Cardiology providers’ recommendations for treatments and use of patient decision aids for multivessel coronary artery disease

Background: Rates of recommending percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) vary across clinicians. Whether clinicians agree on preferred treatment options for multivessel coronary artery disease patients has not been well studied. Methods and results: We distributed a survey to 104 clinicians from the Northern New England Cardiovascular Study Group through email and at a regional meeting with 88 (84.6%) responses. The survey described three clinical vignettes of multivessel coronary artery disease patients. For each patient vignette participants selected appropriate treatment options and whether they would use a patient decision aid. The likelihood of choosing PCI only or PCI/CABG over CABG only was modeled using a multinomial regression. Across all vignettes, participants selected CABG only as an appropriate treatment option 24.2% of the time, PCI only 25.4% of the time, and both CABG or PCI as appropriate treatment options 50.4% of the time. Surgeons were less likely to choose PCI over CABG (RR 0.14, 95% CI 0.03, 0.59) or both treatments over CABG only (RR 0.10, 95% CI 0.03, 0.34) relative to cardiologists. Overall, 65% of participants responded they would use a patient decision aid with each vignette. Conclusions: There is a lack of consensus on the appropriate treatment options across cardiologists and surgeons for patients with multivessel coronary artery disease. Treatment choice is influenced by both patient characteristics and clinician specialty

JACC: Advances Expert Panel Perspective: Shared Decision-Making in Multidisciplinary Team-Based Cardiovascular Care

Shared decision-making (SDM) and multidisciplinary team-based care delivery are recommended across several cardiology clinical practice guidelines. However, evidence for benefit and guidance on implementation are limited. Informed consent, the use of patient decision aids, or the documentation of these elements for governmental or societal agencies may be conflated as SDM. SDM is a bidirectional exchange between experts: patients are the experts on their goals, values, and preferences, and clinicians provide their expertise on clinical factors. In this Expert Panel perspective, we review the current state of SDM in team-based cardiovascular care and propose best practice recommendations for multidisciplinary team implementation of SDM

Association between global leukocyte DNA methylation and cardiovascular risk in postmenopausal women

BACKGROUND: Genetic studies to date have not provided satisfactory evidence regarding risk polymorphisms for cardiovascular disease (CVD). Conversely, epigenetic mechanisms, including DNA methylation, seem to influence the risk of CVD and related conditions. Because postmenopausal women experience an increase in CVD, we set out to determine whether global DNA methylation was associated with cardiovascular risk in this population. METHODS: In this cross sectional study carried out in a university hospital, 90 postmenopausal women without prior CVD diagnosis (55.5 ± 4.9 years, 5.8 [3.0–10.0] years since menopause) were enrolled. DNA was extracted from peripheral leukocytes and global DNA methylation levels were obtained with an ELISA kit. Cardiovascular risk was estimated by the Framingham General Cardiovascular Risk Score (10-year risk) (FRS). Clinical and laboratory variables were assessed. Patients were stratified into two CVD risk groups: low (FRS: <10 %, n = 69) and intermediate/high risk (FRS ≥10 %, n = 21). RESULTS: Age, time since menopause, blood pressure, total cholesterol, and LDL-c levels were higher in FRS ≥10 % group vs. FRS <10 % group. BMI, triglycerides, HDL-c, HOMA-IR, glucose and hsC-reactive protein levels were similar in the two groups. Global DNA methylation (% 5mC) in the overall sample was 26.5 % (23.6–36.9). The FRS ≥10 % group presented lower global methylation levels compared with the FRS <10 % group: 23.9 % (20.6–29.1) vs. 28.8 % (24.3–39.6), p = 0.02. This analysis remained significant even after adjustment for time since menopause (p = 0.02). CONCLUSIONS: Our results indicate that lower global DNA methylation is associated with higher cardiovascular risk in postmenopausal women

Catheter-based intervention for pulmonary vein stenosis due to fibrosing mediastinitis: The Mayo Clinic experience

Fibrosing mediastinitis (FM) is a rare but fatal disease characterized by an excessive fibrotic reaction in the mediastinum, which can lead to life-threatening stenosis of the pulmonary veins (PV). Catheter-based intervention is currently the only viable option for therapy. However, the current literature on how best to manage these difficult cases, especially in regards to sequential interventions and their potential complications is very limited. We searched through a database of all patients who have undergone PV interventions at the Earl H. Wood Cardiac Catheterization Laboratory in Mayo Clinic, Rochester. From this collection, we selected patients that underwent PV intervention to relieve stenosis secondary to FM. Eight patients were identified, with a mean age of 41 years (24–59 years). Five were men, and three were women. Three patients underwent balloon angioplasty alone, and five patients had stents placed. The majority of patients had acute hemodynamic and symptomatic improvement. More than one intervention was required in five patients, four patients had at least one episode of restenosis, and four patients died within four weeks of their first PV intervention. We describe the largest reported case series of catheter-based intervention for PV stenosis in FM. Although catheter-based therapy improved hemodynamics, short-term vascular patency, and patient symptoms, the rate of life-threatening complications, restenosis, and mortality associated with these interventions was found to be high. Despite these associated risks, catheter-based intervention is the only palliative option available to improve quality of life in severely symptomatic patients with PV stenosis and FM. Patients with PV stenosis and FM (especially those with bilateral disease) have an overall poor prognosis in spite of undergoing these interventions due to the progressive and recalcitrant nature of the disease. This underscores the need for further innovative approaches to manage this disease

A Call for an Evidence-Based Approach to the Heart Team for Patients With Severe Aortic Stenosis

AbstractApplication of a Heart Team approach is now a central concept in the care of patients with severe aortic stenosis. It has Class I recommendations from American and European professional societies and is required for reimbursement for transcatheter aortic valve replacement in the United States. The rationale for changing traditional practice models is to improve patient selection, procedural planning, and management of patients at high or prohibitive surgical risk, thus improving outcomes. Although the concept is intuitive, a clear definition of the Heart Team, and data supporting its effectiveness, are lacking. Other specialties, including oncology, provide a precedent for investigation of the use of a multidisciplinary team and its impact on patient care. We highlight the need for clear definitions and shared metrics to advance our understanding of an optimal Heart Team approach, focusing on patient, clinician, and health system outcomes

Abstract 233: Patient Factors Minimally Impact Experience with Informed Consent Documents for Percutaneous Coronary Intervention

Background: In light of well-known deficiencies in the process of informed consent for percutaneous coronary intervention (PCI), we developed and tested a personalized consent form, PRISM; this was shown to improve patients' participation in the consent process, understanding of procedural risks, and engagement in shared decision-making when compared to original PCI consent forms. It is unknown whether patient factors traditionally known to impair the consent process, including socioeconomic status, literacy and numeracy, were associated with greater benefit from the PRISM consents. Methods: We interviewed 590 patients receiving original consent documents and 527 receiving PRISM consents and compared the rates of reviewing the consent form, recalling a risk of bleeding and engaging in discussions about stent type using hierarchical modified Poisson regression analysis. The interaction of patient factors (age, gender, education level, insurance status, literacy and numeracy) with PRISM on outcomes was assessed. Results: Overall, few patient characteristics were associated with outcomes, including review of consent forms, knowledge transfer, or engagement in shared decision-making (see Table), although older patients were less likely to discuss stent types with their doctors (RR=0.84/decade for original and 0.93/decade for PRISM). Those with more than a high school education were less likely to review original consents (RR=0.77; 95% CI=0.66, 0.89) compared to those with less education; this difference was eliminated with the PRISM consents (RR=1.0; 95%CI=0.82, 1.23; p-value for interaction = 0.01). Conclusions: PRISM consent forms led to improved participation in the consent process and knowledge transfer in a 9-center study; there was little variance by sociodemographic, economic, literacy or numeracy factors, both with original consents and with PRISM. </jats:p