Brendan McAdam

The gap between policy and practice: a systematic review of patient-centred care interventions in chronic heart failure.

Patient-centred care (PCC) is recommended in policy documents for chronic heart failure (CHF) service provision, yet it lacks an agreed definition. A systematic review was conducted to identify PCC interventions in CHF and to describe the PCC domains and outcomes. Medline, Embase, CINAHL, PsycINFO, ASSIA, the Cochrane database, clinicaltrials.gov, key journals and citations were searched for original studies on patients with CHF staged II–IV using the New York Heart Association (NYHA) classification. Included interventions actively supported patients to play informed, active roles in decision-making about their goals of care. Search terms included ‘patient-centred care’, ‘quality of life’ and ‘shared decision making’. Of 13,944 screened citations, 15 articles regarding 10 studies were included involving 2540 CHF patients. Three studies were randomised controlled trials, and seven were non-randomised studies. PCC interventions focused on collaborative goal setting between patients and healthcare professionals regarding immediate clinical choices and future care. Core domains included healthcare professional-patient collaboration, identification of patient preferences, patient-identified goals and patient motivation. While the strength of evidence is poor, PCC has been shown to reduce symptom burden, improve health-related quality of life, reduce readmission rates and enhance patient engagement for patients with CHF. There is a small but growing body of evidence, which demonstrates the benefits of a PCC approach to care for CHF patients. Research is needed to identify the key components of effective PCC interventions before being able to deliver on policy recommendations.

Long‐term clinical outcomes after unprotected left main coronary artery stenting in an all‐comers patient population

The goal of treating patients with coronary artery disease is to improve survival and relieve symptoms. Several studies have compared the safety and efficacy of left main coronary artery (LMCA) stenting and coronary‐artery bypass grafting in case control and randomized trials.

Neisseria meningitidis endocarditis: a case report and review of the literature.

Abstract Neisseria meningitidis is the leading cause of bacterial meningitis in children and young adults, with an overall mortality rate of up to 25%, but it is a rare cause of infective endocarditis. We present herein a case of N. meningitidis meningitis complicated with infective endocarditis.

Strategies to address the shortcomings of commonly used advanced chronic heart failure descriptors to improve recruitment in palliative care research: A parallel mixed-methods feasibility study

Background: Recruitment challenges contribute to the paucity of palliative care research with advanced chronic heart failure patients. Aim: To describe the challenges and outline strategies of recruiting advanced chronic heart failure patients. Design: A feasibility study using a pre–post uncontrolled design. Setting: Advanced chronic heart failure patients were recruited at two nurse-led chronic heart failure disease management clinics in Ireland Results: Of 372 patients screened, 81 were approached, 38 were recruited (46.9% conversion to consent) and 25 completed the intervention. To identify the desired population, a modified version of the European Society of Cardiology definition was used together with modified New York Heart Association inclusion criteria to address inter-study site New York Heart Association classification subjectivity. These modifications substantially increased median monthly numbers of eligible patients approached (from 8 to 20) and median monthly numbers recruited (from 4 to 9). Analysis using a mortality risk calculator demonstrated that recruited patients had a median 1-year mortality risk of 22.7 and confirmed that the modified eligibility criteria successfully identified the population of interest. A statistically significant difference in New York Heart Association classification was found in recruited patients between study sites, but no statistically significant difference was found in selected clinical parameters between these patients. Conclusion: Clinically relevant modifications to the European Society of Cardiology definition and strategies to address New York Heart Association subjectivity may help to improve advanced chronic heart failure patient recruitment in clinical settings, thereby helping to address the paucity of palliative care research this population.

Feasibility and acceptability of a patient-reported outcome intervention in chronic heart failure

Patients with chronic heart failure (CHF) have symptoms and concerns which are inadequately addressed. Patient-reported outcome measures (PROMs) can potentially improve the identification and management of advanced symptoms and palliative concerns. However, these have not been used in CHF. Objectives To examine the feasibility and acceptability of using a PROM—the Integrated Palliative care Outcome Scale (IPOS)—together with heart failure nurse education and training to improve the identification and management of symptoms and concerns among patients with CHF. Methods A parallel, mixed methods design with an embedded qualitative component was used to examine the feasibility of recruitment, retention, intervention adherence/compliance and follow-up assessment completion (symptom burden, quality of life, psychological well-being). Patient and nurse qualitative semistructured interviews explored intervention and study design feasibility and its acceptability. Results Conversion to consent was 46.9% (372 screened, 81 approached, 38 recruited). 66% of patient participants completed the IPOS; 6% of IPOS questionnaire items were missing (non-response). Over two-thirds (65.6%) of these missing items related to three patients. No item was consistently missing; appetite was the most frequent missing item (1.4%). 92% of participants who completed the IPOS completed all follow-up assessments (1–2 days, 1–2 weeks and 4–6 weeks post-IPOS completion) with no missing data. The a priori feasibility objectives were met. Patients and nurses reported the intervention and study design feasible and acceptable. Conclusions A palliative-specific PROM-based intervention is feasible and acceptable to both patients with CHF and nurses in nurse-led disease management clinics for the purposes of both clinical care and research.

ALTERATIONS IN THYROID HORMONE LEVELS FOLLOWING GROWTH HORMONE REPLACEMENT EXERT COMPLEX BIOLOGICAL EFFECTS

OBJECTIVE Alterations in the thyroid axis are frequently observed following growth hormone (GH) replacement, but uncertainty exists regarding their clinical significance. We aimed to compare fluctuations in circulating thyroid hormone levels, induced by GH, to changes in sensitive biological markers of thyroid hormone action. METHODS This was a prospective observational clinical study. Twenty hypopituitary men were studied before and after GH replacement. Serum thyroid-stimulating hormone (TSH), thyroid hormones, and insulin-like growth factor 1 were measured. Changes in thyroid hormone concentrations were compared to alterations in resting metabolic rate and cardiac time intervals. Health-related quality of life (QOL) was assessed by disease-sensitive and generic questionnaires. RESULTS Following GH replacement, free thyroxine concentration declined and free triiodothyronine level increased. Resting energy expenditure increased, particularly in subjects with profound hypopituitarism, including TSH deficiency (16.73 ± 1.75 kcal/kg/min vs. 17.96 ± 2.26 kcal/kg/min; P = .01). Alterations in the thyroid axis were more pronounced in subjects with a low/normal baseline respiratory quotient (RQ) who experienced a paradoxical rise in RQ (0.81 vs. 0.86; P = .01). Subjects with a high baseline RQ experienced a slight but nonsignificant fall in RQ without alteration in thyroid axis. The isovolumetric contraction time was shortened during the study; however, this did not reach statistical significance. Improvements in QOL were observed despite alterations in thyroid axis. CONCLUSION Changes in the thyroid axis following GH replacement are associated with complex tissue-specific effects. These fluctuations may induce a hypothyroid phenotype in some tissues while appearing to improve the biological action of thyroid hormone in other organs. ABBREVIATIONS AGHDA = Assessment of Growth Hormone Deficiency in Adulthood; CHOox = carbohydrate oxidation; ET = ejection time; fT3 = free triiodothyronine; fT4 = free thyroxine; GH = growth hormone; GHD = growth hormone deficiency; HB-RQ = high baseline respiratory quotient; HPT = hypothalamic-pituitary-thyroid; ICT = isovolumetric contraction time; IGF-1 = insulin-like growth factor 1; IRT = isovolumetric relaxation time; LB-RQ = low baseline respiratory quotient; LV = left ventricular; NHP = Nottingham Health Profile; QOL = quality of life; REE = resting energy expenditure; RQ = respiratory quotient; rT3 = reverse triiodothyronine; SF-36 = Short Form 36; TSH = thyroid-stimulating hormone; T3 = triiodothyronine; T4 = thyroxine; TT3 = total triiodothyronine; TT4 = total thyroxine.

9 Takotsubo cardiomyopathy: a single centre review from beaumont hospital experience

Introduction Takotsubo cardiomyopathy (TC) has now gained recognition as an independent cardiovascular disease process. It typically presents as suspected acute coronary syndrome (ACS) with an emotional stressor as a precipitant. Several diagnostic criteria have been suggested, of which, those published by the Mayo Clinic (2004, revised 2008) are most widely accepted, requiring temporal resolution of left ventricular regional wall motion abnormalities (RWMA) and the absence of obstructive coronary artery disease (CAD), myocarditis and phaeochromoctyoma. Aim We studied the cohort of patients diagnosed with TC in our centre between 2010–2016. We reviewed the clinical and diagnostic data and reviewed patient outcomes with follow-up. Methods This is a retrospective analysis of patients discharged from Beaumont Hospital with this diagnosis, as coded by HIPE data, between 01/2010 and 12/2016 by chart and electronic records review. 31 cases were identified but 11 of these patients were excluded as they had been incorrectly coded. These cases included dilated cardiomyopathy (n=3), tachycardia-induced cardiomyopathy (n=2), restrictive cardiomyopathy (n=1), intracranial haemorrhage (n=1). There was one case of myocarditis confirmed on CMR and one case of NSTEMI in a 34 year-old female who had severe LAD related infarction diagnosed on CMR. Of note, one patient, with a confirmed diagnosis, presented with TC on two separate occasions within three years. Data were expressed as mean ± SD and %. Results The average age of this cohort was 64 ± 12 years, 90% were female and left ventricular ejection fraction at presentation was 34 ± 9%. All 20 patients had elevated Troponin I with peak level 3.13 ± 2.42 ng/ml. Coronary angiography was performed in all cases and showed no or minor CAD (n=18), 2 had moderate CAD. Classical antero-apical hypokinesis in the LAD territory was observed in all 20 patients. Follow-up imaging with either TTE, CMR or both was performed in 85% (n=17), all of which showed temporal resolution of RWMAs. 1 patient awaits scheduled repeat imaging and 2 patients were lost to follow-up. CMR was performed in 60% (n=12) of cases during initial presentation. Average length of stay was 21.2 ± 52 days and there were no inpatient deaths. There was no clinical indication to assess for phaeochromocytoma in our cohort. Conclusions The number of cases of TC, as derived from HIPE data, seems small and had errors. We are cross-referencing our data with our cath lab database. In our small cohort, most subjects were female and all presented with classical findings. Our results confirm that a multimodality imaging approach, including early coronary angiography, is essential to ensure accurate and early diagnosis. Moreover, we found that early CMR is very helpful in the diagnosis and management of this interesting condition.

12 Observations by transoesophageal echocardiography post-watchman implantation in atrial fibrillation: a cause for concern?

Introduction Data regarding incidence of para-device leaks, persistent inter-atrial septal (IAS) defects and thrombus post-Watchman device implantation for atrial fibrillation is limited. We aimed to observe the incidence of para-device leaks, persistent IAS defects and thrombus detected by transoesophageal echocardiography (TOE), post-Watchman implantation. Methods We retrospectively identified all patients (n=112) who had a Watchman device implanted between 2014–2016 at 2 Beaumont Hospital and Mater Private Hospital by a single operator. Within this cohort, patients who had undergone post-procedural TOE were analyzed for evidence of para-device leaks, IAS defects (including patent foramen ovale (PFO)) and thrombus. Mean LA pressure was at least 12 mmHg for all patients to ensure volume loading for adequate sizing. Data were expressed as mean ± SD and %. Results Baseline demographic of all patients were age, 77 ± 7 years; male, 71%; CHADSVASC2 score, 4.3 ± 1.4; with left ventricular ejection fraction 51 ± 8%. All patients had a 14 F catheter across the inter-atrial septum to facilitate Watchman device delivery with mean size 26.8 ± 3.5 mm. Post-procedurally, 84% were on dual antiplatelet therapy and 16% were anti-coagulated for minimum duration of 8.6 ± 4.5 and 8.8 ± 4.3 weeks, respectively. 67% (n=75) had post-procedural TOE performed with duration from time of implant of 5.3 ± 4.2 months. Within this group, there was a 32% (n=24) incidence of para-device leaks post-Watchman implant. Size of leaks measured <2 mm (17%, n=13), 2–5 mm (13%, n=10), 5–10 mm (1%, n=1). Locations of para-device leaks identified were inferior (11%, n=8), superior (15%, n=11), non-specific (7%, n=5). In addition, one patient had device thrombus. Incidence of PFO pre-Watchman was 16%. There was a 17% (n=8) incidence of de novo IAS defects post-Watchman implant after comparison with pre-procedural TOE. Mean IAS defect size pre- and post-Watchman was 0.12 ± 0.38 vs 0.29 ± 0.58 cm, respectively. This change in IAS defect size of 0.13 ± 0.57 trended towards significance (p=0.09). Conclusions A modest incidence of para-device leaks and rare but significant incidence of para-device thrombus was observed by TOE post-Watchman implantation. Further work is required to correlate potential implications of these findings on longer term outcomes related to recurrent strokes. The significance of persistent IAS defects post device implant also requires further investigation in longitudinal registry follow-up.