Audit of the quality and cost of acute inpatient stroke care in the general medical wards at Groote Schuur Hospital

Introduction: Stroke is the leading cause of death and disability amongst South Africans older than 60 years. The majority of stroke patients in South Africa are managed in general medical wards where little is known about the quality and cost of care. The aim of this study was to determine the cost of stroke care and to identify factors associated with increased expense , as well as to evaluate the quality of stroke care in general medical wards in order to identify areas where quality of care could be improved. Methods: We conducted a retrospective folder review of all acute stroke admissions to the general medical wards at Groote Schuur Hospital from 1 January to 31 December 2012. Patients younger than 45 years and those that received thrombolysis were excluded. The hospital's finance department provided the bed costs, as well as expenditure on consumables, pharmacy, laboratory and radiology for each subject. The quality of care was measured according to the South African Stroke Guidelines. Results: The inpatient care of 261 patients was evaluated. Although neuroradiology was performed on 95% of patients, carotid duplex Doppler ultrasonography and echocardiography were not often done. Although all patients with ischaemic stroke received inpatient antiplatelet or anti - coagulation therapy, not all risk factors were adequately addressed on discharge. The median cost of a stroke admission was R19,072.07 (IQR R10,899.85 to R27,789.43 ). The strongest correlation with cost 12 was with length of stay (LOS), r = 0.9977. The median LOS was 6 days (IQR 3 to 9 days). Using non -¬‐ parametric univariable analysis, clinical factors prolonging LOS were previous stroke ( P = 0.0 2 8) and inpatient complications: fever ( P < 0.0 0 1), urinary tract infections ( P < 0.0 0 1) and acute kidney injury ( P < 0.0 0 1) . The LOS increased as the number of inpatient complications increased (P = 0.059). Mortality was 20% and 68% of patients experienced at least one medical complication during admission. Fever and pneumonia were predict ors of death. Pneumonia was less prevalent amongst patients who were mobilised early (P = 0.002). Early nutritional support was beneficial in reducing the incidence of acute kidney injury (P < 0.001). The median LOS was significantly prolonged by delaying speech therapy (P < 0.001), nutritional support (P < 0.01), physiotherapy (P < 0.01) and occupational therapy (P < 0.001). Discharge to inpatient rehabilitation centres significantly prolonged LOS as compared with patients discharged home (P < 0.001). Conclusions: This is the first study evaluating the cost of acute stroke care in South Africa. Length of stay was the greatest determinant of cost. Improving the quality of care to reduce the number of complications, early referral to allied health professionals and effective discharge planning would result in shorter length of hospital stay and therefore cost saving. There is a need for increased access to stroke unit beds, albeit dedicated stroke beds in the general medical wards, to ensure specialised nursing care and early inpatient rehabilitation to reduce the number of inpatient complications, as well as implementation of protocols to allow for better adherence to national guidelines

Pacing for complete heart block in pregnancy

Whereas sinus tachycardia and paroxysmal supraventricular tachycardia are common during pregnancy, bradyarrhythmias are infrequent. Moreover, bradyarrhythmias are generally well tolerated during pregnancy. Nevertheless, a 12-lead ECG is indicated for pregnant women who present with bradycardia, to rule out sinoatrial (SA) node dysfunction or AV conduction abnormalities. Third-degree AV block (complete heart block, CHB) requires multidisciplinary care during pregnancy, with combined input from Cardiologists and Obstetricians. As CHB is associated with increased mortality and morbidity if left untreated, permanent pacing is usually indicated during pregnancy, even if the patient remains asymptomatic. However, not all pregnant patients with CHB require urgent pacing. In a pregnant patient who has CHB with an escape rhythm with narrow QRS complexes and rate of &gt;50bpm, permanent pacemaker implantation can be delayed until after delivery, as described in this case report

Challenges of managing patients with mechanical heart valve thrombosis in pregnancy: A case series

Mechanical valve thrombosis is a feared complication in pregnant women with mechanical heart valves (MHV). It is associated with a high maternal and foetal morbidity and mortality. Optimal anticoagulation strategies for pregnant women with MHV remain controversial. Vitamin K antagonists (VKA) are the most effective treatment regimen to prevent valve thrombosis and are therefore considered the safest treatment for the mother. However, VKAs increase the risk of embryopathy, foetopathy, foetal haemorrhage and foetal loss. A particular challenge is to balance the need for adequate anticoagulation for MHV during pregnancy against the risk of bleeding, teratogenicity and fetotoxicity. In this case series, we describe complexity of the management of anticoagulation in pregnant patients with MHV, and describe 2 treatment approaches in patients with MHV thrombosis. Our case series high-lights that anticoagulation strategy should be individualised, and that best management is provided by a multidisciplinary cardio-obstetric team

Effectiveness of implantable loop recorder and Holter electrocardiographic monitoring for the detection of arrhythmias in patients with peripartum cardiomyopathy

Background Patients with peripartum cardiomyopathy (PPCM) are at increased risk of sudden cardiac death (SCD). However, the exact underlying mechanisms of SCD in PPCM remain unknown. By means of extended electrocardiographic monitoring, we aimed to systematically characterize the burden of arrhythmias occurring in patients with newly diagnosed PPCM. Methods and results Twenty-five consecutive women with PPCM were included in this single-centre, prospective clinical trial and randomised to receiving either 24 h-Holter ECG monitoring followed by implantable loop recorder implantation (ILR; REVEAL XT, Medtronic®) or 24 h-Holter ECG monitoring alone. ILR + 24 h-Holter monitoring had a higher yield of arrhythmic events compared to 24 h-Holter monitoring alone (40% vs 6.7%, p = 0.041). Non-sustained ventricular tachycardia (NSVT) occurred in four patients (16%, in three patients detected by 24 h-Holter, and multiple episodes detected by ILR in one patient). One patient deceased from third-degree AV block with an escape rhythm that failed. All arrhythmic events occurred in patients with a severely impaired LV systolic function. Conclusions We found a high prevalence of potentially life-threatening arrhythmic events in patients with newly diagnosed PPCM. These included both brady- and tachyarrhythmias. Our results highlight the importance of extended electrocardiographic monitoring, especially in those with severely impaired LV systolic function. In this regard, ILR in addition to 24 h-Holter monitoring had a higher yield of VAs as compared to 24 h-Holter monitoring alone. In settings where WCDs are not readily available, ILR monitoring should be considered in patients with severely impaired LV systolic dysfunction, especially after uneventful 24 h-Holter monitoring

A global perspective on the management and outcomes of peripartum cardiomyopathy : a systematic review and meta-analysis

Aims Peripartum cardiomyopathy (PPCM) remains a major contributor to maternal morbidity and mortality worldwide. The disease is associated with various complications occurring mainly early during its course. Reported adverse outcomes include decompensated heart failure, thromboembolic complications, arrhythmias and death. We sought to systematically and comprehensively review published literature on the management and outcome of women with PPCM across different geographical regions and to identify possible predictors of adverse outcomes. Methods and results We performed a comprehensive search of relevant literature (2000 to June 2021) across a number of electronic databases. Cohort, case-control and cross-sectional studies, as well as control arms of randomized controlled trials reporting on 6- and/or 12-month outcomes of PPCM were considered eligible (PROSPERO registration: CRD42021255654). Forty-seven studies (4875 patients across 60 countries) met the inclusion criteria. Haemodynamic and echocardiographic parameters were similar across all continents. All-cause mortality was 8.0% (95% confidence interval [CI] 5.5–10.8, I2 = 79.1%) at 6 months and 9.8% (95% CI 6.2–14.0, I2 = 80.5%) at 12 months. All-cause mortality was highest in Africa and Asia/Pacific. Overall, 44.1% (95% CI 36.1–52.2, I2 = 91.7%) of patients recovered their left ventricular (LV) function within 6 months and 58.7% (95% CI 48.1–68.9, I2 = 75.8%) within 12 months. Europe and North America reported the highest prevalence of LV recovery. Frequent prescription of beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and bromocriptine/cabergoline were associated with significantly lower all-cause mortality and better LV recovery. Conclusion We identified significant global differences in 6- and 12-month outcomes in women with PPCM. Frequent prescription of guideline-directed heart failure therapy was associated with better LV recovery and lower all-cause mortality. Timely initiation and up-titration of heart failure therapy should therefore be strongly encouraged to improve outcome in PPCM

Clinically contextualised ECG interpretation: the impact of prior clinical exposure and case vignettes on ECG diagnostic accuracy

Background ECGs are often taught without clinical context. However, in the clinical setting, ECGs are rarely interpreted without knowing the clinical presentation. We aimed to determine whether ECG diagnostic accuracy was influenced by knowledge of the clinical context and/or prior clinical exposure to the ECG diagnosis. Methods Fourth- (junior) and sixth-year (senior) medical students, as well as medical residents were invited to complete two multiple-choice question (MCQ) tests and a survey. Test 1 comprised 25 ECGs without case vignettes. Test 2, completed immediately thereafter, comprised the same 25 ECGs and MCQs, but with case vignettes for each ECG. Subsequently, participants indicated in the survey when last, during prior clinical clerkships, they have seen each of the 25 conditions tested. Eligible participants completed both tests and survey. We estimated that a minimum sample size of 165 participants would provide 80% power to detect a mean difference of 7% in test scores, considering a type 1 error of 5%. Results This study comprised 176 participants (67 [38.1%] junior students, 55 [31.3%] senior students, 54 [30.7%] residents). Prior ECG exposure depended on their level of training, i.e., junior students were exposed to 52% of the conditions tested, senior students 63.4% and residents 96.9%. Overall, there was a marginal improvement in ECG diagnostic accuracy when the clinical context was known (Cohen’s d = 0.35, p < 0.001). Gains in diagnostic accuracy were more pronounced amongst residents (Cohen’s d = 0.59, p < 0.001), than senior (Cohen’s d = 0.38, p < 0.001) or junior students (Cohen’s d = 0.29, p < 0.001). All participants were more likely to make a correct ECG diagnosis if they reported having seen the condition during prior clinical training, whether they were provided with a case vignette (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.24–1.71) or not (OR 1.58, 95% CI 1.35–1.84). Conclusion ECG interpretation using clinical vignettes devoid of real patient experiences does not appear to have as great an impact on ECG diagnostic accuracy as prior clinical exposure. However, exposure to ECGs during clinical training is largely opportunistic and haphazard. ECG training should therefore not rely on experiential learning alone, but instead be supplemented by other formal methods of instruction

Electrocardiographic features and their echocardiographic correlates in peripartum cardiomyopathy: results from the ESC EORP PPCM registry

Aims: In peripartum cardiomyopathy (PPCM), electrocardiography (ECG) and its relationship to echocardiography have not yet been investigated in large multi-centre and multi-ethnic studies. We aimed to identify ECG abnormalities associated with PPCM, including regional and ethnic differences, and their correlation with echocardiographic features. Methods and results: We studied 411 patients from the EURObservational PPCM registry. Baseline demographic, clinical, and echocardiographic data were collected. ECGs were analysed for rate, rhythm, QRS width and morphology, and QTc interval. The median age was 31 [interquartile range (IQR) 26–35] years. The ECG was abnormal in &gt; 95% of PPCM patients. Sinus tachycardia (heart rate &gt; 100 b.p.m.) was common (51%), but atrial fibrillation was rare (2.27%). Median QRS width was 82 ms [IQR 80–97]. Left bundle branch block (LBBB) was reported in 9.30%. Left ventricular (LV) hypertrophy (LVH), as per ECG criteria, was more prevalent amongst Africans (59.62%) and Asians (23.17%) than Caucasians (7.63%, P &lt; 0.001) but did not correlate with LVH on echocardiography. Median LV end-diastolic diameter (LVEDD) was 60 mm [IQR 55–65] and LV ejection fraction (LVEF) 32.5% [IQR 25–39], with no significant regional or ethnic differences. Sinus tachycardia was associated with an LVEF &lt; 35% (OR 1.85 [95% CI 1.20–2.85], P = 0.006). ECG features that predicted an LVEDD &gt; 55 mm included a QRS complex &gt; 120 ms (OR 11.32 [95% CI 1.52–84.84], P = 0.018), LBBB (OR 4.35 [95% CI 1.30–14.53], P = 0.017), and LVH (OR 2.03 [95% CI 1.13–3.64], P = 0.017). Conclusions: PPCM patients often have ECG abnormalities. Sinus tachycardia predicted poor systolic function, whereas wide QRS, LBBB, and LVH were associated with LV dilatation

Electrocardiographic findings and prognostic values in patients hospitalised with COVID-19 in the World Heart Federation Global Study

BACKGROUND COVID-19 affects the cardiovascular system and ECG abnormalities may be associated with worse prognosis. We evaluated the prognostic value of ECG abnormalities in individuals with COVID-19. METHODS Multicentre cohort study with adults hospitalised with COVID-19 from 40 hospitals across 23 countries. Patients were followed-up from admission until 30 days. ECG were obtained at each participating site and coded according to the Minnesota coding criteria. The primary outcome was defined as death from any cause. Secondary outcomes were admission to the intensive care unit (ICU) and major adverse cardiovascular events (MACE). Multiple logistic regression was used to evaluate the association of ECG abnormalities with the outcomes. RESULTS Among 5313 participants, 2451 had at least one ECG and were included in this analysis. The mean age (SD) was 58.0 (16.1) years, 60.7% were male and 61.1% from lower-income to middle-income countries. The prevalence of major ECG abnormalities was 21.3% (n=521), 447 (18.2%) patients died, 196 (8.0%) had MACE and 1115 (45.5%) were admitted to an ICU. After adjustment, the presence of any major ECG abnormality was associated with a higher risk of death (OR 1.39; 95% CI 1.09 to 1.78) and cardiovascular events (OR 1.81; 95% CI 1.30 to 2.51). Sinus tachycardia (>120 bpm) with an increased risk of death (OR 3.86; 95% CI 1.97 to 7.48), MACE (OR 2.68; 95% CI 1.10 to 5.85) and ICU admission OR 1.99; 95% CI 1.03 to 4.00). Atrial fibrillation, bundle branch block, ischaemic abnormalities and prolonged QT interval did not relate to the outcomes. CONCLUSION Major ECG abnormalities and a heart rate >120 bpm were prognostic markers in adults hospitalised with COVID-19

Bromocriptine treatment and outcomes in peripartum cardiomyopathy: the EORP PPCM registry

Background and Aims: Peripartum cardiomyopathy (PPCM) remains a serious threat to maternal health around the world. While bromocriptine, in addition to standard treatment for heart failure, presents a promising pathophysiology-based disease-specific treatment option in PPCM, the evidence regarding its efficacy remains limited. This study aimed to determine whether bromocriptine treatment is associated with improved maternal outcomes in PPCM. Methods: PPCM patients from the EORP PPCM registry with available follow-up were included. The main exposure of this exploratory non-randomized analysis was bromocriptine treatment, and the main outcome was a composite endpoint of maternal outcome (death or hospital readmission within the first 6 months after diagnosis, or persistent severe left ventricular dysfunction [left ventricular ejection fraction &amp;lt;35%] at 6-month follow-up). Inverse probability weighting was used to minimize the effects of confounding by indication. Multiple imputation was used to account for missing data. Results: Among 552 patients with PPCM, 85 were treated with bromocriptine (15%). The primary endpoint was available in 491 patients (89%) and occurred in 18 out of 82 patients treated with bromocriptine in addition to standard of care (22%) and in 136 out of 409 patients treated with standard of care (33%) (p=0.044). In complete case analysis, bromocriptine treatment was associated with reduced adverse maternal outcome (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.10-0.83, p=0.021). This association remained after applying multiple imputation and methods to correct for confounding by indication (inverse probability weighted model on imputed data OR 0.39, 95% CI 0.19-0.81, p=0.011). Thrombo-embolic events were observed in 5.9% of the patients in the bromocriptine group versus 5.6% in the standard of care group (p=0.900). Conclusions Among women with PPCM, bromocriptine treatment in addition to standard of care was associated with better maternal outcomes after 6 months

Socio-economic factors determine maternal and neonatal outcomes in women with peripartum cardiomyopathy: a study of the ESC EORP PPCM registry

Background Peripartum cardiomyopathy (PPCM) is a global disease with substantial morbidity and mortality. The aim of this study was to analyze to what extent socioeconomic factors were associated with maternal and neonatal outcomes. Methods In 2011, &gt;100 national and affiliated member cardiac societies of the European Society of Cardiology (ESC) were contacted to contribute to a global PPCM registry, under the auspices of the ESC EORP Programme. We investigated the characteristics and outcomes of women with PPCM and their babies according to individual and country-level sociodemographic factors (Gini index coefficient [GINI index], health expenditure [HE] and human developmental index [HDI]). Results 739 women from 49 countries (Europe [33%], Africa [29%], Asia-Pacific [15%], Middle East [22%]) were enrolled. Low HDI was associated with greater left ventricular (LV) dilatation at time of diagnosis. However, baseline LV ejection fraction did not differ according to sociodemographic factors. Countries with low HE prescribed guideline-directed heart failure therapy less frequently. Six-month mortality was higher in countries with low HE; and LV non-recovery in those with low HDI, low HE and lower levels of education. Maternal outcome (death, re-hospitalization, or persistent LV dysfunction) was independently associated with income. Neonatal death was significantly more common in countries with low HE and low HDI, but was not influenced by maternal income or education attainment. Conclusions Maternal and neonatal outcomes depend on country-specific socioeconomic characteristics. Attempts should therefore be made to allocate adequate resources to health and education, to improve maternal and fetal outcomes in PPCM