Cardiovascular

Introduction

Small vessel disease (SVD) lesions may cause symptoms apart from stroke. We aimed to determine whether white matter hyperintensity (WMH) progression and incident infarcts associate with gait, mood, and cognitive symptoms.

Method

We recruited patients with non-disabling stroke (modified Rankin Scale <3), performed diagnostic MRI, and questioned participants/informants about gait, mood, cognitive, Center Epidemiologic Studies-Depression Scale (CES-D), Neuropsychiatric Inventory-Questionnaire (NPI-Q) symptoms and Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE).

The baseline visit occurred < 3months post-stroke. We repeated MRI and symptoms assessments every 3-6 months for 12 months, assessing WMH change and incident infarcts (i.e. new since previous scan) on DWI or FLAIR. We analysed WMH using cubed root normalised for intracranial volume. We used linear mixed-effects models, adjusting for age, gait speed, modified Rankin Scale, and time for gait symptoms; age, anxiety, MoCA, stroke subtype, and time for cognitive/neuropsychiatric symptoms. 

Results

We recruited 230 participants (mean age=65.8 [SD=11.2] years; 34% female; 56.5% lacunar); median baseline WMH volumes = 8.26mL (IQR 3.65-19.0); one-year = 8.24mL (IQR = 4.15-20.1). Incident infarcts (n=110, 82/110 (74.5%) small subcortical subtype) occurred in 53/230 (23%) of patients.

WMH progression over one year was associated with falls (OR=4.13 [95% CI=1.6-10.1]); self-reported brain fog (OR=3.13 [95% CI=1.11-8.82]); and increasing NPI-Q scores (est=2.12 [95% CI=0.46-3.77] p=0.012). Baseline and one-year WMH volumes were cross-sectionally associated with apathy (baseline OR=8.78 [95% CI=2.56-31.88]; one-year OR=4.83 [95% CI=1.43-17.26]).

Higher CES-D depression scores were associated with incident infarcts (mean 15.2 [12.9] with vs 11.9 [SD10.6] without; est=2.26 (95% CI=0.12-4.4), p=0.038). WMH progression and infarcts were not associated with fatigue, anxiety, subjective memory complaints, confusion, dizziness, or IQCODE scores.

Conclusions

SVD progression following minor stroke co-associates with specific gait/cognitive/mood symptoms. WMH progression and incident infarcts may cause non-focal, non-stroke symptoms which characterise a potential ‘SVD syndrome’.

Introduction

Recent trials like ASCEND, ASPREE, and ARRIVE emphasise the limited efficacy of aspirin in primary cardiovascular prevention and its associated increased bleeding risk, particularly in the elderly. Consequently, the Screening Tool of Older Persons’ Prescriptions (STOPP) criteria does not recommend aspirin treatment for primary cardiovascular prevention in any case. This study aimed to determine the prevalence of inappropriate aspirin use among elderly patients admitted within our department and our ability to correctly identify and discontinue its use.

Methods

Patients aged over 65 years admitted under our team between August-October 2023 were identified retrospectively from our electronic medical record. Inclusion criteria were those admitted on aspirin, while exclusion criteria were incomplete records or in-hospital deaths. Discharge summaries were reviewed to determine if aspirin prescribed for primary prevention was stopped or flagged to GP for review. The secondary outcome assessed statin prescriptions for primary cardiovascular prevention. Data concerning age, sex, and cardiovascular history was extracted.

Results

67 patients were admitted under our team. The mean age was 81.4 years (SD 9.3). There were 27 males (40.3%) and 40 females (59.7%). 18 (26.9%) patients were diagnosed with ischaemic heart disease; 11 (16.4%) had a previous myocardial infarction; 19 (28.3%) had a prior transient ischaemic attack or stroke and 8 (11.9%) patients had previously undergone coronary revascularization. 14 (20.9%) patients were taking aspirin, in which 5 (35.7%) were prescribed for primary prevention, yet none were discontinued or flagged to GP for review.10 patients (14.9%) received statins for primary prevention, with a 90% adherence to the STOPP criteria.

Conclusion

Despite limited evidence, our analysis found a large proportion of patients from our team were discharged on aspirin for primary prevention. However, adherence to STOPP criteria for statin prescriptions was high. Consequently, we are developing a proforma to assist physicians in discerning inappropriate aspirin prescriptions.

Abstract Content - 'The number of patients being diagnosed with Heart Failure (HF) on a global scale continues to rise, placing a huge strain on the National Health Service (NHS). Caring for patients with HF comes with huge cost implications and exacerbates an already growing economic burden for healthcare systems. HF care needs to be standardised and integrated if we are to provide optimal care. Evidence shows that there is potential to improve the detection, diagnosis and management of HF care through innovative care pathways when delivered consistently through strong leadership and collaborative working. A care pathway for clinical nurse assessors was developed and implemented to guide and steer HF care within an 'Out of Hospital' clinical team; create a streamlined process to move patients with HF from one service to another; and encourage collaborative working amongst HF services. In addition, weekly HF MDT meetings were introduced in an attempt to reduce hospital admissions.

The Model for Improvement Framework was used to provide structure and support the change management, along with the RE-AIM Framework which facilitated the implementation of this pathway and supported the translation of this project into practice. 

Following the introduction of the care pathway, comparative data was analysed and the results showed that first line steps in the diagnostic pathway were being carried out quicker in patients presenting with HF symptoms, the time taken to refer on to cardiology services was significantly quicker, and all patients presenting with HF symptoms had a BNP blood test carried out on initial assessment. In addition, the length of time patients remained on the 'Out of Hospital' caseload and the number of hospital admissions were significantly reduced. The results also showed that the majority of patients on the pathway were treated in the comfort of their own homes and the number of patients referred to cardiac rehabilitation had vastly improved.  

To conclude - integrated care pathways together with high level government strategies are vital in the re-organisation of HF care and the standardisation of interconnected guideline-based care and management. Implementing a HF care pathway not only streamlined care for patients diagnosed with HF within the community setting but it had a positive impact on patient outcomes, quality of life and hospital admission rates. The pathway provided clinical nurse assessors within the 'Out of Hospital' team with a structured and standardised approach to HF care and having regular HF MDT meetings significantly improved the outcomes of people living with HF, as complex cases could be managed quicker and more effectively and hospital admissions could be avoided. Communication channels and relationship building between specialist services were also enhanced as a result of the pathway. 

Introduction: Orthostatic Hypotension is a significant cause of falls leading to injury and morbidity in elderly population. In an online survey by Royal College of Physicians (RCP) 271 out of 316 clinicians routinely performed these measurements and there were significant variations in how lying and standing BP is performed. This could have adverse effects on detection rates and accuracy of the procedure resulting in misdiagnosis. As a result, RCP has released guidance on L/S BP2 measurements in view of standardising practice and improving accuracy. The purpose of this QIP is to improve how L/S BP is measured and documented, by introducing poster on wards and re-audit the improvement in the correct method of measuring L/S BP.

Methods: Ward staff are audited to find out whether LS BP is measured as per RCP guidelines. Afterwards a poster of RCP recommended method of measuring LS BP are placed on ward and given to participants. The procedure of L/S BP measurement is re-audited after the intervention to find out changes in performing L/S BP (as per RCP guidelines).

Results: • 20% staff were aware of RCP guidelines on L/S BP procedure (90% after intervention). • 0-15% staff had formal training on how to measure L/S BP. • Over three times improvement in the method of procedure (20% to 65% after intervention). • 25% staff were documenting symptoms (improved to 85% after intervention). • 10% of staff knew how to interpret a positive result, improved to 60% after intervention.

Conclusion: • Staff education improves L/S BP Procedure, documentation and interpretation, it also helped raise staff awareness of the RCP guidelines and how to access them.

Introduction: Orthostatic Hypotension is a significant cause of falls leading to injury and morbidity in elderly population. In an online survey by Royal College of Physicians (RCP) 271 out of 316 clinicians routinely performed these measurements and there were significant variations in how lying and standing BP is performed. This could have adverse effects on detection rates and accuracy of the procedure resulting in misdiagnosis. As a result, RCP has released guidance on L/S BP2 measurements in view of standardising practice and improving accuracy. The purpose of this QIP is to improve how L/S BP is measured and documented, by introducing poster on wards and re-audit the improvement in the correct method of measuring L/S BP.

Methods: Ward staff are audited to find out whether LS BP is measured as per RCP guidelines. Afterwards a poster of RCP recommended method of measuring LS BP are placed on ward and given to participants. The procedure of L/S BP measurement is re-audited after the intervention to find out changes in performing L/S BP (as per RCP guidelines).

Results: • 20% staff were aware of RCP guidelines on L/S BP procedure (90% after intervention). • 0-15% staff had formal training on how to measure L/S BP. • Over three times improvement in the method of procedure (20% to 65% after intervention). • 25% staff were documenting symptoms (improved to 85% after intervention). • 10% of staff knew how to interpret a positive result, improved to 60% after intervention.

Conclusion: • Staff education improves L/S BP Procedure, documentation and interpretation, it also helped raise staff awareness of the RCP guidelines and how to access them.

TITLE: Improving the Practice of Measuring Lying and Standing Blood Pressure Among Nursing Staff at a District General Hospital

INTRODUCTION: 

Postural hypotension is a significant cause of morbidity in the frail and older population, contributing to falls and related injuries. Accurate measurement of lying and standing blood pressure (LSBP) is essential for identifying patients at risk. This quality improvement project (QIP) aimed to address gaps in LSBP measurement practices among nursing staff by aligning them with Royal College of Physicians (RCP) guidelines. The project sought to raise awareness and improve the accuracy of these measurements, thereby enhancing patient care and safety.

METHODS:

Baseline data was collected from patient notes to assess the accuracy of documented LSBP readings. Additionally, a survey was conducted to evaluate nursing staff’s knowledge of postural hypotension and their interest in further education on the topic. In response, RCP posters detailing correct LSBP measurement techniques were displayed across the wards. Information about these resources was disseminated among the Geriatrics Department, including nurses, junior doctors, registrars, and consultants, and introduced during junior doctors' teaching sessions. To reinforce the practice, placards with measurement reminders were attached to all observation machines. Awareness sessions were concurrently conducted during PDSA cycles to ensure continuous staff engagement and understanding.

RESULTS:

Following two intervention cycles, there was a 50% increase in adherence to the standing BP measurement protocol. Pre-intervention, 66% of respondents were aware of the correct LSBP measurement process, which increased to 100% post-intervention. Additionally, 83% reported knowing where to access further resources on postural hypotension, compared to 44% pre-intervention levels.

CONCLUSION:

The sustained improvement in LSBP measurement compliance demonstrates the effectiveness of multi-faceted interventions, including education, visual prompts, and training. These efforts have facilitated a culture shift in patient management and are expected to improve patient outcomes.

The introduction of a standardised documentation proforma for LSBP measurement is anticipated to further support long-term improvements in this practice.

Background Royal Bolton Hospital is a district general hospital in Greater Manchester. In 2023, a Cardiogeriatrics service was introduced to deliver comprehensive geriatric assessment for older cardiology inpatients with frailty.

Introduction

Our aim was to evaluate the Cardiogeriatrics service with respect to the impact on end of life care for older cardiology inpatients.

Methods

Audit standards were defined using metrics for quality in end of life care. All patients between the year 2021 and 2024 aged 75 and over who died as an inpatient or within 30 days of discharge were included. Patients who died following procedural interventions were excluded. Patient’s casenotes were audited and compared before and after the initiation of the service.

Results

Casenotes for 88 inpatient deaths were audited (66 prior to introduction of the Cardiogeriatric service, 22 following). The Cardiogeriatrician initiated end of life care in 31.6% of inpatient deaths. This corresponded with a reduction in unexpected deaths from 26% to 14%, and a reduction in patients initiated on end of life care by the on-call team, from 31.8% to 10.5%. Junior doctors on Cardiology began to initiate resuscitation conversations with patients. Casenotes for 44 deaths within 30 days of discharge were audited, however no meaningful insight could be gained as there were only 6 outpatient deaths after the Cardiogeriatric service began.

Conclusion

After introduction of the Cardiogeriatrics service, there was improved recognition of patients who were approaching end of life, and more proactive management of this. As many patients audited were not seen directly by the Cardiogeriatrician, we believe the service has contributed to a cultural change in the Cardiology team more widely towards more proactive recognition and management of end of life issues in older Cardiology patients.

Introduction

Thomas Sydenham, English physician stated, “a man is as old as his arteries”. Chronological age has been noted to correlate strongly with vascular/ biological age. However, little is known about how chronological and vascular parameters of ageing, correlate with frailty. In this study, we sought to study the correlations between frailty, chronological age and parameters of vascular ageing.

Methods

Data from two studies with participants aged ≥ 60years investigating the associations between Cytomegalovirus infection and frailty indices and vascular parameters were included. Two hundred and sixty community dwelling adults were enrolled in both studies. Vascular parameters were measured by cardio-ankle vascular index (CAVI) using VaSera VS-2000® and pulse wave velocity-PWV (carotid-femoral and carotid-radial) using COMPLIOR®. Hand grip strength (HGS) and Charlson co-morbidity index (CCI) were measured for clinical frailty data. Patients were excluded if they had malignancy, were on active treatment for cancer or were unable to give consent.

Results

There were 260 study participants, (mean age ± SD; 72 ± 8years), with gender distribution M:F (50:50). Chronological age strongly correlated positively with vascular ageing parameters such as CAVI (r=0.6, p<0.001) and cf-PWV(r=0.5, p<0.01). Similarly, chronological age correlated positively with CCI (r=0.7, p˂0.001) and negatively with HGS (r= - 0.3, p˂0.001). Vascular ageing as measured by CAVI (estimated CAVI age) correlated positively with CCI (r=0.5, p<0.01) and negatively with HGS (r = -0.2, p=0.01). Other measures of vascular ageing such as cf-PWV positively correlated with CCI (r= 0.4, p<0.01) and negatively with HGS (r=- 0.1, p =0.09).

Conclusion

Clinical frailty parameters correlate strongly with measures of vascular ageing and chronological age. Vascular ageing is a strong independent predictor of frailty.

Background and aims

Delirium carries an eightfold risk of future dementia. Small vessel disease (SVD), best seen on MRI, increases delirium risk, yet delirium is understudied in MRI research. We aimed to determine MRI feasibility, tolerability, image usability, and prevalence of acute and chronic SVD lesions in acute delirium.

Methods

This case-control feasibility study performed MRI (3D T1/T2-weighted, FLAIR, Susceptibility-weighted, and Diffusion-weighted imaging (DWI) on 20 medical inpatients >65 years: 10 with delirium ≥3 weeks and 10 without delirium, matched for vascular risk, Clinical Frailty Scale (CFS), and cognitive status. We excluded acute stroke, agitation necessitating sedation, assistance of >2 staff to mobilise, and MRI contraindications. We measured scan duration, tolerability, image usability, acute infarcts on DWI, and chronic SVD features. Six months later, we recorded CFS and cognitive diagnoses.

Results

Mean age was 83.5 years (delirium 78.7 vs non-delirium 88.4); 13/20 were female; 17/20 had premorbid cognitive decline/impairment or dementia. Acquisition took mean 26.8 minutes. MRI was well-tolerated in 16/20 (7/10 in delirium arm; 9/10 in non-delirium arm). 4/20 had early scan termination but 20/20 had clinically interpretable images. We detected DWI-hyperintense lesions in 3/10 (33.3%) with delirium (2/10 small subcortical and 1/10 cortical) and in 3/10 (33.3%) without delirium (2/10 small subcortical; 1/10 cortical). Mean SVD score was 2.4 in delirium vs 3.3 without.

Conclusions

MRI is feasible, usable, and tolerable in delirium, and we detected DWI hyperintense lesions in one third of patients overall. This study indicates acute vascular contributions, including SVD, to delirium, supporting the need for larger studies.

Introduction:

It is expected that by the fourth decade of the 21st century, chronic obstructive pulmonary disease (COPD) will become the third leading cause of death worldwide. These data require awareness among treating physicians of these patients. 

Material and Methods:

A pilot study was conducted from January 2020 - December 2022 in a South American health institution in which cardiovascular risk was estimated using GLOBORISK and ATP-III criteria. Data derived from the metabolic profile included in the ATP-III criteria were collected. Quantitative variables are presented as mean ± standard deviation or median (interquartile range) according to their distribution and qualitative variables as percentages. Student's t-test was performed to evaluate differences between two variables. All statistical analyses were performed with (SPSS for Windows, v.22.1; Chicago, IL).

Results:

The present study showed that metabolic syndrome variables in these patients were elevated. Male sex was 77% and female 23%, smoking 61%. The GLOBORISK equation found mostly patients with low to moderate cardiovascular risk. It was found that there was a higher cardiovascular risk in those patients with FEV1 less than 30%, showing a statistical correlation of this alteration for the GLOBORISK scale.

Conclusions:

This is the first pilot study that estimates cardiovascular risk using GLOBORISK in the COPD population. We consider integrating national and international networks to compare the results found here.