Cardiovascular

Pulmonary embolism (PE) is the third most common among acute cardiovascular diseases, after myocardial infarction and stroke, with a significant mortality rate. At Portsmouth University Hospital's acute medical and respiratory departments, inadequate understanding of pulmonary embolism diagnosis and management, which led to unnecessary investigations and medications putting the patients at risk of the side effects and complications of that, was the main impetus for initiating this audit. The hospital did not adhere to the NICE recommendation of regular interim anticoagulation for patients awaiting imaging for probable PE. A significant number of patients unnecessarily admitted to the hospital due to PE could have benefited from outpatient treatment. We collected data for eight weeks both before and after the implementation of the new hospital PE pathway, following a baseline audit and PDSA-based problem-solving, which underscores the significance of accurately utilising the Wells Score and PE rule out criteria (PERC). We obtained PE diagnosis criteria from NICE standards for comparison. The new hospital PE pathway was a result of the initial audit. The results from the re-audit showed an improvement in documentation and calculation of the Wells score from 16.1% to 66.1%, the PERC score from 9.1% to 58.3%, and the PE severity index (sPESI) score increased from 9.1% to 58.3%, as well as an increase in the number of junior doctors who initiated the PE pathway from 19.6% to 41.9%. Additionally, the proportion of inappropriately requested investigations, such as D-dimer and CTPA, was reduced. Also, the number of CTPAs requested in line with the guidelines increased from 11.11% to 52.27%, and the diagnostic yield of PE on CTPAs increased from 36.08% to 64.85%. A simple diagnostic pathway resulted in a decrease in unnecessary investigations and an increase in the diagnostic yield of PE.

Introduction: Orthostatic hypotension is very common and increases with age, affecting about 20% of community-dwelling older adults and it increases up to 50% in long-term care units. Measuring lying and standing blood pressure (LSBP) is an important and simple bedside clinical test needed to diagnose the condition. The regulation of blood pressure depends on the baroreflexes, normal blood volume, and defenses against excessive venous pooling. These mechanisms are altered in older adults that lead to increased incidence of OH. Orthostatic hypotension leads to symptoms of dizziness, syncope, cognitive decline, impaired mobility and falls if it is left untreated.

Objective:

1. The primary aim is to standardize the approach to falls assessment on long term care units amongst all members of the multi-disciplinary team. We plan to address this by focusing on OH.

2. To educate all the multi-disciplinary team and increase knowledge of OH.

3. To improve accuracy in recording and documentation of LSBP to proactively screen patients and plan the clinical management accordingly.

Method: The study adopted an educational approach to orthostatic hypotension assessment in long term care. We did survey questionnaire before and after the study to check the understanding of MDT about the OH. We have undertaken two rounds of data collection with orthostatic hypotension related variables in each cycle. After round one, we did a PDSA that involved small group education sessions by physicians, pharmacists and physiotherapists to raise awareness of orthostatic hypotension.

Results: The study developed a standardized approach to measure LSBP in all long-term care units. It also improved the accuracy in assessment and recording of LSBP and it helped to raise awareness of OH among the MDT in long term care units. The knowledge domain improved to 90% from 10% in MDT. The documentation of LSBP improved to 85% on Long Term Care.

Introduction :

Pulmonary hypertension assessed by echocardiography in patients with COVID-19 has not been adequately studied and it is unknown precisely whether it is linked to worse outcomes.

Materials and Methods :

Retrospective study of 306 adults infected with COVID-19 by antigenic or molecular testing. The main objective was to evaluate the role of the probability of echocardiographic pulmonary hypertension and its relationship with morbidity and mortality according to the ROX index in patients with COVID-19 infection. In the inferential statistical analysis, the OR odds ratios with their confidence intervals greater than 95% were used as measures of association. Qualitative variables were evaluated using the Chi square test or Fisher's exact test, and in the case of numerical or quantitative variables, the Student's T test or Mann-Whitney test was used.

Results :

The highest frequency in gender was Male 78% and Female 22%, the ROX values were higher in survivors at 2 h 5.8 (4.7 - 6.9), in relation to the deceased 4.5 (3.6 - 5 ,6). Likewise, at 12 h the values were higher in the group of survivors 7.8 (5.2 - 8.7) in relation to the deceased 4.9 (3.8 - 6.0). The odds ratio adjusted for age and gender of the ROX index was 8.5, CI (2.0 - 91.4) at 2 h and 17.6, CI (2.8 - 93.6) at 12 h. A statistical correlation was evident between lower values of the ROX index with values of high probability of pulmonary hypertension (p=0.048) as well as higher mortality (p=0.037).

Discussion :

The present study showed a correlation between the ROX index with pulmonary pressure values estimated by transthoracic echocardiogram and older age groups, showing higher mortality in those over 70 years of age and a higher rate of comorbidities and lower ROX.

Conclusions:

A greater probability of pulmonary hypertension is linked to high mortality in COVID-19; studies with larger groups of patients are required to validate the results found here.

Introduction:

Metabolic syndrome has been associated with an increased risk of cancer. This study evaluated this association in a South American cohort.

Methods:

Retrospective observational study in 100 patients older than 60 years with metabolic syndrome for more than 10 years from a hospital outpatient center. Anthropometric (waist circumference, body mass index), biochemical (triglycerides, HDL cholesterol, fasting glucose) and clinical (arterial hypertension, type 2 diabetes mellitus) parameters were evaluated. The association between metabolic syndrome, its components and cancer risk was analyzed using proportional hazards and chi-square models.

Results:

A statistically significant association was found between abdominal obesity (average waist circumference of 103.8 cm and BMI of 36.05), hypertension and hyperglycemia with an increased risk of cancer. The highest prevalence of cancer occurs in people over 60 years of age. In this group, 72.1% of the cases of the disease are diagnosed in men and 65.8% in women. A higher risk is reported in patients with grade I obesity (BMI 30-34 kg/m2.

Conclusion:

MS is strongly associated with increased cancer risk in older South American adults, especially due to central obesity, hypertension and hyperglycemia.

Introduction:

Assessment of lying and standing blood pressure is commonly undertaken in geriatric medicine to make a diagnosis of orthostatic or postural hypotension. We carried out the audit to review the clinical practice and assess its adherence to the Royal College of Physicians (RCP) guidance on how to accurately measure the lying and standing blood pressure (Falls and Fragility Fracture Audit Programme).

Method:

It was a prospective audit. The first audit cycle was conducted in July 2020 and the second cycle in April 2021

Results:

During the first data collection, the practice was reviewed in 69 patients. 35 were female (age range 63-92 years) and 34 male (age range 72-95 years). The lying and standing blood pressures were measured in 27 patients. Only 4 were performed as per the RCP guidance. 34 team members (including doctors, nurses, healthcare assistants, etc.) were randomly surveyed on how to correctly measure lying and standing blood pressure. None were aware of the RCP guidance in this context. We delivered local presentations of the results of the audit and RCP guidance flyers were displayed on the bulletin boards in the department. During the second cycle, the practice was reviewed in 58 patients. 30 were female (aged 67-94 years) and 28 male (aged 68-96 years). The lying and standing blood pressures were measured in 32 patients, of which 20 were recorded according to the RCP guidance. There was an increase of adherence to the guidance from 14.8% to 62.5% after undertaking the aforementioned interventions.

Conclusions:

Following dissemination of the RCP guidance on how to accurately measure the lying and standing blood pressures, we witnessed an improvement in the practice suggestive of an improved clinical effectiveness. Robustly evaluating a service followed by education of the staff can lead to enhanced clinical care and quality improvement.

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.

INTRODUCTION 
 
Postural hypotension (PH) is an identifiable and potentially reversible cause of falls in the elderly patients admitted to hospital. The National Audit of Inpatient Falls recommends lying and standing blood pressure (LSBP) measurement for patients aged over 65. Our project aims to review current clinical practice and to develop a standardised approach to correctly investigate and manage PH in patients admitted following a fall to the geriatric department.
 
METHOD: 
 
We performed two cycles of retrospective data collection across three geriatric wards, looking at percentage of patients investigated for PH and the use of correct technique for LSBP measurements as recommended by the Royal College of Physicians (RCP) guidelines.

Between cycles, formal and informal educational strategies were implemented and the RCP LSBP measurement guidelines were displayed on doctors’ noticeboards and blood pressure monitoring devices. A PH sticker was designed to ensure correct technique was used and documented.
 
RESULTS:  
 
Following the interventions, the percentage of patients who had LSBP measurements performed improved from 28% to 96% [p<0.00001(X2 test)]. Introduction of the PH stickers improved use of correct technique from 12% to 37.5%. Performance and documentation of medication reviews for patients diagnosed with postural hypotension improved from 0% to 87.5% and lifestyle advice given and documented improved from 0% to 37.5%.  
 
CONCLUSIONS: 
 
Our study highlighted the need for further training on investigation and management of PH. Our results demonstrate that educational interventions and a standardised sticker to ensure clear documentation can significantly improve diagnosis of PH. The sticker and a patient advice leaflet have been approved by the local Falls Prevention Team and are now being processed by the Documents Control Team for official usage across all three Mid and South Essex sites. 

The 2022 national heart failure audit noted, "Older patients are less likely to access diagnostics, lifesaving drugs, and specialist care.” Additionally, there is evidence suggesting that they are less frequently initiated on disease-modifying drugs (DMD). The National Institute for Health and Care Excellence (NICE) supports the use of SGLT2 inhibitors for those with heart failure with reduced ejection fraction (HFrEF). However, this has recently expanded to those with preserved ejection fraction (HFpEF). This is significant for elderly heart failure patients as SGLT2 inhibitors offer a favourable side effect profile. 

Our research was conducted in 2022 at a tertiary hospital. This research involved the analysis of thirty-eight heart failure patients that were admitted under the care of the geriatric medicine team. We investigated the initiation of diagnostics, the utilisation of DMDs and the coordination of post-discharge follow-up arrangements. 

Our study revealed significant inconsistencies with the management of heart failure within this patient demographic. Notably, a substantial proportion of patients lacked prescriptions for DMDs, and the initiation of SGLT2 inhibitors was inadequate. Moreover, over 62% of patients did not receive scheduled follow-up appointments. We also found that a considerable number of patients missed essential diagnostic echocardiograms, which are critical for determining the appropriate DMD prescriptions.

These results highlight the urgent requirement for improved education and access to diagnostics and DMDs. We plan to share our findings at the forthcoming local geriatric meeting and aim to collaborate more closely with the cardiology department to enhance care quality and integration.

Introduction:

The presence of ischemic cerebrovascular accident in COVID 19 patients is a complication that has stood out due to its complications, the predisposing factors are the procoagulant state derived from the infection as well as cardiovascular arrhythmic causes. Patients: Describe the frequency of cerebral ischemia and cardiac rhythm disturbances in patients admitted to the emergency room from July 2020 to January 2021 and its impact on prognosis and mortality.

Methods:

Retrospective study of 306 adults infected by SARS COV2 by antigenic or molecular test. The presence of these events was examined in a follow-up and the associated complications were described.

Results:

There was a higher frequency of COVID 19 in the Male gender 78% in relation to the Female 22%, the ROX values were higher in the survivors at 2 h 5.7 (4.6 - 6.8), in relation to the deceased 3 ,2 (2.9 - 4.2), The presence of ischemic cerebrovascular events occurred in 9 patients (2.9%), occurring in 8 of the male gender and 1 of the female gender, the average age of those who presented said complication was 72, 3 years with standard deviations of 62.9 and 81.7 respectively, 3 of them presented cardiorespiratory arrest. Arrhythmic causes were found in only 1 of the patients, the rest were cryptogenic events. None of the cerebral panangiography studies showed aneurysms or vascular malformations. The mortality of patients with cerebral ischemia was 33% (3/9). It was not possible to perform thrombolysis in any patient. Only 1 patient was a candidate for mechanical thrombectomy.

Conclusions:

The present study showed that the presence of cerebral ischemia is not so uncommon, approaching what has been published in other series and reported works. Studies with larger groups of patients are required to validate the results found here.