Cost-effectiveness analysis of simulation-based training in transesophageal echocardiography: Insights from the SIMULATOR trial

International audienceIntroductionRecently our working group has shown that simulation-based training provides a significant improvement in TEE theoretical knowledge and practical skills, and with a statistically significant 1.1-minute reduction in TEE examination after the training compared to traditional education within the SIMULATOR trial.ObjectiveThis ancillary analysis of the SIMULATOR-trial was designed to perform a cost analysis of simulation-based training on TEE learning using incremental cost-effectiveness ratio compared to traditional teaching to enlighten the decision-making process of financing this type of program.MethodBetween November 2020 and November 2021, 342 consecutive cardiology fellows inexperienced from TEE were randomized (1:1, n = 324) through 42 French university centers into two groups with or without simulation support. Regarding the economic analysis, costs associated with simulation-based training were measured based on data collected by representatives in each hospital center (simulator cost, maintenance cost, simulator duration of use, hourly trainer income, number of training hours). Three scenarios were considered depending on the number of fellows recruited in each University Hospital Center (n = 20, 40 or 60). An average training cost per fellow has been estimated for each scenario. Given the primary outcome and the cost analysis result, an incremental cost-effectiveness ratio (ICER, cost per point gained to the global score) has been assessed.ResultsCompared to the traditional group, the cost to gain two points in the global score (i.e. 1% of both theoretical knowledge and practical skills) in the simulation group was respectively €140.4, €74.6, and €52.4 per fellows for 20, 40 and 60 fellows. Therefore, the average additional cost per fellow of the simulation program was respectively €1,785, €942 or €662 for 20, 40 and 60 fellows. Using the incremental cost-effectiveness ratio (ICER), the ICER, cost per point gained to the global score of the simulation program (including simulator) was respectively €70.6, €37.5 or €26.2 depending on the number of fellows to be trained on 10 years per center (20, 40 and 60) compared with the traditional group (Table 1).ConclusionThe favorable cost-effectiveness ratio underlined by this economic analysis adds to the convincing results of the interest of TEE simulation-based program highlighted by the SIMULATOR-trial

Prevalence and Prognostic Impact of Drug Use in Patients Hospitalized for Acute Heart Failure

International audienceNo abstract availabl

Cardiovascular manifestations secondary to COVID-19: A narrative review

International audienceThe coronavirus disease 2019 (COVID-19) pandemic has spread rapidly, becoming a major threat to global health. In addition to having required the adaptation of healthcare workers for almost 2 years, it has been much talked about, both in the media and among the scientific community. Beyond lung damage and respiratory symptoms, the involvement of the cardiovascular system largely explains COVID-19 morbimortality. In this review, we emphasize that cardiovascular involvement is common and is associated with a worse prognosis, and that earlier detection by physicians should lead to better management. First, direct cardiac involvement will be discussed, in the form of COVID-19 myocarditis, then secondary cardiac involvement, such as myocardial injury, myocardial infarction and arrhythmias, will be considered. Finally, worsening of previous cardiovascular disease as a result of COVID-19 will be examined, as well as long-term COVID-19 effects and cardiovascular complications of COVID-19 vaccines

Machine learning score using cardiac MRI to predict cardiovascular events in patients with acute myocarditis

International audienceIntroductionWhile acute myocarditis (AM) represents a risk of major adverse cardiovascular events (MACE), no prediction score has yet been established.ObjectiveTo investigate the feasibility and accuracy of machine learning (ML) score to predict MACE in patients with AM, and compare its performance with traditional statistical methods.MethodBetween 2008–2017, all consecutive patients with AM based on CMR were recruited in two centres (ICPS Hospital, n = 203 and Amiens Hospital, n = 185) to constitute the derivation cohort. Another centre constituted external validation cohort (n = 218, Lariboisiere Hospital). The primary outcome was MACE defined by: cardiac death, cardiac transplantation, ventricular arrythmia, hospitalization for heart failure, recurrence of AM, and unplanned hospitalization for cardiac reason. Using LASSO regression to select variables, several ML models were then trained on the index cohort. Their performance was compared using receiver operating characteristics (AUROC) and precision-recall (PR) curves.ResultsOf the 388 AM patients (39 ± 7 years, 77% male) included in the derivation cohort, 71 experienced a MACE (18%) after a median follow-up of 7.5 [IQR 6.6–8.9] years. Among those, 30 patients (7.7%) had a recurrence of AM. CMR was performed 4 ± 2 days after index presentation. Out of 56 clinical, biological, and CMR variables, 7 variables were selected as being the most important in predicting MACE: age, initial presentation with syncope, LV ejection fraction, myocardial extent of LGE, mid-wall pattern of LGE, septal location of LGE, and number of segments with T2-hypersignal (T2-STIR) (Fig. 1). The Random Forest model showed the best performance compared with the other ML models (AUROC = 0.74, PR-AUC = 0.33). This ML model exhibited a higher AUC compared with a traditional model using logistic regression analysis (AUROC 0.74 vs. 0.70; P < 0.001), and also a good performance for predicting MACE in the external validation cohort (AUROC 0.73) (Fig. 2).ConclusionA machine learning score including clinical and CMR data exhibited a better performance than traditional statistical methods to predict MACE in patients with acute myocarditis

Efficacy of simulation-based training on transoesophageal echocardiography learning in a multicentre randomised controlled trial: SIMULATOR study

Background Evidence on the impact of simulation-based training in transesophageal echocardiography (TEE) is scarce. Purpose We aimed to assess the efficacy of simulation-based versus traditional teaching on TEE knowledge and skills for cardiology residents. Methods Between November 2020 and November 2021, all consecutive cardiology residents inexperienced from TEE were randomised (1:1, n=324) through 42 French University Centers into two groups with or without simulation support (either a simulation group or a traditional group). The coprimary outcomes were the scores in the final theoretical and practical tests 3 months after the training. TEE duration and the feelings of residents were also assessed. An economic analysis was also performed. Results While the theoretical and practical test scores were similar between the two groups before the training (respectively P=0.80 and P=0.51), the residents in the simulation group displayed higher theoretical test and practical test scores after the training than those in the traditional group (respectively 47.2±15.6% vs. 38.3±19.8%, P&lt;0.0001 and 74.5±17.7% vs. 59.0±25.1%, P&lt;0.0001). Subgroups analyses showed that the efficacy of the simulation training was even greater when performed at the beginning of residency (P&lt;0.0001). After the training, the duration to perform a complete TEE was significantly lower in the simulation group than in the traditional group (respectively 8.3±1.4 min vs. 9.4±1.2 min, P&lt;0.0001). Finally, residents' feelings were better in the simulation group than in the traditional group across all components (P&lt;0.0001). Compared to the traditional group, the average additional cost per resident of the simulation program was respectively €1,785, €942 or €662 for 20, 40 and 60 residents. Conclusion Simulation-based teaching on TEE showed a significant improvement in knowledge, skills, and feelings of cardiology residents as well as a reduction in the duration to complete the examination. Funding Acknowledgement Type of funding sources: None

TAPSE/sPAP prognostic value for In-Hospital Adverse Events in Patients Hospitalized for Acute Coronary Syndrome

International audienceAIMS: Although several studies have shown that the right ventricular to pulmonary artery (RV-PA) coupling, assessed by the ratio between tricuspid annular plane systolic excursion and systolic pulmonary artery pressure (TAPSE/sPAP) using echocardiography, is strongly associated with cardiovascular events, its prognostic value is not established in acute coronary syndrome (ACS). We aimed to assess the in-hospital prognostic value of TAPSE/sPAP among patients hospitalized for ACS in a retrospective analysis from the prospective ADDICT-ICCU study. METHODS AND RESULTS: 481 consecutive patients hospitalized in intensive cardiac care unit (mean age 65±13 years, 73% of male, 46% STEMI) for ACS (either ST-elevation [STEMI] or non-ST-elevation [NSTEMI] myocardial infarction) with TAPSE/sPAP available were included in this prospective French multicentric study (39 centers). The primary outcome was in-hospital major adverse cardiovascular events (MACEs) defined as all-cause death, resuscitated cardiac arrest or cardiogenic shock and occurred in 33 (7%) patients. ROC-curve analysis identified 0.55 mm/mmHg as the best TAPSE/sPAP cut-off to predict in-hospital MACEs. TAPSE/sPAP \textless0.55 was associated with in-hospital MACEs, even after adjustment with comorbidities (OR:19.1, 95%CI[7.78-54.8]), clinical severity including left ventricular ejection fraction (OR:14.4, 95%CI[5.70-41.7]) and propensity-matched population analysis (OR:22.8, 95%CI[7.83-97.2], all p\textless0.001). After adjustment, TAPSE/sPAP \textless0.55 showed the best improvement in model discrimination and reclassification above traditional prognosticators (C-statistic improvement: 0.16; global chi-square improvement: 52.8; LR-test p\textless0.001) with similar results for both STEMI and NSTEMI subgroups. CONCLUSION: A low RV-PA coupling defined as TAPSE/sPAP ratio \textless0.55 was independently associated with in-hospital MACEs and provided incremental prognostic value over traditional prognosticators in patients hospitalized for ACS. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05063097

TAPSE/sPAP prognostic value for In-Hospital Adverse Events in Patients Hospitalized for Acute Coronary Syndrome

International audienceAIMS: Although several studies have shown that the right ventricular to pulmonary artery (RV-PA) coupling, assessed by the ratio between tricuspid annular plane systolic excursion and systolic pulmonary artery pressure (TAPSE/sPAP) using echocardiography, is strongly associated with cardiovascular events, its prognostic value is not established in acute coronary syndrome (ACS). We aimed to assess the in-hospital prognostic value of TAPSE/sPAP among patients hospitalized for ACS in a retrospective analysis from the prospective ADDICT-ICCU study. METHODS AND RESULTS: 481 consecutive patients hospitalized in intensive cardiac care unit (mean age 65±13 years, 73% of male, 46% STEMI) for ACS (either ST-elevation [STEMI] or non-ST-elevation [NSTEMI] myocardial infarction) with TAPSE/sPAP available were included in this prospective French multicentric study (39 centers). The primary outcome was in-hospital major adverse cardiovascular events (MACEs) defined as all-cause death, resuscitated cardiac arrest or cardiogenic shock and occurred in 33 (7%) patients. ROC-curve analysis identified 0.55 mm/mmHg as the best TAPSE/sPAP cut-off to predict in-hospital MACEs. TAPSE/sPAP \textless0.55 was associated with in-hospital MACEs, even after adjustment with comorbidities (OR:19.1, 95%CI[7.78-54.8]), clinical severity including left ventricular ejection fraction (OR:14.4, 95%CI[5.70-41.7]) and propensity-matched population analysis (OR:22.8, 95%CI[7.83-97.2], all p\textless0.001). After adjustment, TAPSE/sPAP \textless0.55 showed the best improvement in model discrimination and reclassification above traditional prognosticators (C-statistic improvement: 0.16; global chi-square improvement: 52.8; LR-test p\textless0.001) with similar results for both STEMI and NSTEMI subgroups. CONCLUSION: A low RV-PA coupling defined as TAPSE/sPAP ratio \textless0.55 was independently associated with in-hospital MACEs and provided incremental prognostic value over traditional prognosticators in patients hospitalized for ACS. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05063097

Sequencing and titrating approach of therapy in heart failure with reduced ejection fraction following the 2021 European Society of Cardiology guidelines: an international cardiology survey

Aims In symptomatic patients with heart failure and reduced ejection fraction (HFrEF), recent international guidelines recommend initiating four major therapeutic classes rather than sequential initiation. It remains unclear how this change in guidelines is perceived by practicing cardiologists versus heart failure (HF) specialists.Methods and results An independent academic web-based survey was designed by a group of HF specialists and posted by email and through various social networks to a broad community of cardiologists worldwide 1 year after the publication of the latest European HF guidelines. Overall, 615 cardiologists (38 [32-47] years old, 63% male) completed the survey, of which 58% were working in a university hospital and 26% were HF specialists. The threshold to define HFrEF was <= 40% for 61% of the physicians. Preferred drug prescription for the sequential approach was angiotensin-converting enzyme inhibitors or angiotensin receptor-neprilysin inhibitors first (74%), beta-blockers second (55%), mineralocorticoid receptor antagonists third (52%), and sodium-glucose cotransporter 2 inhibitors (53%) fourth. Eighty-four percent of participants felt that starting all four classes was feasible within the initial hospitalization, and 58% felt that titration is less important than introducing a new class. Age, status in training, and specialization in HF field were the principal characteristics that significantly impacted the answers.Conclusion In a broad international cardiology community, the 'historical approach' to HFrEF therapies remains the preferred sequencing approach. However, accelerated introduction and uptitration are also major treatment goals. Strategy trials in treatment guidance are needed to further change practices.[GRAPHICS]