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s S49 (HF). The ACC/AHA 2008 and ESC 2007 guidelines recommended CRT in patients with sinus rhythm, left ventricular ejection fraction (LVEF) 35%, QRS 120ms, and New York Heart Association (NYHA) class III or IV. In previous studies of unselected HF hospitalizations, 6% to 10% of patients fulfilled CRT indications. Updated international guidelines have expanded the indications for CRT to include mildly symptomatic patients, alongside clearer support for patients with AF and chronic right ventricular pacing. New guidelines also favour left bundle branch block (LBBB) morphology in patients with moderate QRS prolongation (QRS 120-150ms). Our aim was to define how many patients hospitalized with HF fulfil the new expanded criteria for CRT. METHODS/RESULTS: Single centre retrospective cohort study of 363 consecutive patients hospitalised with HF (438 admissions). Electronic imaging, electrocardiograms and medical records were reviewed. Mean age was 74 14 years, length of stay 11 days, with more than half of patients (54%) admitted to internal medicine, and one third (33%) to cardiology. Approximately one third of patients had diabetes (36%), chronic kidney disease (CKD) (32%), and angina (35%). Most patients had LVEF documented (97%), the majority using echocardiography (95%). Overall 153 patients (42%) had LVEF 35%, and 34% of patients had QRS prolongation. 80 patients (22%) were potentially eligible with both LVEF 35% and QRS 120ms, or existing CRT. The majority (68 of 80) had a class I or IIa recommendation according to ACC or ESC criteria (LBBB or non-LBBB QRS 150ms or RV pacing). Only a minority (12 of 80) had moderate QRS prolongation of non-LBBB morphology. One quarter (n1⁄422) of patients fulfilling criteria were ineligible for reasons including dementia, comorbidities, or palliative care. A further 8 patients required optimisation of medical therapy. CRT was therefore immediately indicated in 50 patients. Of these, 29 were implanted or had existing CRT systems. 21 of the 80 patients eligible for CRT were not identified or treated (6% of the total hospitalised cohort). CONCLUSION: A quarter of elderly real-life patients hospitalised with HF fulfil LVEF and QRS criteria for CRT, most having a class I or IIa indication. However, a large proportion are ineligible due to comorbidities or require medical optimisation. Although uptake of CRT was reasonable, there remains scope for improvement. Our findings highlight the opportunity presented by hospitalisation to readily identify device eligible patients using existing data, without additional costly interventions. Medtronic 099 IMPLEMENTATION OF CLOZAPINE MYOCARDITIS MONITORING IN HOSPITAL INPATIENTS J Syms, V Powell, T Tajirian Toronto, Ontario BACKGROUND: Clozapine-associated myocarditis is a potentially fatal yet likely under-diagnosed complication of clozapine therapy. It typically presents with fever, tachycardia and non-specific espiratory, gastrointestinal and/or genitourinary symptoms within 3 weeks of clozapine initiation. If tested, the troponin and CRP are usually abnormal. Among countries that actively monitor for clozapine myocarditis, incidence is estimated to be as high as 3%. In Canada, patients that are started on clozapine must first be registered with one of three clozapine registries which monitor weekly bloodwork for evidence of agranulocytosis and neutropenia. There are no Canadian requirements or guidelines for monitoring for clozapine myocarditis. The purpose of this study was to trial an evidence-based clozapine myocarditis monitoring protocol, and identify barriers to its implementation. METHODS: We enrolled a consecutive sample of 25 patients with treatment-resistant schizophrenia admitted to a large psychiatric teaching hospital for clozapine initiation. No patients were excluded. Adopting a modified version of the clozapine myocarditis monitoring protocol published by Ronaldson et al., we created a new electronic health record order set designed to build on existing registry-mandated CBC monitoring order sets. We added serial troponin and CRP levels to pre-treatment bloodwork and subsequent weekly bloodwork for 4 weeks. The outcome measure was completion of the new 4-week clozapine myocarditis monitoring protocol. RESULTS: Eighteen patients completed the protocol. Of the remaining 7, 5 did not have pre-treatment myocarditis bloodwork ordered by the psychiatrist, 1 was transferred to a medical hospital for gastrointestinal clozapine complications and 1 was transferred to a medical hospital for query myocarditis. CONCLUSION: Clozapine myocarditis is a potentially fatal complication of clozapine therapy. Existing registry-mandated monitoring for neutropenia and agranulocytosis already requires regular clinical assessments and 6 months of weekly bloodwork. Implementation of an evidence-based myocarditis monitoring protocol required only the addition of CRP and troponin to the first 5 blood samples. Barriers to monitoring included inter-hospital discontinuity of care, and physician education. Further research is required to explore the role of echocardiography in myocarditis monitoring. 100 COST EFFECTIVENESS OF THE ASSESSMENT OF HEART MURMURS IN PEDIATRIC PATIENTS AT THE IWK HEALTH CENTER A COMPARISON OF TWO STRATEGIES F Alzahrani, A Caddell, K Ritchie, A Warren Halifax, Nova Scotia BACKGROUND: International evidence implies that referral to pediatric cardiologists before performing echocardiograms is a more cost-effective method of diagnosing organic heart disease for patients with heart murmurs. Our goal in this study was to compare the costs of two different strategies of assessing heart murmurs at the IWK Heart Center. Strategy 1 required |
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