maine HSAs in behavioral risks: smoking (12.4%-28.6%); poor diet (43.6%-73.0%); and physical inactivity (16.4%-37.9%). After adjustment for behavioral risks, rates of utilization varied by HSA: stress tests (28.2-62.4 per 1,000 person-years, coefficient of variation=17.5); diagnostic cardiac catheterization (10.0-19.8 per 1,000 person-years, coefficient of variation=17.3); and revascularization (4.6-6.2 per 1,000 person-years; coefficient of variation=9.1). Strong HSA-level associations between behavioral risk factors and cardiovascular disease mortality were observed: smoking (R CONCLUSIONS: There is substantial regional variation in behavioral risks and cardiac utilization. Behavioral risk factors are associated with cardiovascular disease mortality regionally, whereas revascularization is not. Efforts to reduce cardiovascular disease mortality in populations should focus on prevention efforts targeting modifiable risk factors