Atrial Fibrillation and Hypertension: “Quo Vadis”

Hypertension is one of the most well-established risk factors for atrial fibrillation. Long-standing untreated hypertension leads to structural remodeling and electrophysiologic alterations causing an atrial myopathy that forms a vulnerable substrate for the development and maintenance of atrial fibrillation. Hypertension-induced hemodynamic, inflammatory, hormonal, and autonomic changes all appear to be important contributing factors. Furthermore, hypertension is also associated with several atrial fibrillation-related comorbidities. As such, hypertension may represent an important target for therapy in atrial fibrillation. Clinicians should be aware of pitfalls of the blood pressure measurement in atrial fibrillation. While the auscultatory method is preferred, the use of automated devices appears to be an acceptable method in the ambulatory setting. There are pathophysiologic bases and emerging clinical evidence suggesting the benefit of renin-angiotensin system inhibition in risk reduction of atrial fibrillation development particularly in patients with left ventricular hypertrophy or left ventricular dysfunction. A better understanding of hypertension’s pathophysiologic link to atrial fibrillation may lead to the development of novel therapies for the primary prevention of atrial fibrillation. Finally, future studies are needed to address optimal blood pressure goal to minimize the risk of atrial fibrillation-related complications.

Monoclonal Antibody Therapy for COVID-19: A Public Health Perspective From Arkansas

COVID-19 monoclonal antibodies revolutionized the treatment for eligible patients who have tested positive for SARS CoV-2 infection in an ambulatory setting. In this short report, we describe our experience assisting in the distribution of monoclonal antibodies in Arkansas during the summer surge of the delta variant.

Evaluating the Role of Breathing Guidance on Game-Based Interventions for Relaxation Training

Working in a fast-paced environment can lead to shallow breathing, which can exacerbate stress and anxiety. To address this issue, this study aimed to develop micro-interventions that can promote deep breathing in the presence of stressors. First, we examined two types of breathing guides to help individuals learn deep breathing: providing their breathing rate as a biofeedback signal, and providing a pacing signal to which they can synchronize their breathing. Second, we examined the extent to which these two breathing guides can be integrated into a casual game, to increase enjoyment and skill transfer. We used a 2 × 2 factorial design, with breathing guide (biofeedback vs. pacing) and gaming (game vs. no game) as independent factors. This led to four experimental groups: biofeedback alone, biofeedback integrated into a game, pacing alone, and pacing integrated into a game. In a first experiment, we evaluated the four experimental treatments in a laboratory setting, where 30 healthy participants completed a stressful task before and after performing one of the four treatments (or a control condition) while wearing a chest strap that measured their breathing rate. Two-way ANOVA of breathing rates, with treatment (5 groups) and time (pre-test, post-test) as independent factors shows a significant effect for time [F(4, 50) = 18.49, p &lt; 0.001, ηtime2=0.27] and treatment [F(4, 50) = 2.54, p = 0.05, η2 = 0.17], but no interaction effects. Post-hoc t-tests between pre and post-test breathing rates shows statistical significance for the game with biofeedback group [t(5) = 5.94, p = 0.001, d = 2.68], but not for the other four groups, indicating that only game with biofeedback led to skill transfer at post-test. Further, two-way ANOVA of self-reported enjoyment scores on the four experimental treatments, with breathing guide and game as independent factors, found a main effect for game [F(1,20)=24.49,p<0.001, ηgame2=0.55], indicating that the game-based interventions were more enjoyable than the non-game interventions. In a second experiment, conducted in an ambulatory setting, 36 healthy participants practiced one of the four experimental treatments as they saw fit over the course of a day. We found that the game-based interventions were practiced more often than the non-game interventions [t (34) = 1.99, p = 0.027, d = 0.67]. However, we also found that participants in the game-based interventions could only achieve deep breathing 50% of the times, whereas participants in the non-game groups succeeded 85% of the times, which indicated that the former need adequate training time to be effective. Finally, participant feedback indicated that the non-game interventions were better at promoting in-the-moment relaxation, whereas the game-based interventions were more successful at promoting deep breathing during stressful tasks.

Characteristics of Children Diagnosed With SARS-CoV-2 in the Ambulatory Setting

The objective of this study was to characterize the clinical presentation and outcomes of children and adolescents testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the ambulatory setting. We found that about 8% of children tested positive for SARS-CoV-2, with the large majority being symptomatic (80%). The average age of our population was 12.5 years, and females and males were affected equally. However, African American patients (62%) were substantially more likely to test positive compared with other races. Children in this study tended to have a mild course, mostly presenting with respiratory symptoms, and very few required hospitalization. As the epidemiology of the pandemic evolves, it will be important to monitor the effects that changing variants have on infected children and the impact that vaccination programs have on mitigating infection risk.

The Prognostic Value of Lung Ultrasound in Patients With Newly Diagnosed Heart Failure With Preserved Ejection Fraction in the Ambulatory Setting

Background: Heart failure with preserved ejection fraction (HFpEF) is a growing healthcare burden, and its prevalence is steadily increasing. Lung ultrasound (LUS) is a promising screening and prognostic tool in the heart failure population. However, more information on its value in predicting outcome is needed.Aims: The aim of our study was to assess the prognostic performance of LUS B-lines compared to traditional and novel clinical and echocardiographic parameters and natriuretic peptide levels in patients with newly diagnosed HFpEF in an ambulatory setting.Methods: In our prospective cohort study, all ambulatory patients with clinical suspicion of HFpEF underwent comprehensive echocardiography, lung ultrasound and NT-proBNP measurement during their first appointment at our cardiology outpatient clinic. Our endpoint was a composite of worsening heart failure symptoms requiring hospitalization or loop diuretic dose escalation and death.Results: We prospectively enrolled 75 consecutive patients with HFpEF who matched our inclusion and exclusion criteria. We detected 11 events on a 26 ± 10-months follow-up. We found that the predictive value of B-lines is similar to the predictive value of NT-proBNP (AUC 0.863 vs. 0.859), with the best cut-off at &gt;15 B-lines. Having more B-lines than 15 significantly increased the likelihood of adverse events with a hazard ratio of 20.956 (p = 0.004). The number of B-lines remained an independent predictor of events at multivariate modeling. Having more than 15 B-lines lines was associated with a significantly worse event-free survival (Log-rank: 16.804, p &lt; 0.001).Conclusion: The number of B-lines seems to be an independent prognostic factor for adverse outcomes in HFpEF. Since it is an easy-to-learn, feasible and radiation-free method, it may add substantial value to the commonly used diagnostic and risk stratification models.

24 Gliflozins and ventricular function in patients affected by chronic heart failure with diabetes mellitus

Aims Diabetes is the most common comorbidity of HF patients. SGLT2 inhibitors has been shown to reduce hospitalization in patients with HF. The cardioprotective mechanisms of gliflozines have not been elucidated. The aim of our study was to evaluate the effect of SGLT2 inhibitors on right and left ventricular function in T2DM patients with HF. Methods and results One hundred and fifteen consecutive outpatients with CHF and T2DM were screened in the Daunia Heart Failure Registry. Seventy-eight of them were enrolled and followed up between May 2019 and September 2020. All patients underwent conventional, TDI and strain echocardiography in an ambulatory setting, at the beginning and after 3 months of therapy with SGLT2 inhibitors. Seventy-eight consecutive outpatients with CHF and T2DM (mean age 67.4 ± 8.4 years, male: 83%) were enrolled in the study. Thirty-eight of them started the treatment with SGLT2 inhibitors, while the remaining forty continued their original therapy. After 3 months of therapy, LVEF, LVEDD, and LVESD statistically improved (respectively, from 39.68 ± 7.78% to 45.08 ± 9.04%, P: 0.001 and 57.32 ± 9.76 mm to 54.16 ± 6.54 mm, P: 0.01 and from 47.51 ± 1.58 mm to 43.24 ± 8.12, P: 0.0008). Changes in left ventricular function and dimensions were not significant in patients who did not started a therapy with SGLT2 inhibitors. There was a statistically significant reduction of E/E′ (from 16.51 ± 22.55 to 9.73 ± 3.35, P: 0.0007) in patients with treatment with SGLT2i. Moreover, there was an improvement of right ventricular function, due to a statistically significant reduction of PAPs and increase of TAPSE (respectively, from 30.63 ± 8.80 to 24.00 ± 8.35, P: 0.008; from 19.16 ± 2.54 to 21.18 ± 2.84, P: 0.0003) and S′ (10.42 ± 2.09 to 12.91 ± 2.50, P: 0.000) 3 months after the administration of SGLT2 inhibitors therapy vs. the control group. Conclusions In a real-world scenario, our results showed that the treatment with SGLT-2 inhibitors in patients with CHF and diabetes is associated with an echocardiographic biventricular function improvement.

Evaluation of a social determinants of health screening questionnaire and workflow pilot within an adult ambulatory clinic

Background There is increased recognition in clinical settings of the importance of documenting, understanding, and addressing patients’ social determinants of health (SDOH) to improve health and address health inequities. This study evaluated a pilot of a standardized SDOH screening questionnaire and workflow in an ambulatory clinic within a large integrated health network in Northern California. Methods The pilot screened for SDOH needs using an 11-question Epic-compatible paper questionnaire assessing eight SDOH and health behavior domains: financial resource, transportation, stress, depression, intimate partner violence, social connections, physical activity, and alcohol consumption. Eligible patients for the pilot receiving a Medicare wellness, adult annual, or new patient visits during a five-week period (February-March, 2020), and a comparison group from the same time period in 2019 were identified. Sociodemographic data (age, sex, race/ethnicity, and payment type), visit type, length of visit, and responses to SDOH questions were extracted from electronic health records, and a staff experience survey was administered. The evaluation was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Results Two-hundred eighty-nine patients were eligible for SDOH screening. Responsiveness by domain ranged from 55 to 67%, except for depression. Half of patients had at least one identified social need, the most common being stress (33%), physical activity (22%), alcohol (12%), and social connections (6%). Physical activity needs were identified more in females (81% vs. 19% in males, p < .01) and at new patient/transfer visits (48% vs. 13% at Medicare wellness and 38% at adult wellness visits, p < .05). Average length of visit was 39.8 min, which was 1.7 min longer than that in 2019. Visit lengths were longer among patients 65+ (43.4 min) and patients having public insurance (43.6 min). Most staff agreed that collecting SDOH data was relevant and accepted the SDOH questionnaire and workflow but highlighted opportunities for improvement in training and connecting patients to resources. Conclusion Use of evidence-based SDOH screening questions and associated workflow was effective in gathering patient SDOH information and identifying social needs in an ambulatory setting. Future studies should use qualitative data to understand patient and staff experiences with collecting SDOH information in healthcare settings.

P-EGS28 Management of obstructive jaundice secondary to gall stones in an ambulatory setting

Background Our data from Leeds shows a 30% increase in patient attendance to the Surgical Assesment Unit (SAU) across a 5 year period, putting unprecedented demands on the acute surgical service. A new Ambulatory Surgical Centre (ASC) was established for the advancement of ambulatory care pathways that would ensure that acute patients are seen promptly and kept safe with monitoring in an appropriate setting without needing admission to the hospital bed base. Gallstone related disease accounts for a third of patient attendance to the emergency surgical services. We present our experience with an ambulatory pathway to manage patients with obstructive jaundice caused by gall stones, and propose a protocol driven pathway. Methods The ASC operates an acute, consultant led clinic, with access to urgent blood tests and dedicated USS, CT and MRI imaging capacity, and offers a direct referral service from Primary Care Networks (PCNs) through the Primary Care Access Line (PCAL). Patients referred with clinical jaundice or RUQ/Epigastric pain are investigated for derangement in their liver function, and assessed for the presence and severity of Acute Cholangitis (AC), according to the 2018 Tokyo Guidelines. Patients without evidence of cholangitis, or with AC Grade I are planned for management in the ambulatory setting, including investigations, monitoring and endoscopic/surgical intervention. Outcome data was collected retrospectively from PCAL data source, spanning from Oct 2020 till July 2021. Results A total of 98 patients were referred to the acute surgical service during this period. Out of these, 47% had Grade II (n = 35) or Grade III (n = 17) AC. 48% were suitable for ambulatory management, with no evidence of AC(n = 5) or Grade I AC(n = 43). 20% patients were found to have a cause other than gall stone disease. 55% have undergone intervention (33 Laparoscopic cholecystectomies, 22 ERCP) while 12 are on the waiting list for surgery. Conclusions Our protocol offers a safe, comprehensive and timely pathway for the management of patients with gall stone related obstructed jaundice in an ambulatory setting. This has helped reduce the demand on hospital beds for surgical patients.