Prevention of sudden cardiac death with omega-3 fatty acids in patients with coronary heart disease: A meta-analysis of randomized controlled trials

Aim. To systematically review trials concerning the effects of omega-3 fatty acids on sudden cardiac death (SCD), cardiac death, and all-cause mortality in coronary heart disease (CHD) patients.

Methods. PubMed, Embase, and the Cochrane database (1966–2007) were searched. We identified randomized controlled trials that compared dietary or supplementary intake of omega-3 fatty acids with control diet or placebo in CHD patients. Eligible studies had at least 6 months of follow-up data, and cited SCD as an end-point. Two reviewers independently assessed methodological quality. Meta-analysis of relative risk was carried out using the random effect model.

Results. Eight trials were identified, comprising 20,997 patients. In patients with prior myocardial infarction (MI), omega-3 fatty acids reduced relative risk (RR) of SCD (RR = 0.43; 95% CI: 0.20–0.91). In patients with angina, omega-3 fatty acids increased RR of SCD (RR = 1.39; 95% CI: 1.01–1.92). Overall, RR for cardiac death and all-cause mortality were 0.71 (95% CI: 0.50–1.00) and 0.77 (95% CI: 0.58–1.01), respectively.

Conclusions. Dietary supplementation with omega-3 fatty acids reduces the incidence of sudden cardiac death in patients with MI, but may have adverse effects in angina patients.     

Feasibility of Out-of-Hospital Cardiac Arrest Ultrasound by EMS Physicians

Introduction: Point-of-care ultrasound (POCUS) has been suggested as a useful tool to predict survival and guide interventions in out-of-hospital cardiac arrest (OHCA). While POCUS has been deployed in prehospital settings, a minimal amount of data exists on prehospital use, particularly by personnel with limited ultrasound experience. We aimed to characterize the feasibility and barriers to prehospital POCUS during OHCA by emergency medicine services (EMS) physicians in training. Methods: We deployed the SonoSite iViz portable ultrasound device for use by EMS physicians for OHCA in an urban EMS system. All physicians received POCUS education as part of their graduate medical training and were provided an instructional video on use of the SonoSite iViz device. POCUS use was limited to identifying cardiac motion during pulse checks, without interrupting resuscitation, and the results could be used to supplement management at the physicians’ discretion. Data were recorded prospectively by saving images on the device and through a custom electronic form within the patient care report. The primary measure was the frequency of use of POCUS during OHCA. Secondarily, we characterized agreement by expert (ultrasound fellowship trained) faculty (using a kappa statistic) and identified reported barriers to the use of prehospital POCUS. Results: From November 2016 to March 2017, 348 physician field responses were reviewed, including 127 cases of OHCA. There were 106 patients remaining in arrest on physician arrival, with 56 (52.8%) cases of POCUS use. Still or video images were recorded in 48 cases; video in 34 cases. From video images, agreement in identifying cardiac motion between the EMS physician and expert reviewer occurred in 91% of cases (K?=?0.82). Reasons cited for not using POCUS included return of circulation soon before or after arrival, prioritizing clinical interventions, not having the ultrasound device, mechanical failure, and cessation of resuscitation per advanced directives. Conclusion: Use of POCUS by EMS physicians to detect cardiac activity in OHCA is feasible and correlates with expert interpretation. Several avoidable barriers were identified and should be considered in the future implementation of prehospital POCUS. Larger studies are needed to determine what role POCUS may play in prehospital cardiac arrest management.     

Thermogenic Supplement Use Does Not Alter Characteristics of Sudden Death in the Young

Background: To evaluate supplement use, most notably ephedra, which has been temporally associated with sudden death. Animal models suggest increased myocardial irritability may predispose to primary arrhythmic death. Methods: Clinical, pathological, and investigative records from the Office of the Armed Forces Medical Examiner's Cardiovascular Death Registry were reviewed. Forty‐eight cases of those with known supplement use were compared to 144 age‐, gender‐, and socioeconomic‐matched controls in a 1:3 case:control manner. Results: Of the 48 sudden deaths temporally associated with supplement use, the mean age was 34.2 ± 10.0 years and predominantly male (n = 44, 91.7%). The underlying cause of death was fatal atherosclerotic coronary disease in 18 (37.5%), sudden unexplained death in 16 (33.3%), and hypertrophic cardiomyopathy in six (12.5%). Compared with controls, there were no statistically significant differences in adjudicated cause of death. On autopsy, there were no differences in cardiac mass, ventricular wall thickness, or presence of atherosclerosis in those known to be taking identified supplements compared to a control population. In the subject ≥35 years, and known to be taking supplements, there was a significant increase in causality of death as due to sudden unexplained death (relative risk = 5.1 [95% confidence interval, 1.4–18.7]). Conclusions: Active surveillance of mortality in an autopsy‐derived series of young adults finds atherosclerotic coronary disease and idiopathic sudden death are common etiologies of death when taking supplements, but no cardiac structural or histologic mechanism to suggest different pathologic process than a matched control population. (PACE 2012; 35:1332–1337)     

Right Ventricular Dysfunction and the Incidence of Implantable Cardioverter‐Defibrillator Therapies

Introduction: Implantable cardioverter‐defibrillator (ICD) therapy is well established in preventing sudden cardiac death in patients with left ventricular dysfunction. The influence of right ventricular (RV) function on ICD therapy for sudden cardiac death (SCD) is not known. Methods: We retrospectively studied 222 patients receiving an ICD for primary prevention of SCD. Baseline clinical and echocardiographic data were gathered. RV systolic function was qualitatively assessed as normal or abnormal (described as mildly, moderately, or severely reduced). Primary endpoint was combined ICD therapy or death and secondary endpoint was ICD therapy alone. Results: The mean follow‐up was 940 ± 522 days. The mean left ventricular ejection fraction was 0.23 ± 0.07. By Kaplan‐Meier analysis, RV dysfunction was predictive of combined ICD therapy or death when comparing between normal and abnormal RV function (P = 0.008) and among qualitative ranges of RV function (P = 0.012). RV dysfunction was not predictive of ICD therapy alone with either type of classification. After adjusting for clinical covariates, severe RV dysfunction was predictive of the combined endpoint of ICD therapy or death (HR 2.02, 95% CI 1.04–3.92, P = 0.037). Conclusion: Severe RV dysfunction appears to be an independent predictor of the combined endpoint of ICD therapy or death. RV dysfunction does not reliably predict the incidence of ICD therapy alone.     

Novel spectral indexes of heart rate variability as predictors of sudden and non‐sudden cardiac death after an acute myocardial infarction

Background. Various indexes of 24‐hour heart rate variability (HRV) have been able to predict all‐cause mortality after an acute myocardial infarction (AMI), but their value in predicting specific modes of cardiac death has been limited.

Aim. The aim of this study was to assess the role of two novel spectral indexes of HRV as predictors of either sudden (SCD) or non‐sudden cardiac death after an AMI.

Method. We used two novel methods of spectral analysis of HRV: 1) the high‐frequency (HF) spectral component, V_index, calculated as an average HF power from the most linear portion of HF power versus the R‐R interval regression curve, and 2) the prevalent low‐frequency oscillation of heart rate (PLF). V_index, conventional HRV measures, and PLF were analyzed from 24‐hour Holter recordings of 590 patients with a recent AMI.

Results. During the mean follow‐up of 39±14 months, SCD occurred in 3% (n = 17) and non‐sudden cardiac death in 5% (n = 28) of the patients. In univariate analysis, V_index was the most potent predictor of SCD (RR: 6.0, 95% CI: 1.7–20.7, P<0.01), also remaining the most powerful predictor of SCD after adjustment for clinical variables and ejection fraction (RR: 4.2, 95% CI: 1.2–15.2, P<0.05). PLF was a potent predictor of non‐sudden cardiac death (RR: 13.9, 95% CI: 5.9–32.5, P<0.001), but it did not predict SCD.

Conclusions. Novel spectral HRV analysis methods, V_index and PLF, provide significant information of the risk of the specific mode of death after an AMI.     

Use of the Wearable External Cardiac Defibrillator in Children

Background: The wearable cardiac defibrillator (WCD) is an alternative to the implantation of cardioverter defibrillator (ICD) for patients at risk for sudden death who do not fulfill standard criteria for ICD implantation or in whom the risk:benefit ratio is equivocal. Published data pertaining to the WCD in children is sparse. We describe the utility of the WCD in children at a single tertiary care center. Methods: We retrospectively identified all patients aged birth to 18 years of age who were prescribed a WCD between January 1, 2007, and June 30, 2009. Patient information regarding diagnosis, clinical history, electrocardiograms, rhythm reports, and outcome at last follow‐up was reviewed. Information regarding the WCD was obtained including indication for use, patient compliance, and accuracy of rhythm determination, inappropriate and appropriate shock events, and other complications. Results: Since 2007, four patients age less than or equal to 18 years have been prescribed the WCD at our institution. None of the patients had an inappropriate shock. Two patients had documented noncompliance with wear, which resulted in failure to detect and treat a life‐threatening arrhythmia in one. Two patients required downsizing of the WCD during use in order to improve electrode contact and rhythm detection. Conclusions: The WCD is an option for children of appropriate size who are at increased risk for sudden cardiac death, but in whom the risk of ICD implantation outweighs the benefit. Careful patient selection and education is important to ensure safety, as noncompliance with wear was common in this series of children. (PACE 2010; 33:742–746)     

Nurse and Physician Perceptions of Working With Goal-Directed Therapy in the Perioperative Period

PurposeTo explore nurse and physician perceptions of working with and collaborating about arterial wave analysis for goal-directed therapy to identify barriers and facilitators for use in anesthesia departments, postanesthesia care units, and intensive care units.DesignA qualitative study drawing on ethnographic principles in a field study using the technique of nonparticipating observation and semistructured interviews.MethodsData collection occurred using semistructured interviews with nurses (n = 23) and physicians (n = 12) and field observations in three anesthetic departments. An inductive approach for content analysis was used.FindingsThe results showed one overarching theme Interprofessional collaboration encourage and impede based on three categories: (1) interprofessional and professional challenges; (2) obtaining competencies; and (3) understanding optimal fluid treatment.ConclusionsSeveral barriers identified related to interprofessional collaboration. Nurses and physicians were dependent on each other's skills and capabilities to use arterial wave analysis. Education of nurses and physicians is important to secure optimal use of goal-directed therapy.     

Adolescents with implantable cardioverter defibrillators: a patient and parent perspective

Background: An implantable cardioverter defibrillator (ICD) is a device used in the treatment of individuals with life‐threatening cardiac conditions. These include genetic disorders such as long QT syndrome, hypertrophic cardiomyopathy, and Brugada syndrome, all of which have the propensity to cause sudden cardiac death. Adults with ICDs consistently report elevated levels of anxiety and depression, as well as negative lifestyle changes associated with the device. Compared to older ICD recipients, young patients face decades of life with the device and the long‐term impact and implications are important to consider. This research explores the experiences of adolescents living with an ICD. Parents of these adolescents were also included to explore the impact on them as the primary caregivers. Methods: A qualitative approach was chosen to explore the lived experience; semistructured interviews with six adolescents and six parents were conducted from which a number of key themes emerged. Results: The experiences described by participants included the restrictions adolescents face, the ICD shock experience, and ongoing challenges post‐ICD implantation. However, both adolescents and parents were able to adjust to life after receiving an ICD and described several benefits associated with having the device. Findings also emerged relating to communication between health professionals and adolescents, and the limitations adolescents impose on themselves post‐ICD implantation. Conclusion: These findings have important implications for clinical practice and may help guide medical management for adolescents with ICDs and their families. (PACE 2012; 35:62–72)     

我国大中城市院前心脏性猝死流行病学调查分析

目的调查我国大中城市院前心脏性猝死患者流行病学情况,探讨院前心脏性猝死病例特点。方法从我国8个大中城市急救中心系统数据库中导出2008年度全部死亡数据,就其有完整记录的资料进行统计分析。结果①院前心脏性猝死的调度时间、到达时间、现场时间、返回时间、总时间、急救半径分别为（2．12±1．02）min、（14．10±7．05）min、（24．79±12．08）min、（13．79±6．61）min、（54．80±25．36）min、7．90±3．92（km）;②院前心脏性猝死的病例数以第一季度为最多,且最多时间段是8：00～10：00,最少时间段是2：00～4：00;③男性院前心脏性猝死明显多于女性,但年龄明显小于女性;④院前心脏性猝死目击者CPR为4．48％,医护人员现场CPR成功率2．26％。结论①心脏性猝死已成为我国大中城市最常见的院前死亡原因;②加强心血管病防治,提高中老年患者的常见急危重症早期识别与院前急救水平以及普及公众CPR对降低死亡有重要意义。     

Accessibility of Medical Diagnostic Equipment for Patients With Disability: Observations From Physicians

ObjectiveTo explore attitudes and practices of physicians relating to accessible medical diagnostic equipment in serving patients with mobility disability.DesignOpen-ended individual telephone interviews, which reached data saturation. Interview recordings were transcribed verbatim for qualitative conventional content analysis.SettingMassachusetts, the United States, October 2017-January 2018.ParticipantsPracticing physicians from 5 clinical specialties (N=20).InterventionsNot applicable.Main Outcome MeasuresCommon themes concerning physical accessibility.ResultsMean ± SD time in practice was 27.5±12.5 years; 14 practices had height-adjustable examination tables; and 7 had wheelchair-accessible weight scales. The analysis identified 6 broad themes: height-adjustable examination tables have advantages; height-adjustable examination tables have drawbacks; transferring patients onto examination tables is challenging; rationale for examining patients in their wheelchairs; perceptions of wheelchair-accessible weight scales; and barriers and facilitators to improving physical accessibility. Major barriers identified by participants included costs of equipment, limited space, and inadequate payment for extra time required to care for persons with disability. Even physicians with accessible examination tables sometimes examined patients seated in their wheelchairs.ConclusionsEven if physicians have accessible equipment, they do not always use it in examining patients with disability. Future efforts will need to consider ways to eliminate these access barriers in clinical practice. Given small sample size, results are not generalizable to physicians nationwide and globally.     

Useful but Different: Resident Physician Perceptions of Interprofessional Feedback

Phenomenon: Based on recently formulated interprofessional core competencies, physicians are expected to incorporate feedback from other healthcare professionals. Based on social identity theory, physicians likely differentiate between feedback from members of their own profession and others. The current study examined residents' experiences with, and perceptions of, interprofessional feedback. Approach: In 2013, Anesthesia, Obstetrics-Gynecology, Pediatrics, and Psychiatry residents completed a survey including questions about frequency of feedback from different professionals and its perceived value (5-point scale). The authors performed an analysis of variance to examine interactions between residency program and profession of feedback provider. They conducted follow-up interviews with a subset of residents to explore reasons for residents' survey ratings. Findings: Fifty-two percent (131/254) of residents completed the survey, and 15 participated in interviews. Eighty percent of residents reported receiving written feedback from physicians, 26% from nurses, and less than 10% from other professions. There was a significant interaction between residency program and feedback provider profession, F(21, 847) = 3.82, p < .001, and a significant main effect of feedback provider profession, F(7, 847) = 73.7, p < .001. On post hoc analyses, residents from all programs valued feedback from attending physicians higher than feedback from others, and anesthesia residents rated feedback from other professionals significantly lower than other residents. Ten major themes arose from qualitative data analysis, which revealed an overall positive attitude toward interprofessional feedback and clarified reasons behind residents' perceptions and identified barriers. Insights: Residents in our study reported limited exposure to interprofessional feedback and valued such feedback less than intraprofessional feedback. However, our data suggest opportunities exist for effective utilization of interprofessional feedback.     

Barriers to referral to inpatient palliative care units in Japan: a qualitative survey with content analysis

Objectives We investigated the barriers to referral to inpatient palliative care units (PCUs) through a qualitative study across various sources of information, including terminal cancer patients, their families, physicians, and nurses. Materials and methods There were 63 participants, including 13 advanced cancer patients, 10 family members, 20 physicians, and 20 nurses in palliative care and acute care cancer settings from five regional cancer institutes in Japan. Semi-structured interviews were conducted regarding barriers to referral to PCU, and data were analyzed by content analysis method. Results A total of 21 barriers were identified by content analysis. The leading barriers were (1) a negative image of PCUs by patients and families (n = 39), (2) delay of termination of anti-cancer treatment by physicians in the general wards (n = 24), (3) unwillingness to end anti-cancer treatment and denial of the fatal nature of the disease by patients and families (n = 22), (4) patient’s wish to receive care from familiar physicians and nurses (n = 20), and (5) insufficient knowledge of PCUs by medical staff in general wards (n = 17). Conclusions To correct these unfavorable images and misconceptions of PCUs, it is important to eliminate the negative image of PCUs from the general population, patients, families, and medical staffs. In addition, early introduction of palliative care options to patients and communication skills training regarding breaking bad news are relevant issues for a smooth transition from anti-cancer treatment to palliative care.     

Sudden cardiac death: the perspectives of Spanish survivors

Sudden cardiac death is an episode of sudden death from cardiac causes in previously healthy patients. The aim of this study was to investigate the life experiences of patients who were resuscitated successfully following a sudden cardiac death. Purposeful sampling was used to recruit the nine participants through the snowball technique. Unstructured interviews were carried out until data saturation was reached. The Giorgi method of analysis, which seeks to reduce the participant's experience to minimal thematic units, common thematic groups, and essential themes in order to describe it, was used. Four essential themes were found: "facing fear"; "the search for meaning"; "feeling death up close and personal"; and "loneliness and estrangement". Nurses must integrate the lifestyle changes of patients who survive a cardiac death in order to provide adequate care following hospital discharge. Patients should undertake follow-up programs in order to receive counseling from health professionals. As a result, the creation of interdisciplinary support groups and the implementation of follow-up programs after hospital discharge are fundamental. Survivors' experiences can inform the development of nursing programs and hospital follow-up services that address the survival of cardiac death.     

NAEMSP 2001 A NNUAL M EETING

Abstract

Recently, emphasis has been placed on the simultaneous implementation of resuscitation interventions currently recommended within the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). The rate of successful outcomes from out-of-hospital cardiac arrest remains relatively low in most U.S. communities. Accurate measures of these rates are difficult to determine because of ineffective reporting mechanisms. In many cases of acute myocardial infarction, the initial presentation of symptoms is quickly followed by sudden death. Little information exists regarding the system-of-care components most likely to result in successful outcomes. Inconsistent application of these components may be responsible in part for the variability of survival rates among communities. We present a case of acute myocardial infarction followed by sudden cardiac arrest benefiting from the application of coordinated, community-based systems of care.     

Impact of Language Barrier on Acute Care Medical Professionals Is Dependent Upon Role

Communication with patients is essential to providing quality medical care. The study was conducted to evaluate the effects of language barriers on health care professionals. It is hypothesized that these language barriers are commonly perceived by health care professionals and they are a source of workplace stress in acute care environments. We designed and distributed a survey tool of staff experiences and attitudes regarding the English-Spanish language barrier among patients in an acute care surgical environment of a tertiary medical center. Responses were anonymous, stratified by professional role and comparisons made using paired t tests. Sixty-one nurses and 36 physicians responded to the survey. Overall, 95% of nurses reported that the language barrier was an impediment to quality care, whereas 88% of physicians responded similarly (P = .0004). More nurses than physicians report experiencing stress (97% vs. 78%) and the degree of stress appears to be greater for nurses (P < .0001). The basis of stress was unique between the two groups. This study demonstrates that acute care hospital medical professionals perceive language barriers as an impediment to quality care delivery and as a source of workplace stress. Nurse and physician perceptions differ; therefore, strategies to address these language barriers should be specific to those professional roles. These barriers create a void in health care quality and safety that has effects on health care professionals.     

Perceived barriers and enablers for implementing water protocols in acute stroke care: A qualitative study using the Theoretical Domains Framework

Abstract

Purpose: To identify perceived enablers and barriers that may influence the implementation of water protocols (WPs) as an intervention for dysphagia in acute stroke settings.

Method: Semi-structured interviews were conducted with nine nurses, eight speech-language pathologists (SLPs), five doctors and four dietitians working in acute stroke units in a major city in Australia. Data were thematically analysed and themes were mapped to the Theoretical Domains Framework.

Result: Ten barriers and nine enablers were identified. Key barriers were: nurses lack oral care skills and agency nurses lack stroke-specific skills; only SLPs are perceived to be involved with WPs; WP rules will not get followed and may lead to adverse patient outcomes; WPs increase nursing workload; transient workforce impacts efficiency of implementation; and established culture of using thickened fluids. Key enablers were: patients would benefit from WPs; communication and education systems are already in place; acute hospital brings unique benefits; and peer support and modelling support implementation.

Conclusion: The perceptions of barriers and enablers to implementation of WPs can be used to inform future studies designed to evaluate the safety and efficacy of WPs and subsequently facilitate their uptake in acute stroke as an alternate dysphagia management strategy.     

Barriers to accessing safe motherhood and reproductive health services: the situation of women with disabilities in Lusaka,Zambia

Purpose:?To ascertain how well health services in Lusaka, Zambia currently meet the safe motherhood and reproductive health care needs of women who have physical impairment leading to disability.

Methods:?A qualitative study was conducted in Lusaka, Zambia. In-depth tape-recorded interviews were conducted with 24 purposively selected women with disabilities and with 25 safe motherhood/reproductive public sector health service providers. Qualitative analysis was conducted using NVivo software.

Results:?Women with disabilities encounter various social, attitudinal and physical barriers to accessing safe motherhood and reproductive health (RH) services in this particular setting. The strong desire for children and affection can increase vulnerability to sexual exploitation. At the same time, a generalized assumption among reproductive health service providers that women with disabilities will not be sexually active, and not require RH services, leads to increased vulnerability to sexually transmitted infection including HIV. Once pregnant, traditional beliefs about transmission of disabilities can create barriers to integration in ante-natal clinics. Nurse-midwives' fear of delivery complications in women with physical impairments can also result in routine over-referral to a tertiary maternity facility which is outside the locality and harder for women with mobility limitations to get to.

Conclusion:?Greater understanding of the influences underpinning societal attitudes towards sexuality and disability in this setting, and more extensive communication between health care staff and women with disabilities would facilitate positive action towards improving safe motherhood and reproductive health services for women with disabilities.