Coverage of the annual AHA Scientific Sessions

AHA Scientific Sessions 2020

: A woman in her 60’s with a history of COPD (who still smokes) presents to the ED for 6 days of vomiting and diarrhea and 1 day of constant LLQ pain. She denies fever, bleeding, recent travel or antibiotic use, chest pain, SOB that is any worse than her usual baseline or any other complaints.

: Vital signs are normal except for a pulse ox of 92% on room air, which she thinks may be normal for her and a temperature of 99.4. Exam is remarkable for diffuse abdominal tenderness without rebound that is more pronounced on the left than on the right.

NSR at 86 with PR 152ms, QRS or 84ms and QTc 379ms

Articles

Check out our latest case report from Dr. Brady Pregerson, which features a smoker in her 60 with a history of COPD presenting with 6 days of vomiting and diarrhea and 1 day of constant LLQ pain. Can you determine the correct diagnosis?

Case Report: Older Woman with 6 Days of Vomiting and Diarrhea

A new study from the University of Pittsburgh is providing insight into the risk of incident cardiovascular disease events associated with 

Using data from the Study of Women’s Health Across the Nation (SWAN) study, results of the study suggest women with frequent vasomotor menopausal symptoms (VMS) were at a 52% greater risk of experiencing a cardiovascular event.

“This study is the largest, longitudinal study to date to address the relationships between midlife VMS and risk of subsequent incident cardiovascular disease events. We found that frequent VMS at baseline as well as frequent VMS that persisted over time were associated with elevated risk of a combined outcome of incident fatal and nonfatal cardiovascular disease events,” wrote investigators.

Despite recent advances in care, cardiovascular disease remains among the leading causes of death in women. With recent studies indicating experiencing VMS could impact cardiovascular health, investigators designed the current study to evaluate the relationship between VMS and cardiovascular disease events.

Launched in 1996, SWAN was designed as a longitudinal cohort study to examine the menopause transition. The study enrolled 3302 women between the ages of 42 and 52 years who were followed for up to 22 years and attended up to 16 follow-up visits.

As part of SWAN, VMS were assessed through questionnaires at baseline and each follow-up visit. For the purpose of the analysis, VMS frequency was defined as no VMS, VMS 1-5 days per 2 weeks, and VMS 6 or more days per 2 weeks. Using SWAN, investigators also obtained data related to physical measurements, phlebotomy, and reported cardiovascular disease events.

Of note, 219 women from the 3302-woman cohort were excluded from the current study. These women were excluded due to missing data on cardiovascular disease events, missing data on VMS, or missing follow-up data. Cardiovascular events of interest for the current study included myocardial infarction, cerebrovascular accident/stroke, heart failure, or revascularization procedures.

In Cox proportional hazards models adjusted for demographics, medication use, and other risk factors, results indicated experiencing VMS 6 or more days in a 2-week period was associated with a 51% increase in risk of cardiovascular disease events compared to women not experiencing VMS (HR, 1.51; 95% CI, 1.05-2.17; 

=.03). Further analysis indicated women reporting frequent VMS that persisted over time, which investigators defined as more than 33% of study visits, were at a 77% greater risk of a cardiovascular event than those who reported VMS at 33% or fewer studies (HR, 1.77; 95% CI, 1.33-2.35; 

“We found that frequent VMS or persistent VMS over midlife are associated with a 50% to 77% increased risk of future cardiovascular disease events. Thus, VMS may represent a novel, female‐specific cardiovascular disease risk factor, as VMS may point to women at risk of future cardiovascular disease events beyond those identified on the basis of traditional cardiovascular disease risk factors,” added investigators.

Menopausal Vasomotor Symptoms and Risk of Incident Cardiovascular Disease Events in SWAN

Journal of the American Heart Association.

An analysis of data from more than 3k women followed for up to 20 years indicates increased frequency of vasomotor menopausal symptoms was associated with a 52% greater risk of incident cardiovascular disease.

Menopause Symptoms Linked to Increased Risk of Cardiovascular Events

An analysis of data from within the UK Biobank cohort has found a casual, but direct link between smoking and the risk of subarachnoid hemorrhage (SAH). 

Results of the study, which included genetic data from more than 400,000 individuals, suggest smoking half a pack to 20 packs per year were at a 27% increased risk of experiencing SAH. 

Senior author Guido J. Falcone, MD, ScD, MPH, assistant professor of neurology, Yale School of Medicine, and colleagues built a polygenic risk score using independent genetic variants known to associate (

 <5x10-8) with smoking behavior, as a representative of the genetic susceptibility to smoking initiation.

They found a 21% increased risk of smoking (odds ratio [OR], 1.21; 95% CI, 1.20–1.21; 

 <.001) and a 10% increased risk of SAH for each additional standard deviation (SD) of the smoking polygenic risk score.

"Previous studies have shown that smoking is associated with higher risks of SAH, yet it has been unclear if smoking or another confounding condition such as high blood pressure was a cause of the stroke,” Falcone said in a statement.

 “A definitive, causal relationship between smoking and the risk of SAH has not been previously established as it has been with other types of stroke.”

The study evaluated 408,609 participants (mean age, 57 years [SD, 8]; female, 220,937 [54%]), 132,566 (32%) of which smoked regularly, and 904 (0.22%) who had a SAH. SAH cases were ascertained using a combination of self-reported, electronic medical record, and death registry data.

The primary MR analysis, which utilized the ratio method, indicated that genetic susceptibility to smoking was associated with a 63% increase in the risk of SAH (OR, 1.63; 95% CI, 1.15–2.31; 

 = .006). Secondary analysis, which included the inverse variance weighted (OR, 1.57; 95% CI, 1.13–2.17; 

 = .007) and weighted median methods (OR, 1.74; 95% CI, 1.06–2.86; 

The researchers noted that smoking as a risk factor for aneurysm formation and rupture, leading to SAH, had been previously observed in animal and observational studies. However, it had not been established whether there was a definitive causal relationship between smoking and the risk of SAH.

Falcone and colleagues found the relationship between smoking and SAH risk to be linear, with those who smoked half a pack to 20 packs of cigarettes per year having a 27% increased risk. Additionally, there was a 3-fold risk for SAH in heavier smokers, those who smoked more than 40 packs of cigarettes per year.

"Our results provide justification for future studies to focus on evaluating whether information on genetic variants leading to smoking can be used to better identify people at high risk of having one of these types of brain hemorrhages," Julian N. Acosta, MD, neurologist, postdoctoral research fellow, Yale School of Medicine, and lead study author, said in a statement. "These targeted populations might benefit from aggressive diagnostic interventions that could lead to early identification of the aneurysms that cause this serious type of bleeding stroke."

Genetically Determined Smoking Behavior and Risk of Nontraumatic Subarachnoid Hemorrhage

Findings from a 1-sample Mendelian randomization study using data from the UK Biobank revealed a causal link between smoking and the risk of subarachnoid hemorrhage.

Study Details Link Between Smoking and Subarachnoid Hemorrhage

The US Food and Drug Administration has approved vericiguat (Verquvo), a soluble guanylate cyclase (sGC) stimulator, for reducing the risk of 

Based on the results of the pivotal VICTORIA trial, vericiguat (Verquvo) received approval for reducing the risk of cardiovascular death and heart failure hospitalization following a hospitalization for heart failure or need for outpatient intravenous diuretics in adults with symptomatic chronic heart failure and ejection fraction less than 45%.

“Patients with symptomatic chronic heart failure and reduced ejection fraction have a high risk for hospitalization after experiencing symptoms of heart failure requiring outpatient IV diuretic treatment or hospitalization. By some estimates, more than half of these patients are rehospitalized within a month of discharge due to a worsening event and approximately one in five die within two years,” said Paul W. Armstrong, MD, cardiologist and Distinguished University Professor of Medicine at the Canadian VIGOUR Centre, University of Alberta, and study chair of the VICTORIA trial, in the 

 “The approval of VERQUVO provides doctors, health care professionals, and patients with a welcome new option to current available therapies.”

Despite historic progress in therapeutics in recent years, heart failure still carries one of the grimmest prognoses of any cardiovascular condition. The first treatment approved specifically for patients following a hospitalization for heart failure or need for intravenous diuretics, vericiguat received approval based on the results of the phase 3 VICTORIA trial, which was 

VICTORIA was designed as a randomized, parallel-group, placebo-controlled, double-blind, event-driven, multicenter trial and enrolled 5050 patients with New York Heart Association-defined class II, III, or IV chronic heart failure from 600 medical centers in 42 countries. In the trial, which had a primary composite endpoint of death from cardiovascular causes or hospitalization for heart failure, use of vericiguat led to a 10% reductions in the primary endpoint in a time-to-event analysis (HR, 0.90; 95% CI, 0.82-0.98; 

Additionally, results of the trial indicated vericiguat was associated with a 4.2% reduction in annualized absolute risk compared to placebo, which indicates vericiguat had a number needed to treat of 24 patients.

The release from Merck notes vericiguat 2.5 mg, 5 mg, and 10 mg tablets are being jointly developed with Bayer AG.

“VERQUVO has been shown to reduce the risk of cardiovascular death and heart failure hospitalization following a hospitalization for heart failure or need for outpatient IV diuretics. We are pleased to offer a meaningful new treatment option for appropriate patients with symptomatic chronic heart failure,” said Roy Baynes, MD, PhD, senior vice president and head of global clinical development, chief medical officer, Merck Research Laboratories. “This approval builds upon Merck’s proud history of developing therapies for the treatment of patients with cardiovascular disease.”

The release from Merck also notes the vericiguat label also contains a boxed warning. This boxed warning indicates that vericiguat should not be administered to pregnant females because it may cause fetal harm. The release also points out hypotension and anemia were observed adverse events with vericiguat compared to placebo during VICTORIA.

The release from Merck did not mention when the company expects vericiguat to become available to patients within the US.

The US FDA has approved vericiguat (Verquvo) for reducing the risk of cardiovascular death and heart failure hospitalization following a hospitalization for heart failure or need for outpatient intravenous diuretics in patients with HFrEF. 

FDA Approves Vericiguat (Verquvo) for Treatment of Heart Failure

About this time last year, the first cases of COVID-19 were cropping up here in the United States. I myself was largely unaware of any potential infectious disease implications for my patients and the greater community. I along with my large family boarded a plane for Aspen, Colorado for my yearly medical conference and our traditional ski holiday. Generally oblivious to the rising threat we flew home the second week of February 2020 to a completely different reality.

Like many other clinicians, I was skeptical that a novel coronavirus would pose a real threat since the most obligatory coronavirus, also known as the common cold, typically results in far less morbidity and mortality than the seasonal flu. In February, I was even among the group of physicians suggesting no one overreact without more information. With no excuses made, I was wrong.

The COVID-19 global pandemic has taken more lives than World War I, the Vietnam War, and the Korean War combined. Mortality aside, the cost in resources, mental and physical health, and loss of income is staggering. However, a second global pandemic that is just as insidious and highly transmissible has infected the healthy and infirm spreading even more quickly than COVID-19. Removing any distance and thwarted by no measure of personal protective equipment, the global pandemic of misinformation and conspiracy theory carried by a willing host, the social network, has provided the novel coronavirus with the richest of media to spread and thrive to spite the medical communities’ best efforts at containment.

Oddly enough, taking care of sick patients and even being exposed to a potentially deadly virus have not been the most demoralizing or worrisome problems facing me as a clinician over the last year. While being recognized as heroes for running into the burning building that is COVID care represents a pleasant change from the norm, the truth is that we run into buildings with unknown dangers every day as a matter of course.

We have taken oaths and promised through our training and licensure that we will care for patients no matter the ailment. What I wasn’t ready for was the viral ignorance, fear, and hostility directed at the scientific community, directed at me.

Social media has become a very large part of the common discourse with billions of people interacting who otherwise would not. Initially, social media was a place for me to share photos of my kids so that grandma could see them from a distance. More recently, social media has become a powerful way for physicians to communicate with their community.

With increasing responsibilities and more patients, using web-based communication allows us to reach more patients and promote better health without packing the office. However, with an increasing number of patients looking for and finding medical advice on the internet, the costs have begun to overtake the benefits.

The problem was evident before COVID-19. We have all had patients come in and inform us of their search engine diagnosis and question our advice and treatment plans as in conflict with what Aunt Betty prescribed. By and large, engaging the patient in a reassuring and informed conversation usually alleviates these trepidations and restores the physician-patient relationship, at least until recently.

Somewhere in the last half-decade, the very concept of scientific fact has come into question. Now, a free pass has been given to fringe groups once relegated to the shadows for fear of ridicule and exposure. In particular, anti-vaccination groups have been emboldened by the renewed interest in vaccines and the speed with which the COVID-19 vaccines have been developed. Clinicians for the first time became pariahs, profiteers, snake-oil salespeople—anything but healers.

I have watched on social media as friends who are nurses and physicians try to explain why the COVID-19 vaccines are safe and effective only to be ridiculed by a small but noticeable element citing false data and reposting misinformation from highly questionable sources. I have heard of colleagues, including established experts with the CDC, receiving threats to their lives and the lives of their families. I can tell you that after taking care of mortally ill COVID-19 patients in the intensive care unit, the pain of losing those patients is amplified tenfold when people I know and see every day question the very existence of this virus and flaunt their rights to endanger everyone they encounter. This is real pain and something every clinician I know is experiencing right now.

In the midst of promoters of pseudoscience, I found many friends and acquaintances on social media asking good questions. “Is the vaccine safe?”, “Will the vaccine alter my DNA?”, “I’m young and healthy, why should I worry?” I started answering their questions. I saw my physician friends doing the same.

Unfortunately, not one single thread went without someone, often unknown to the other parties, claiming irrefutable proof that the science was wrong, that doctors are making money off of saying COVID-19 is dangerous, that vaccines are merely a control tactic by the deep state. I found myself ending my advice with, “You are all entitled to your view. I only want to provide you with the best scientific information and if it saves even one of your lives it is worth it.”

With 2021 upon us we can only have hope. As clinicians, we have to stay positive and continue to follow the science. The first rule of triage is that you cannot save everyone a fact that vexes every good clinician. What we can do is inform our patients and our communities. We can go out and join vaccination teams and support those who are working to make sure everyone who can be inoculated is.

Finally, it is important that we continue to set a good example for everyone else. Once the vaccine was available my social media feed began to be filled with friends posting pictures of themselves getting vaccinated, showing everyone that it was safe and real. In the end, the truth wins and we will get through this.

While social media and technology have allowed greater sharing of ideas and knowledge, they have also become a major source of misinformation. In this column, Dr. Weiss reflects on practicing during the age of misinformation. 

Practicing Medicine in the Age of Misinformation with Gregory Weiss, MD

Results of a new study are drawing a direct link between consumption of fried food and increased risk of 

A meta-analysis of more than a dozen observational studies, the new study suggests every additional serving of fried food per week was linked to a 3% increase in risk of major adverse cardiovascular events, a 2% increase in risk of coronary heart disease, and a 12% increase in risk of heart failure.

“Our study provided evidence for the adverse effects of consuming fried food on CVD and can be useful for dietary guidelines,” wrote investigators. “WHO suggested limiting fried-food consumption to reduce the amount of total fat intake and industrially produced trans-fatty acid intake for a healthy diet. However, no dietary guideline is approved for the specific effect of fried food consumption on CVD.”

With an interest in determining the association of fried food consumption with risk of cardiovascular disease and all-cause mortality, investigators sought to evaluate these potential associations through an analysis of studies published in the EMBASE, PubMed, and Web of Science databases from inception through April 11, 2020. An initial search of these databases returned 80 full-text articles for review. Of these, 19 articles examining were identified for inclusion in the current meta-analysis.

From these studies, investigators obtained information related to 562,445 individuals and 36,727 major cardiovascular events. Of note, 6 cohort studies examined all-cause mortality—these studies included 754,873 participants who were followed for a median of 9.5 years. Of note, 85,906 deaths occurred during the follow-up period of these studies.

When comparing those with the highest levels of fried food intake to those with the lowest, results suggested increased intake was associated with a 28% increase in risk of major cardiovascular events (RR, 1.28; 95% CI, 1.15-1.43; I2=82%), a 22% increase in risk of coronary heart disease (RR, 1.22; 95% CI, 1.07-1.40; I2=77.9%), a 37% increase in risk of stroke, and a 37% increase in risk of heart failure. Further analysis indicated a 2% increase in risk of cardiovascular mortality and a 3% increase in risk for all-cause mortality.

Investigators performed additional analyses to determine how risk ratios may have differed based on study design. For major cardiovascular events, analysis of prospective studies yielded a RR of 1.24 (95% CI, 1.12-1.38; I2=75.7%) and case-control studies yielded a RR of 1.91 (95% CI, 1.15-3.17; I2=92.1%). For coronary heart disease, analysis of prospective studies yielded a RR of 1.16 (95% CI, 1.05-1.29; I2=44.6%) and case-control studies yielded a RR of 1.91 (95% CI, 1.05-3.47; I2=93.9%).

“The association between fried-food consumption and risk of stroke, heart failure, cardiovascular mortality and all-cause mortality has not been firmly established, so more studies are warranted to investigate the association,” wrote investigators.

Fried-food consumption and risk of cardiovascular disease and all-cause mortality: a meta-analysis of observational studies

A meta-analysis of nearly 20 studies is offering clinicians further insight into the effects of consuming fried foods on cardiovascular health.

Meta-Analysis Provides Insight on Fried Food and its Impact on Heart Health

With many recent studies outlining the potential prognostic value of abdominal aortic calcification (AAC) as seen in noninvasive imaging modalities, results of a meta-analysis and systematic review are providing clinicians with an overview of 

 associated with AAC these observational studies.

Insights from the study, which included data from 52 studies completed by March 2018, indicate patients with any or advanced AAC saw their risk of cardiovascular disease events, cardiovascular mortality, and all-cause mortality increase by 80% or more compared to their counterparts without AAC.

"Heart disease is often a silent killer as many people don't know they are at risk or that they have the early warning signs, such as abdominal or coronary artery calcification," said lead investigator Josh Lewis, PhD, associate professor in cardiometabolic health at Edith Cowan University, 

 "The abdominal aorta is one of the first sites where the build-up of calcium in the arteries can occur - even before the heart. If we pick this up early, we can intervene and implement lifestyle and medication changes to help stop the condition progressing."

With a growing interest in the potential prognostic value of AAC, Lewis and a team of colleagues sought to compile and assess findings from prospective studies examining AAC and incident cardiovascular events and all-cause mortality. For their study, investigators performed searches of the MEDLINE and Embase databases from inception through 2018 with the aim of identifying cohort or case-control studies reporting associations between AAC and conditions including, coronary heart disease, cerebrovascular disease, heart failure, peripheral arterial disease, and/or all‐cause mortality.

Studies included in the meta-analysis and systematic review evaluated AAC using computed tomography, x-ray, or DXA. Summary risk ratios were estimated using random-effects models comparing the higher AAC groups to groups with the lowest reported AAC.

Overall, investigators identified 458 publications and 52 met inclusion criteria. Of the 52 studies chosen for inclusion, 50 were cohort studies and 2 were case-control studies. From these 52 studies, investigators obtained data related to 46 distinct cohorts and 36,092 individuals. Of note, only studies of patients with chronic kidney disease (57%) and the general older-elderly populations (26%) had sufficient data to include in the meta-analysis.

Upon analysis, results indicated people with any or more advanced AAC had a greater risk of cardiovascular events (RR, 1.83; 95% CI, 1.40-2.39), fatal cardiovascular events (RR, 1.85; 95% CI, 1.44-2.39), and all‐cause mortality (RR, 1.98; 95% CI, 1.55-2.53) compared to those in the lowest group of AAC. Additionally, this risk became greater when assessing risk among patients with chronic kidney disease and any or more advanced AAC, with increased risk noted for cardiovascular events (RR, 3.47; 95% CI, 2.21-5.45), fatal cardiovascular events (RR, 3.68; 95% CI, 2.32-5.84), and all‐cause mortality (RR, 2.40; 95% CI, 1.95-2.97).

"This can signal an early warning for doctors that they need to investigate and assess their patient's risk of heart attack or stroke,” added Lewis. "Ultimately, if we can identify this condition sooner, people can make lifestyle changes and start preventative treatments earlier, which could potentially save many lives in the future."

Prognostic Value of Abdominal Aortic Calcification: A Systematic Review and Meta‐Analysis of Observational Studies

Results from a systematic review and meta-analysis of more than 50 studies assessing cardiovascular risk with levels of abdominal aortic calcification indicate increased AAC was linked to 80% increase in risk of cardiovascular events and cardiovascular death.

Abdominal Aortic Calcification Tied to 80% Increase in Risk of CV Events, Death

An analysis of questionnaires from more than 400 diabetic patients diabetes is offering further insight into how the ongoing pandemic has impacted diabetes management, including glycemic control, body weight, and stress levels.

Results of the study describe a situation where diabetics have experienced increases in stress, anxiety, and body weight, but no deterioration of glycemic control in patients with type 1 and type 2 diabetes during lockdown periods.

“We show that in people with relatively well controlled type 1 and type 2 diabetes the COVID-19 pandemic and lockdown measures increased stress and resulted in weight gain and less physical exercise during this short observational period. However, despite these factors no deterioration in glycemic control was observed,” wrote investigators.

To learn more about the effects of lockdown measures on various aspects of diabetes management, investigators from Leiden University Medical Center designed the current study as a short-term observational cohort study of patients treated at the outpatient diabetes clinic at the medical center. For inclusion in the study, patients needed to be at least 18 years of age and be sufficient enough in Dutch to perform fingerpicks and complete an online questionnaire.

Of note, patients were excluded if they were pregnant, diagnosed with a malignancy within the previous 6 months, were receiving immunotherapy or chemotherapy, or were admitted to a hospital or rehabilitation center. In total, 435 people were identified for inclusion in the current study—280 with type 1 diabetes and 155 with type 2 diabetes.

Of the 435 patients included in the study, 76.8% were using a basal-bolus regimen and 8.3% were using basal insulin only. In comparison to their counterparts with type 1 diabetes, patients with type 2 diabetes were on average 12.3 years older and had a higher BMI. Of the 435 included in the study, 399 completed the questionnaire on daily routines, physical activity, psychological stress, glycemic control, and medication use. For the purpose of analysis, HbA1c measurements during the lockdown were compared with the last known HbA1c prior to lockdown.

During the lockdown, 34.1% of respondents reported elevated stress—33.6% of type 1 diabetics and 35.1% of type 2 diabetics. Additionally, 27.3% of all participants reported increased levels of anxiety—27.5% of type 1 diabetics and 26.9% of type 2 diabetics. In analyses, changes in perceived stress was associated with a change in HbA1c (95% CI, 0.015-0.38; 

=.034) but changes in anxiety levels were not associated with changes in HbA1c.

When assessing exercise and weight gain, investigators found 40.9% of patients reported weight gain and 45.7% reported getting less exercise during the pandemic. Investigators noted 12% of respondents reported losing weight and 10% reported more exercise. In an analysis, change in exercise or weight gain was not associated with changes in HbA1c.

In regard to glycemic control, there was improvements among those in the highest HbA1c tertile in both type 1 (-0.39% [-4.3 mmol/mol], 

 <.0001) and type 2 (-0.62% [-6.8 mmol/mol], 

=.0036) diabetics. Further analysis indicated time in range was higher (60.5% vs 63.4%; 

=.0009) and time above range was lower (34.6% vs 32.1%; 

 <.003) during the lockdown period than in the pre-lockdown period for the entire study cohort.

“Our short-term observational study shows that lockdown measures resulted in increased levels of perceived stress, weight gain and less exercise in both people with relatively well-controlled type 1 and type 2 diabetes, however this did not negatively impact glycemic control,” wrote investigators.

Increased stress, weight gain and less exercise in relation to glycemic control in people with type 1 and type 2 diabetes during the COVID-19 pandemic

Data from questionnaires given to type 1 and type 2 diabetes patients from an outpatient clinic is providing insight into how the COVID-19 pandemic has impacted diabetes management. 

Lockdowns Led to Weight Gain, Increases in Stress But No Changes in Glycemic Control Among Diabetics

A simple switch in electronic health records could lead to fewer deaths and rehospitalizations among patients with 

A new study from the Perelman School of Medicine at the University of Pennsylvania found making clinicians opt-out of cardiac rehabilitation instead of opt-in led to a 47-percentage point increase in referrals to cardiac rehabilitation.

"Referral for cardiac rehab has traditionally been a manual process that involved many stakeholders," said lead investigator Mitesh Patel, MD, director of Penn Medicine's Nudge Unit, 

. "By restructuring the pathway as an opt-out decision, we were able to leverage technology to automate the process and significantly reduce the burden on clinicians and patients."

With an interest in evaluating how changes in the cardiac rehabilitation referral decision pathways could influencereferral rates, Patel and a team of colleagues designed and conducted the current study at a trio of Penn Medicine hospital in Philadelphia, Pennsylvania. Beginning in January 2017, an opt-out referral decision pathway was implemented into the electronic health record to automatically identify eligible patients and notify staff through secure messaging at 1 of the 3 hospitals.

Check out this related study from Penn Medicine examining how an EHR ‘nudge’ might effect statin prescribing rates

All cardiac rehabilitation referrals were manually verified. Additionally, all patients received educational material on the importance and relevance of rehabilitation. For the purpose of analysis, investigators obtained data for 1 year before and 2 years after the intervention was implemented for comparison.

A linear probability model was used to perform a difference-in-differences analysis to evaluate changes in referral rates at the intervention site compared to the 2 control sites during the preintervention and post-intervention periods. Of note, all models were adjusted for age, sex, race/ethnicity, insurance, annual household income, body mass index, and history of myocardial infarction, congestive heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, hypertension, diabetes, and smoking.

During the study period, a sample of 2832 patients with ischemic heart disease were identified for inclusion at the 3 Penn Medicine hospitals. This cohort had a mean age of 66.7 (SD, 11.4) years, 812 were female, 1870 were White, and 564 were Black. Initial analysis indicated trends in referral rates for cardiac rehabilitation did not differ between the intervention and control sites during the preintervention period.

At the completion of the study, the investigator’s comparison indicated the percentage of referrals at the intervention site reached 85.7% compared to 31.6% at the study’s control sites, which resulted in a 47-percentage point difference (95% CI, 39.2-55.1; 

"When we surveyed our providers prior to launching the intervention, we learned they were largely interested in having their patients participate in a cardiac rehab program after discharge, but they were not properly equipped to make that happen," said Elizabeth Jolly, RN, an interventional cardiology transitions coordinator at the Hospital of the University of Pennsylvania, in the aforementioned statement. "With our interventions, we saw that the opt-out pathway coupled with the list of facilities made the referral process effortless."

Referral Rates for Cardiac Rehabilitation Among Eligible Inpatients After Implementation of a Default Opt-Out Decision Pathway in the Electronic Medical Record

A quality improvement study conducted at a trio of Penn Medicine hospitals suggests changing cardiac rehabilitation referrals from an opt-in to an opt-out decision in their EHR could drastically improve referral rates.

Simple EHR Switch Could Dramatically Improve Referral Rates for Cardiac Rehabilitation

Confirming what many already suspected, a new analysis of data from the UK Biobank cohort study indicates there was no limit to the cardiovascular benefits derived from physical activity.

Results of the analysis, which included data from more than 90,000 patients without cardiovascular disease at baseline, demonstrated the lowest risk of cardiovascular disease was seen among the most active participants—indicating there was no threshold for how much physical activity could lower 

“This is the largest ever study of exquisite device-measured physical activity and cardiovascular disease. It shows that physical activity is probably even more important for the prevention of cardiovascular disease than we previously thought,” said study investigator Aiden Doherty, PhD, an associate professor at the University of Oxford’s Nuffield Department of Population Health, 

. “Our findings lend further weight to the new WHO guidelines on physical activity which recommend at least 150 to 300 minutes of moderate to vigorous aerobic activity per week for all adults.”

In an effort to more clearly define the effects of physical activity on risk cardiovascular disease, Doherty and colleagues from Oxford designed the current analysis as a retrospective cohort study of patients form within the UK Biobank database. While many studies have examined associations between physical activity and risk of cardiovascular disease, investigators noted most of these have relied on self-reported data and few, if any, had examined associations using accelerometer data.

As part of the UK Biobank study, patients were asked to wear an accelerometer over a 7-day period during a time period lasting from 2013-2015. Using this group, investigators identified 90,211 participants without prior or concurrent cardiovascular disease.

From the accelerometer data, investigators extracted total volume of physical activity and this was used to estimate number of minutes spent in moderate and vigorous physical activity per week. Of note, total activity volume and each intensity of physical activity were categorized into equal quarters for the purpose of analysis. The primary outcomes of the study was incident cardiovascular disease, which was defined as the first hospital admission or death from cardiovascular disease.

In their initial assessment, investigators found those in the lowest category of physical activity smoked more, had a higher BMI, had increased levels of C-reactive protein, and were more likely to have been diagnosed with hypertension than those in categories defined by increased physical activity. During 440,004 person-years of follow-up, investigators found there were 3617 incident cases of cardiovascular disease. Analysis revealed a linear dose-response relationship for physical activity, whether measured as moderate-intensity, vigorous-intensity, or as total volume, with risk of incident of cardiovascular disease.

In their analyses, investigators compared risk of incident cardiovascular disease for each category with the lowest category of physical activity. For moderate-intensity physical activity the hazard ratios for each increasing quarter of physical activity relative to the lowest were: 0.71 (0.65-0.77), 0.59 (0.54-0.65), and 0.46 (0.41-0.51). For vigorous-intensity physical activity, the hazard ratios for increasing quarters compared to the lowest quarter were: 0.70 (0.64-0.77), 0.54 (0.49-0.59), and 0.41 (0.37-0.46). For total volume of physical activity, the hazard ratios for increasing quarters compared to the lowest quarter were: 0.73 (0.67-0.79), 0.63 (0.57-0.69), and 0.47 (0.43-0.52).

Investigators cautioned clinicians to consider the limitations of their study and the potential for confounding and reverse causality when interpreting the results of their study.

“The results of this study enhance confidence that physical activity is likely to be an important way of preventing cardiovascular disease. The potential risk reduction estimated in those engaging in relatively high levels of activity is substantial and justifies a greater emphasis on measures to increase levels of physical activity in the community,” said lead investigator Terry Dwyer, MD, a professor in the University of Oxford’s Nuffield Department of Women’s and Reproductive Health, in the aforementioned statement.

Accelerometer measured physical activity and the incidence of cardiovascular disease: Evidence from the UK Biobank cohort study

An analysis of nearly 100k people from the UK Biobank study suggests there was no upper threshold on the reduction in risk of cardiovascular disease derived from physical activity. 