ObjectiveTo evaluate the impact of intraoperative neuromonitoring (IONM) on stroke and operative mortality after coronary and/or valvular operations.MethodsThis was an observational study of coronary and/or valvular heart operations from 2010 to 2021. Baseline characteristics and postoperative outcomes were compared by the use or non-use of IONM, which included both electroencephalography and somatosensory-evoked potentials. Propensity-score matching was employed to assess the association of IONM usage with operative mortality and stroke.ResultsA total of 19 299 patients underwent a cardiac operation, of which 589 (3.1%) had IONM. Patients with IONM were more likely to have had baseline cerebrovascular disease (60% vs 22%). Patients with IONM had increased operative mortality (5.3% vs 2.5%) and stroke (4.9% vs 1.9%). Moreover, stroke and mortality were highly correlated, with 14% of strokes resulting in death, while only 2% of non-strokes resulted in death (p<0.001). The unadjusted Kaplan-Meier survival estimate was significantly lower among the group with IONM (p<0.001, log-rank). After propensity matching, however, there was no difference in operative mortality or stroke across each group: 3.6% vs 5.3% for mortality and 3.7% vs 5.4% for stroke. In the propensity-matched cohort, the Kaplan-Meier survival estimates were not significantly different across each group (p=0.419, log-rank).ConclusionsAdjusting for baseline risk, there was no significant difference in adverse outcomes across each group. IONM may serve as a biomarker of cerebral ischaemia, and empirical adjustments based on changes may provide benefits for neurologic outcomes in high-risk patients. The efficacy of IONM during cardiac surgery should be prospectively validated.

BackgroundKnowledge about how patients with symptomatic aortic stenosis (AS) perform on cardiopulmonary exercise testing (CPET) is sparse. Since exercise testing in patients with symptomatic AS is not advised, submaximal parameters could be of special interest. We aimed to investigate maximal and submaximal physical capacity by CPET before and 1 year after surgical aortic valve replacement (sAVR) in patients with severe AS.MethodsIn this prospective longitudinal study, 30 adult patients (age 66±10 years) with severe AS referred for sAVR underwent maximal CPET (respiratory exchange ratio ≥1.05) on a bicycle ergometer before (PRE) and 1 year after (POST) sAVR. Normally distributed data are presented as mean (±SD) and non-normally distributed data are presented as median (IQR).ResultsMedian peak workload increased by 8% from 133 (55) watts at PRE to 144 (67) watts at POST (p<0.001). Median ventilatory threshold (VO2@VT) increased from 1216 (391) to 1328 (309) mL/min (p=0.001, n=28). Mean peak oxygen uptake (peakVO2) was not significantly different between PRE and POST; 1871±441 vs 1937±404 mL/min (p=0.08). The oxygen uptake efficacy slope (OUES) was significantly correlated to PeakVO2 at both PRE (r=0.889, p<0.05) and POST (r=0.888, p<0.05)ConclusionPhysical work capacity was improved 1 year following sAVR, in terms of higher median peak workload and VO2@VT. The strong correlation between the submaximal variable OUES and peakVO2 suggests that OUES might be a useful surrogate of peakVO2 in this group of patients where maximal exercise testing is not always recommended.

BackgroundValvular heart disease (VHD) represents a significant burden on healthcare systems worldwide, necessitating specialised care through multidisciplinary valve clinics. However, there is a lack of a standardised training and certification framework for clinical scientists and specialist physiologists (CSSPs) working within specialist valve clinics (SVCs). This study aimed to design, implement and validate a competency framework dedicated to training and certifying valve CSSPs to enhance patient outcomes and establish standardised care.MethodsA comprehensive competency framework was developed and implemented, consisting of two levels: Enhanced Valve Clinic Training (EVCT) and Advanced Valve Clinic Training (AVCT). The programme was trialled at Guy’s Valve Clinic, London, over a 12-month period. Validation was undertaken through trainee and patient feedback, including multiple-choice questions, clinical skills assessments, and patient satisfaction surveys.ResultsNine CSSPs completed the EVCT and four the AVCT. All participants passed their certification examinations with scores ranging from 80% to 95%. The time to complete each programme averaged 6 months. After certification, clinical queries raised by EVCT trainees averaged 1.2 per session but dropped by 75% to 0.3 per session in the AVCT group, indicating greater confidence and independence in managing cases. Physician review of trainee-led cases led to additional tests or treatment changes in 23% of cases and referrals to physician clinics in 11%. Patient feedback was positive: 95% felt confident in the clinical scientists' knowledge, and 100% were satisfied with the clarity of their care plans and follow-up.ConclusionsThe implementation of this training and certification framework demonstrated enhanced clinical outcomes and care delivery in SVCs. By advocating for formal recognition and accreditation of valve clinic training, this framework could serve as a model for national and international standardisation in valve care and clinical training.

In the current issue of Open Heart, the study by Butler and colleagues completed a much-needed investigation that provides valuable insights into the risk of developing incident myocarditis in the general population following COVID-19 or influenza infection.

ObjectiveMost patients who have an implantable cardioverter-defibrillator (ICD) implant do not receive life-prolonging therapy from it. Little research has been undertaken to determine which patients benefit the least from ICD therapy. As patients age and accumulate comorbidities, the risk of death increases and the benefit of ICDs diminishes. We sought to evaluate the impact of comorbidity, frailty, functional status on death with no prior appropriate ICD therapy.MethodsA prospective, multicentre, observational study involving 12 English hospitals was undertaken. Patients were eligible for inclusion for the study if they were scheduled to have a de novo, upgrade to or replacement of a transvenous or subcutaneous ICD or cardiac resynchronisation therapy device and defibrillator (CRT-D). Baseline characteristics were collected. Participants were asked to complete a frailty assessment (Fried score) and a functional status questionnaire (EuroQol 5-Dimension 5-Level (EQ-5D-5L)). The Charlson Comorbidity Index was calculated. Patients were prospectively followed up for 2.5 years. The primary outcome was death with no prior appropriate therapy.ResultsIn total, 675 patients were enrolled, mean age 65.7 (IQR 65–75) years. A total of 63 patients (9.5%) died during follow-up, 58 without receiving appropriate ICD therapy. Frailty was present in 86/675 (12.7%) and severe comorbidity in 69/675 (10.2%). Multivariate predictors of death with no appropriate therapy were identified and a risk score comprising frailty, comorbidity, increasing age, estimated glomerular filtration rate and EQ-5D-5L was developed.ConclusionComorbidities, frailty and the EQ-5D-5L score are powerful, independent predictors of death with no prior appropriate therapy in ICD/CRT-D recipients.

BackgroundThe COVID-19 pandemic disrupted cardiovascular disease management in primary care in England.ObjectiveTo describe the impact of the pandemic on blood pressure screening and hypertension management based on a national quality of care scheme (Quality and Outcomes Framework, QOF) across key demographic, regional and clinical subgroups.MethodsWith NHS England approval, a population-based cohort study was conducted using OpenSAFELY-TPP on 25.2 million NHS patients registered at general practices (March 2019 to March 2023). We examined monthly changes in recorded blood pressure screening in the preceding 5 years in patients aged ≥45 years and recorded the hypertension prevalence and the percentage of patients treated to target (≤140/90 mmHg for patients aged ≤79 years and ≤150/90 mmHg for patients aged ≥80 years) in the preceding 12 months.ResultsThe percentage of patients aged ≥45 years who had blood pressure screening recorded in the preceding 5 years decreased from 90% (March 2019) to 85% (March 2023). Recorded hypertension prevalence was relatively stable at 15% throughout the study period. The percentage of patients with a record of hypertension treated to target in the preceding 12 months reduced from a maximum of 71% (March 2020) to a minimum of 47% (February 2021) in patients aged ≤79 years and from 85% (March 2020) to a minimum of 58% (February 2021) in patients aged ≥80 years before recovery. Blood pressure screening rates in the preceding 5 years remained stable in older people, patients with recorded learning disability or care home status.ConclusionsThe pandemic substantially disrupted hypertension management QOF indicators, which is likely attributable to general reductions of blood pressure measurement including screening. OpenSAFELY can be used to continuously monitor changes in national quality-of-care schemes to identify changes in key clinical subgroups early and support prioritisation of recovery from care disrupted by COVID-19.

BackgroundIndividual variation in the need for healthcare constitutes knowledge gaps for young atrial fibrillation (AF) patients. We aimed to estimate the prevalence and primary care burden of early-onset AF in Norway, emphasising sex differences, in a nationwide healthcare database.MethodsWe used data from the Norwegian Control and Payment of Health Reimbursement database to identify all Norwegian residents ≥18 years of age registered with a primary care physician (PCP) in 2019, with onset of AF at ≤50 years of age (early-onset AF) in the period 2006–2019. From the accumulated number of early-onset AF cases among current residents, we calculated the prevalence in 2019. The group-level primary care burden was calculated as the total number of annual AF consultations divided by the annual number of AF patients (2014–2018), and individual burden as the mean number of consultations per AF patient per year within the study period. We analysed the distribution of AF consultations between PCP and primary care emergency room (ER) services in total and by sex.ResultsWe identified 10 925 Norwegian residents with early-onset AF in 2019 (26.3% women, mean age 48.4 years). The prevalence of early-onset AF was 0.34% (women: 0.19%, men: 0.50%). The early-onset AF population had on average one annual primary care consultation for AF. The individual burden of annual AF consultations varied widely; <1: 66% of women and 54% of men, (1–5]: 25% of women and 36% of men, (5–10]: 6% of women and 8% of men, ≥10: 2% of women and 2% of men. A higher proportion of men (71%) than women (38%) attended both PCP and ER services due to AF.ConclusionsThe study confirmed a low prevalence of early-onset AF, with substantial sex differences and individual variation in primary healthcare needs. Our results signal a need for a higher resolution with regard to age groups in future research on burden and sex differences in early-onset AF.

ObjectivePostoperative delirium (POD), especially after cardiac surgery with cardiopulmonary bypass (CPB), is a relatively common and severe complication increasing side effects, length of hospital stay, mortality and healthcare resource costs. This study aimed to determine the impact of using mannitol serum in the prime of CPB for preventing the occurrence of delirium in patients undergoing coronary artery bypass surgery.MethodsThis study is a single-centre, double-blinded, randomised, controlled trial that was conducted from December 2022 to May 2023. Patients in the age range of 18–70 who underwent elective coronary artery bypass surgery were included in the study. In the control group (n=45), the prime solution included Ringer’s lactate serum. In the intervention group (n=45), the prime solution consisted of 200 mL mannitol serum and Ringer’s lactate serum. The primary outcome of the study was the incidence of POD. Secondary outcomes included the duration of mechanical ventilation, length of stay in the intensive care unit (ICU) and 30-day in-hospital mortality.ResultsThere were no statistically significant differences in demographic characteristics and risk factors between the control and intervention groups (p<0.05). However, the incidence of POD was significantly lower in the intervention group compared with the control group (22.25% vs 42.2%, p=0.035). There were no significant differences between the two groups regarding CPB time, aortic cross-clamp time, duration of mechanical ventilation and length of stay in ICU (p<0.05). Additionally, mortality rates and rates of return to the operating room did not differ significantly between the two groups (p<0.05).ConclusionsThis study concluded that adding mannitol to the prime of CPB pump can help reduce the incidence of delirium after cardiac surgery.Trial registration numberIRCT20221129056660N1.

Background and aimIncreased mortality during the COVID-19 pandemic is not explained exclusively by COVID-19 infection and its complications. We analysed non-COVID-19 causes of mortality in a population analysis based on data from the Spanish National Institute of Statistics.MethodsUsing monthly mortality data in Spain (January 2010–December 2020), we analysed deaths associated with cancer, blood, endocrine, mental, nervous, cardiovascular, respiratory and digestive diseases and explored the COVID-19 impact using a difference-in-difference strategy. We calculated monthly interannual variations in mortality and computed percentage change in terms of the log of deaths in month h of year t minus the log of deaths in month h in the previous year t−1.ResultsIn 2020 in Spain, mortality increased 17.9% compared with 2019. COVID-19 was the leading cause of death (n=60 358), followed by ischaemic heart disease (n=29 654). Throughout 2020, monthly interannual variations in cardiovascular mortality showed an average upward trend of 1.7%, while digestive, cancer and blood diseases showed a downward trend.ConclusionsDuring the COVID-19 pandemic in Spain in 2020, excess mortality was primarily related to cardiovascular mortality while mortality associated with digestive, cancer and blood diseases was reduced.

ObjectiveImplantable loop recorders (ILRs) are increasingly used for long-term rhythm monitoring after ischaemic and cryptogenic stroke, with the goal of detecting atrial fibrillation (AF) and subsequent initiation of oral anticoagulation to reduce risk of adverse clinical outcomes. There is a need to determine the effectiveness of different rhythm monitoring strategies in this context.MethodsWe conducted a retrospective cohort analysis of individuals with commercial and Medicare Advantage insurance in Optum Labs Data Warehouse who had incident ischaemic or cryptogenic stroke and no prior cardiovascular implantable electronic device from 1 January 2016 to 30 June 2021. Patients were stratified by rhythm monitoring strategy: ILR, long-term continuous external cardiac monitor (>48 hours to 30 days) or Holter monitor (≤48 hours). The primary outcome was risk-adjusted all-cause mortality at 12 months. Secondary outcomes included new diagnosis of AF and oral anticoagulation, bleeding, and costs.ResultsAmong 48 901 patients with ischaemic or cryptogenic stroke, 9235 received an ILR, 29 103 long-term continuous external monitor and 10 563 Holter monitor only. Mean age was 69.9 (SD 11.9) years and 53.5% were female. During the 12-month follow-up period, patients who received ILRs compared with those who received long-term continuous external monitors had a higher odds of new diagnosis of AF and oral anticoagulant initiation (adjusted OR 2.27, 95% CI 2.09 to 2.48). Compared with patients who received long-term continuous external monitors, those who received ILRs had similar 12-month mortality (HR 1.00; 95% CI 0.89 to 1.12), with approximately $13 000 higher costs at baseline (including monitor cost) and $2500 higher costs during 12-month follow-up.ConclusionsIn this large real-world study of patients with ischaemic or cryptogenic stroke, ILR placement resulted in more diagnosis of AF and initiation of oral anticoagulation, but no difference in mortality compared with long-term continuous external monitors.