Cardiac Catheterization ; instrumentation ; methods ; Cardiac Output ; Confidence Intervals ; Female ; Hemodynamics ; Humans ; Middle Aged ; Mitral Valve Stenosis ; pathology ; Pulmonary Artery ; physiology ; Statistics as Topic

Cardiac Catheterization ; instrumentation ; methods ; Echocardiography, Three-Dimensional ; instrumentation ; methods ; Heart Valve Prosthesis ; adverse effects ; Hemodynamics ; Humans ; Hypertension, Pulmonary ; Male ; Middle Aged ; Mitral Valve ; pathology ; Mitral Valve Insufficiency ; pathology ; therapy

INTRODUCTIONIn end-stage heart failure (HF) that is not eligible for mechanical assist device or heart transplant, palliative care serves to maximise symptom control and quality of life. We sought to evaluate the impact of home-based advance care programme (ACP) on healthcare utilisation in end-stage HF patients.

MATERIALS AND METHODSProspectively collected registry data on all end-stage HF recruited into ACP between July 2008 and July 2010 were analysed. Chart reviews were conducted on HF database and hospital electronic records. Phone interview and home visit details by ACP team were extracted to complete data entry. HF and all-cause hospitalisations 1 year before, and any time after ACP inception were defined as events. For the latter analysis, follow-up duration adjustment to event episodes was performed to account for death less than a year.

RESULTSForty-four patients (mean age 79 years, 39% men) were followed up for 15±8 months. Fifty-seven percent had diabetes, 80% ischaemic heart disease, and 60% chronic kidney disease. All reported functional class III/IV at enrolment. Mean serum sodium was 136±6 mmol/L, and creatinine 186±126 mmol/L. Thirty (68%) died within the programme. Mean time to death was 5.5 months. Mean all-cause and HF hospitalisations were 3.6 and 2.0 per patient before enrolment, but improved to 1.0 and 0.6 respectively after ACP. Thirty-six (71%) patients had fewer HF hospitalisations. When only those who survived more than a year were considered (n = 14), 10 (71%) and 9 (64%) experienced reduced HF (mean: 1.4 episodes per patient) and all-cause hospitalisations (mean: 2.2 episodes per patient) respectively.

CONCLUSIONHome-based advance care programme is potentially effective in reducing healthcare utilisation of end-stage HF patients, primarily by reducing HF rehospitalisations, and in probably saving costs as well.

Aged ; Aged, 80 and over ; Diabetes Mellitus ; Female ; Health Care Costs ; Health Services ; economics ; utilization ; Heart Failure ; complications ; economics ; therapy ; Home Care Services, Hospital-Based ; economics ; Hospitalization ; economics ; statistics & numerical data ; Humans ; Male ; Myocardial Ischemia ; complications ; Palliative Care ; economics ; methods ; Prospective Studies ; Registries ; Renal Insufficiency, Chronic ; complications ; Tertiary Care Centers

Diagnostic errors can occur when physicians rely solely on computer electrocardiogram interpretation. Cardiologists often receive referrals for computer misdiagnoses of atrial fibrillation. Patients may have been inappropriately anticoagulated for pseudo atrial fibrillation. Anticoagulation carries significant risks, and such errors may carry a high cost. Have we become overreliant on machines and technology? In this article, we illustrate three such cases and briefly discuss how we can reduce these errors.

INTRODUCTION: Risk stratification in dilated cardiomyopathy (DCM) is imprecise, relying largely on echocardiographic left ventricular ejection fraction (LVEF) and severity of heart failure symptoms. Adverse cardiovascular events are increased by the presence of myocardial scarring. Late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging is the gold standard for identifying myocardial scars. We examined the association between LGE on CMR imaging and adverse clinical outcomes during long-term follow-up of Asian patients with DCM. METHODS: Consecutive patients with DCM undergoing CMR imaging at a single Asian academic medical centre between 2005 and 2015 were recruited. Clinical outcomes were tracked using comprehensive electronic medical records and mortality was determined by cross-linkages with national registries. Presence and distribution of LGE on CMR imaging were determined by investigators blinded to patient outcomes. Primary endpoint was a composite of heart failure hospitalisations, appropriate implantable cardioverter-defibrillator shocks and cardiovascular mortality. RESULTS: Of 86 patients, 64.0% had LGE (80.2% male; mean LVEF 30.1% ± 12.7%). Mid-wall fibrosis (71.7%) was the most common pattern of LGE distribution. Over a mean follow-up period of 4.9 ± 3.2 years, 19 (34.5%) patients with LGE reached the composite endpoint compared to 4 (12.9%) patients without LGE (p = 0.01). Presence of LGE, but not echocardiographic LVEF, independently predicted the primary endpoint (hazard ratio 4.15 [95% confidence interval 1.28-13.50]; p = 0.02). CONCLUSION LGE presence independently predicted adverse clinical events in Asian patients with DCM. Routine use of CMR imaging to characterise the myocardial substrate is recommended for enhanced risk stratification and should strongly influence clinical management.