Cardiovascular

Introduction Hospital-at-Home (HaH) is an innovative care model delivering hospital-level care to community patients. A key priority for Bromley HaH has been to streamline strategies, providing integrated, individualised care for patients with heart failure (HF). Our study revealed that our length of stay (LOS) exceeded the 7-day target, and readmission rates surpassed the 0-10% target. Recognising the complexities of managing HF in the community, we evaluated the impact of a new HF bundle to enhance clinician confidence, reduce LOS, and improve outcomes and service capacity. Method An adapted HF bundle was developed in collaboration with local cardiologists to integrate services. The bundle included standardised assessment/management tools, technology-enabled care (point-of-care and remote monitoring), and clear discharge criteria. It was implemented alongside departmental teaching, HF clinic/MDT attendance for experiential learning, and weekly consultant-led MDMs to build confidence. Retrospective data was collected before and after the bundle's introduction to assess impact on LOS and readmission rates. Results Between February 2023 and May 2024, 48 unique patients were seen (mean age 81, 28 hospital step-downs, 20 community step-ups). Initial clinician surveys showed 83% lacked confidence, 75% struggled with diuretic titration, and 60% unsure about optimising prognostics. Baseline data from February 2023 to January 2024 showed an average LOS of 13 days and a readmission rate of 15.7%. Post-bundle implementation, average LOS reduced to 10.95 days, and readmission rates dropped to 7%. Clinician surveys reported increased confidence, and over 90% of service users rated their care as excellent. Conclusion The implementation of our HF bundle significantly improved clinician confidence, halved readmission rates, and reduced LOS, thereby increasing patient throughput and service capacity, and achieving a 41% reduction in cost per bed-day. The study also contributed to the development of a dashboard to continuously monitor the effectiveness of these interventions and highlight areas of further development.

Introduction

Venous thromboembolism (VTE) risk following acute stroke is high. Current guidelines recommended intermittent pneumatic compression (IPC) stockings for up to 30 days in those who are immobile following acute stroke. The concern post-stroke is haemorrhagic complications when using low molecular weight heparin (LMWH). The CLOTS3 trial favoured IPC for safety in the first 30 days. However, in many cases, doses suitable for VTE prophylaxis can be used but with caution if IPC cannot be used.

Method

A spot audit of patients current VTE prophylaxis was undertaken in a stroke rehabilitation unit to look at IPC and LMWH usage. 10 patients were selected at random to look retrospectively at choice of VTE prophylaxis and how this changed during their admission.

Results

35 patients' full records were available. Five patients were within 30 days of admission. 12(34.3%) were anticoagulated, predominantly for atrial fibrillation. 15(42.8%) were on LMWH. VTE prophylaxis was not indicated in 3(8.6%) patients. 5(14.3%) were on no VTE prophylaxis. Of the 10 patients reviewed in depth 7(70%) had used IPCs for a time during their admission. IPCs were discontinued in 3 after starting anticoagulants and in 4 at the patients request. In 3 of the patients where IPCs were not tolerated there was a delay in starting an alternative form of VTE prophylaxis. Complex decisions were required in a patient started on LMWH post-neurosurgical intervention.

Conclusions

Decisions regarding VTE prophylaxis following acute stroke are complex. Changes are required frequently during inpatient admission and delays occur both on admission and when non-specialist team members are not confident in prescribing an alternative to IPCs. We would recommend a prompt to ensure VTE prophylaxis is considered on initial ward round and regular review during admission with anticipatory consideration of an alternative to IPCs by specialist clinicians if they are subsequently not tolerated.

Abstract Content - 'The number of patients being diagnosed with Heart Failure (HF) on a global scale continues to rise, placing a huge strain on the National Health Service (NHS). Caring for patients with HF comes with huge cost implications and exacerbates an already growing economic burden for healthcare systems. HF care needs to be standardised and integrated if we are to provide optimal care. Evidence shows that there is potential to improve the detection, diagnosis and management of HF care through innovative care pathways when delivered consistently through strong leadership and collaborative working. A care pathway for clinical nurse assessors was developed and implemented to guide and steer HF care within an 'Out of Hospital' clinical team; create a streamlined process to move patients with HF from one service to another; and encourage collaborative working amongst HF services. In addition, weekly HF MDT meetings were introduced in an attempt to reduce hospital admissions.

The Model for Improvement Framework was used to provide structure and support the change management, along with the RE-AIM Framework which facilitated the implementation of this pathway and supported the translation of this project into practice. 

Following the introduction of the care pathway, comparative data was analysed and the results showed that first line steps in the diagnostic pathway were being carried out quicker in patients presenting with HF symptoms, the time taken to refer on to cardiology services was significantly quicker, and all patients presenting with HF symptoms had a BNP blood test carried out on initial assessment. In addition, the length of time patients remained on the 'Out of Hospital' caseload and the number of hospital admissions were significantly reduced. The results also showed that the majority of patients on the pathway were treated in the comfort of their own homes and the number of patients referred to cardiac rehabilitation had vastly improved.  

To conclude - integrated care pathways together with high level government strategies are vital in the re-organisation of HF care and the standardisation of interconnected guideline-based care and management. Implementing a HF care pathway not only streamlined care for patients diagnosed with HF within the community setting but it had a positive impact on patient outcomes, quality of life and hospital admission rates. The pathway provided clinical nurse assessors within the 'Out of Hospital' team with a structured and standardised approach to HF care and having regular HF MDT meetings significantly improved the outcomes of people living with HF, as complex cases could be managed quicker and more effectively and hospital admissions could be avoided. Communication channels and relationship building between specialist services were also enhanced as a result of the pathway. 

Introduction

Recent trials like ASCEND, ASPREE, and ARRIVE emphasise the limited efficacy of aspirin in primary cardiovascular prevention and its associated increased bleeding risk, particularly in the elderly. Consequently, the Screening Tool of Older Persons’ Prescriptions (STOPP) criteria does not recommend aspirin treatment for primary cardiovascular prevention in any case. This study aimed to determine the prevalence of inappropriate aspirin use among elderly patients admitted within our department and our ability to correctly identify and discontinue its use.

Methods

Patients aged over 65 years admitted under our team between August-October 2023 were identified retrospectively from our electronic medical record. Inclusion criteria were those admitted on aspirin, while exclusion criteria were incomplete records or in-hospital deaths. Discharge summaries were reviewed to determine if aspirin prescribed for primary prevention was stopped or flagged to GP for review. The secondary outcome assessed statin prescriptions for primary cardiovascular prevention. Data concerning age, sex, and cardiovascular history was extracted.

Results

67 patients were admitted under our team. The mean age was 81.4 years (SD 9.3). There were 27 males (40.3%) and 40 females (59.7%). 18 (26.9%) patients were diagnosed with ischaemic heart disease; 11 (16.4%) had a previous myocardial infarction; 19 (28.3%) had a prior transient ischaemic attack or stroke and 8 (11.9%) patients had previously undergone coronary revascularization. 14 (20.9%) patients were taking aspirin, in which 5 (35.7%) were prescribed for primary prevention, yet none were discontinued or flagged to GP for review.10 patients (14.9%) received statins for primary prevention, with a 90% adherence to the STOPP criteria.

Conclusion

Despite limited evidence, our analysis found a large proportion of patients from our team were discharged on aspirin for primary prevention. However, adherence to STOPP criteria for statin prescriptions was high. Consequently, we are developing a proforma to assist physicians in discerning inappropriate aspirin prescriptions.

Abstract

Background: Cholinesterase inhibitors (ChEIs) are the primary medication for dementia treatment. Bradycardia is a possible adverse effect associated with ChEIs. However, the relationship between ChEIs and bradycardia has not been definitively established, particularly in the Asian population. We conducted a study investigating the association between ChEIs and heart rate.

Methods: We retrieved data from electronic medical records (EMR) of patients aged over 60 who were diagnosed with mild cognitive impairment or dementia at Ramathibodi Hospital between January 2009 and December 2022. These patients had outpatient records at 3, 6, and 12 months after the diagnosis. After filtering out by eligibility criterias, patients were categorised into ChEIs and non-ChEIs use, and then were 1:1 matched by baseline characteristics. We compared heart rate changes between the groups using Student’s t-tests or Mann Whitney U test depending on their distribution and Bayesian linear regression. Bradycardia was analysed using Kaplan-Meier Estimates and Cox proportional hazards model.

Results: 790 eligible patients were included, with 395 patients in each group. The median of difference of changes from baseline heart rate between group were -0.5 BPM (p = 0.06), -1.5 BPM (p = 0.12), and -1.5 BPM (p = 0.002) at 3, 6, and 12 months, respectively. The bradycardia incidence was higher in the ChEIs group (38.5%) compared with the non-ChEIs group (30.6%) at 12 months, but this difference was not statistically significant (p = 0.2). Among all regarded variables, baseline heart rate, age and beta-blocker usage associated with bradycardia, with adjusted hazard ratios (aHR) = 0.888 (95% CI 0.873–0.904, p<0.001), 1.019 (95% CI 1.001 –1.037, p=0.035) and 1.334 (95% CI 1.045-1.703, p=0.021).

Conclusions: The use of ChEIs was found to be associated with a decrease in heart rate. However, the changes were minimal and may not have had clinical implications for the patient.

Introduction: Neuroimaging plays an important role in assessing patients referred to a memory assessment service. CT scans are a cost-effective option and are useful to identify other causes of cognitive impairment and provide valuable information regarding the subtype of dementia. In our trust, there is no standardised request proforma for CT head scans and not all relevant criteria have been included that are in line with the guidance from the British Society of Neuroradiologists (BSNR) proposed structure dementia template for routine clinical practice. This audit aims to assess CT head scan reports of patients with cognitive impairment referred for a memory assessment to determine whether information from the request has been addressed in the report.

Methods: Retrospective review of CT head scan reports from an outpatient memory assessment clinic between July and September 2022. Data was collected from Cito, Rio. 58 scans were reviewed against CT request proforma which requested to comment on evidence of different atrophy in medial temporal lobe, hippocampus, amygdala; evidence of ischaemia, infarction, and small cerebral vessel disease; rule out Space Occupying Lesion (SOL).

Results: CT scans were reviewed against the CT request. 67% commented on the medial temporal lobe, 31% on the hippocampus, and 0% on the amygdala. 21 out of 58 reports commented on the Medial Temporal Atrophy score. In terms of ischaemia/infarcts all 58 reports mentioned this, while 78% commented on evidence of small vessel disease and 95% on SOL.

Conclusion: Reviewing the criteria against each CT report, not all information was commented on by the radiologists. The CT request proforma overlaps with some of the proposed BSNR guidelines; however, it could be improved to include relevant information that will aid the referrer with the diagnosis. Action plan: discuss with local old age psychiatry to refine the CT request proforma.

Introduction: A growing body of evidence suggests that metabolic syndrome is associated with endocrine disorders, including thyroid dysfunction. Thyroid dysfunction in patients with metabolic syndrome may further increase the risk of cardiovascular disease, thus increasing mortality. This study was conducted to assess thyroid function in patients with metabolic syndrome and to assess its relationship to components of metabolic syndrome.

Methods: A cross-sectional study was carried out among 170 geriatric patients. Anthropometric measurements (height, weight, waist circumference) and blood pressure were taken. Fasting blood samples were analyzed for glucose, triglycerides, high-density lipoprotein (HDL) cholesterol, and thyroid hormones (triiodothyronine, thyroxine, and thyroid-stimulating hormone).

Results: Thyroid dysfunction was observed in 31.9% (n = 54) of patients with metabolic syndrome. Subclinical hypothyroidism (26.6%) was the main thyroid dysfunction followed by overt hypothyroidism (3.5%) and subclinical hyperthyroidism (1.7%). Thyroid dysfunction was much more common in women (39.7%, n=29) than in men (26%, n=25), but not statistically significant (p=0.068). The relative risk of having thyroid dysfunction in women was 1.525 (CI: 0.983-2.368) compared to men. Significant differences (p = 0.001) were observed in waist circumference between patients with and without thyroid dysfunction and HDL cholesterol that had a significant negative correlation with thyroid-stimulating hormone.

Conclusion: Thyroid dysfunction, particularly subclinical hypothyroidism, is common among patients with metabolic syndrome and is associated with some components of metabolic syndrome (waist circumference and HDL cholesterol).

Introduction:

Atrial Fibrillation (AF) causes 15% of ischaemic strokes. The National Clinical Guideline for Stroke recommends at least 24 hours of cardiac monitoring and a longer duration if cardio-embolic stroke is suspected. The British Heart Rhythm Society suggests up to 72 hours of cardiac monitoring. Currently, there is little data on the use of telemetry in detecting AF in acute strokes.

Aims:

Our study aims to evaluate the detection rate of new onset AF in acute stroke with telemetry and to determine if there was any correlation between the duration of telemetry and the detection rate of AF.

Methods:

All patients with ischaemic stroke who were admitted to stroke ward over a 3-month period were retrospectively analysed. Exclusion criteria were patients who were known to have AF, had new AF on admission electrocardiogram, patients receiving palliative care, patients who were discharged home early without having a telemetry and patients with missing records.

Results:

61 patients met the inclusion criteria and 5 (8.2%) had AF on telemetry. Two patients had AF on day 1, one on day 2 and two on day 3. All of these patients were anticoagulated. The duration of telemetry ranged between 1- 19 days however no AF was detected beyond the third day of this study.

Conclusions:

AF was detected in 8% of patients with ischaemic stroke within the first 72 hours of admission. Among the patients in whom AF was detected, 5% were detected between 24 hours and 72 hours of admission. Studies (EMBRACE and CRYSTAL trials) have shown that prolonged cardiac monitoring (30 days and 6 months to a year respectively) resulted in higher detection rates of AF. This study suggests that patients with ischaemic stroke should be monitored for at least 72 hours due to a higher detection rate of AF.

Intravenous diuretics remain the mainstay of treatment for patients admitted with decompensated/acute heart failure. NICE recommends close monitoring of the renal function, body weight and urine output during diuretic therapy as part of the initial pharmacological treatment of acute heart failure. The aim is to ensure a safe and satisfactory response to treatment.

We looked at the compliance to serial measurement of Body Weight and Fluid Balance in the geriatric population admitted with Decompensated/Acute Heart Failure to Acute Care Units at Kettering General Hospital. Fifty (50) patients, 65 years or above, admitted with decompensated/acute heart failure were randomly selected from MAU and Clifford ward (Acute Care Units).
Acutely unwell patients or those with urgent care stay duration less than 24 hours were excluded. Patients who had other causes of fluid overload were also excluded.

By the end of the 1st cycle, only 28% of the patients had weight measured daily, whilst only 18% had accurate fluid balance charting done. Barriers leading to poor compliance in measurement of these parameters were identified. Nursing managers were involved and audit results were shared with the clinical staff. Written reminders to check and record daily weight and fluid balance were put around the acute care units.

We liaised with the Trust’s digital team to assist with introducing these measures on the Trust’s software called ‘CareFlow Vitals’ as these were ‘vital’ parameters for a patient with acute heart failure. This eventually improved our results with almost 100% compliance by the end of our 3rd cycle.

Introduction:

Infection caused by the SARS-CoV-2 has been found to have serious consequences for the cardiovascular system. Among these, the development of heart failure (HF) has been stipulated; however, its causality has not yet been established. Therefore, the purpose of this study is to evaluate the role of clinical and laboratory parameters in determining the risk of developing HF in patients infected with SARS-CoV-2.

Methodology:

151 electronic medical records were taken from hospitalized patients with confirmed SARS-CoV-2 infection and pneumonia, from 03/11/20 to 10/02/21. HF was diagnosed by signs and symptoms, elevated NTproBNP and echocardiogram. Nonparametric statistical tests were applied due to the lack of normality in the data distribution.

Results were considered statistically significant at p<.05. uncorrelated clinical and laboratory indicators were selected to predict hf validated with separate samples. confidence intervals (95% ci) calculated for all listed metrics. oversampling was used in the training set. resulting binary classification model showed validity evaluated metrics roc curves. results: study included 46 patients 105 without hf. median age 66.2 (50-92) years, a predominance of women 91 (60.3%). most both groups had concomitant diseases, however group more ≥4 diseases (63%). significant risk predictors ≥66 years (p < 0.001), procalcitonin level ≥0.09 ng />ml (p <.001), thrombocytopenia ≤220-10^9 />l (p = 0.01), neutrophil-to-lymphocyte ratio ≥4,11% (p =0,010), history of chronic kidney disease (p =0.018).

Conclusion:

A possible predictive model including age, procalcitonin, creatinine, bilirubin, C-reactive protein, lactate dehydrogenase, platelets, international normalized ratio, neutrophil-to-lymphocyte ratio, as well as QTc interval on electrocardiogram and history of chronic kidney disease has been found that could identify patients with COVID-19 at risk of developing heart failure, which will allow more effective and earlier care