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Sliwa K, Viljoen CA, Stewart S, Miller MR, Prabhakaran D, Kumar RK, Thienemann F, Piniero D, Prabhakaran P, Narula J, Pinto F. Cardiovascular disease in low- and middle-income countries associated with environmental factors. Eur J Prev Cardiol 2024; 31:688-697. [PMID: 38175939 DOI: 10.1093/eurjpc/zwad388] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 01/06/2024]
Abstract
There is a growing recognition that the profound environmental changes that have occurred over the past century pose threats to human health. Many of these environmental factors, including air pollution, noise pollution, as well as exposure to metals such as arsenic, cadmium, lead, and other metals, are particularly detrimental to the cardiovascular health of people living in low-to-middle income countries (LMICs). Low-to-middle income countries are likely to be disproportionally burdened by cardiovascular diseases provoked by environmental factors. Moreover, they have the least capacity to address the core drivers and consequences of this phenomenon. This review summarizes the impact of environmental factors such as climate change, air pollution, and metal exposure on the cardiovascular system, and how these specifically affect people living in LMICs. It also outlines how behaviour changes and interventions that reduce environmental pollution would have significant effects on the cardiovascular health of those from LMICs, and globally.
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Affiliation(s)
- Karen Sliwa
- Cape Heart Institute, Chris Barnard Building, University of Cape Town, Faculty of Health Sciences, Cnr Anzio Road and Falmouth Road, 7925, Observatory, Cape Town, South Africa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Main Road, 7925, Observatory, Cape Town, South Africa
| | - Charle André Viljoen
- Cape Heart Institute, Chris Barnard Building, University of Cape Town, Faculty of Health Sciences, Cnr Anzio Road and Falmouth Road, 7925, Observatory, Cape Town, South Africa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Main Road, 7925, Observatory, Cape Town, South Africa
| | - Simon Stewart
- Institute for Health Research, University of Notre Dame Australia, 32 Mouat St, Fremantle, Western Australia, 6160, Australia
- Eduardo Mondlane University, 3435 Avenida Julius Nyerere, Maputo, Mozambique
| | - Mark R Miller
- Centre for Cardiovascular Science, University of Edinburgh, Queens Medical Research Institute, 47 Little France Crescent, Edinburgh, EH4 3RL, UK
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, C1/52, Safdarjung Development Area, New Delhi, 110016, India
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Ponekkara PO, Cochin 682041, Kerala, India
| | - Friedrich Thienemann
- Cape Heart Institute, Chris Barnard Building, University of Cape Town, Faculty of Health Sciences, Cnr Anzio Road and Falmouth Road, 7925, Observatory, Cape Town, South Africa
- Department of Internal Medicine, University Hospital Zurich, University of Zurich, 100 Rämistrasse, 8091 Zurich, Switzerland
| | - Daniel Piniero
- Facultad de Medicina, Universidad de Buenos Aires, Arenales 2463, Buenos Aires, C1124AAN, Argentina
| | - Poornima Prabhakaran
- Centre for Chronic Disease Control, C1/52, Safdarjung Development Area, New Delhi, 110016, India
| | - Jagat Narula
- Department of Cardiology, McGovern Medical School, University of Texas Health, 7000 Fannin St, Houston, TX 77030, USA
| | - Fausto Pinto
- Department of Cardiology, Faculty of Medicine, University of Lisbon, Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
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Hoevelmann J, Engel ME, Muller E, Hohlfeld A, Boehm M, Sliwa K, Viljoen CA. Global prevalence of mortality and LV recovery in women with PPCM – a systematic review and meta-analysis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Peripartum cardiomyopathy (PPCM) remains a major contributor to maternal morbidity and mortality worldwide. The disease is associated with various complications mainly occurring early during its course. Reported adverse outcomes include decompensated heart failure, thromboembolic complications, arrhythmias and death.
Purpose
We aimed to systematically summarize the outcomes of women with PPCM across different geographical regions and to identify possible predictors of adverse outcomes.
Methods
For this systematic review and meta-analysis, we performed a comprehensive search of all articles published between January 2000 and June 2021 on PubMed/MEDLINE, Web of Science, Scopus and EBSCO Host, including Academic Search Premier, Africa-Wide Information, CINAHL. All cohort, case-control and cross-sectional studies, as well as control arms of randomized controlled trials (RCTs) reporting on the in-hospital complications and 6- and/or 12-month outcomes of PPCM were considered eligible.
Results
Forty-seven studies (4875 participants across 60 countries) met the eligibility criteria. Hemodynamic and echocardiographic parameters were similar across all continents. In-hospital mortality was reported as 1.9% [95% CI 0.5–4.0] across all regions. About 10% of patients received invasive ventilation, 21.5% inotropic and 3.1% received mechanical support, respectively. Left ventricular (LV) thrombus complicated 9.0% [95% CI 6.5–11.9] of patients and all-cause embolic events (i.e., stroke, arterial embolism, deep vein thrombosis, pulmonary embolus) occurred in 6.1% [95% CI 3.8–8.9]. Arrhythmias were seldomly reported. All-cause mortality was 8.0% [95% CI 5.5–10.8, I2=79,1%) at 6 months and 9.8% [95% CI 6.2–14.0], I2=80.48%) at 12 months respectively. Overall, 44.4% ([95% CI 36.2–52.8], I2=91.7%) of patients recovered their LV function within 6 months and 58.7% ([95% CI 48.1–68.9], I2=75.8%) within 12 months, respectively. The lowest rate of LV recovery was reported by studies conducted in the Middle East (13.6% [95% CI 9.5–18.1], 3 studies), whereas the highest rate of LV recovery was reported for patients from Europe (56.8% [95% CI 38.1–74.7], 6 studies, I2=93.3%). All-cause mortality was highest in Africa and Asia/Pacific. Europe and North America reported the highest prevalence of LV recovery. (Figure 1) Frequent prescription of beta-blockers, ACE-I/ARB and bromocriptine/cabergoline treatment was associated with significantly lower all-cause mortality and better LV recovery (Figure 2).
Conclusion
We identified significant global differences in prescribed treatment, prevalence of in-hospital complications and six- and 12-month outcomes. Frequent prescription of guideline-directed heart failure therapy was associated with better LV recovery and lower all-cause mortality. Timely initiation and up-titration of heart failure therapy should therefore be strongly encouraged to improve outcome in women with PPCM.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- J Hoevelmann
- Saarland University Hospital, Department of Cardiology , Homburg , Germany
| | - M E Engel
- University of Cape Town, Department of Medicine , Cape Town , South Africa
| | - E Muller
- University of Cape Town, Cape Heart Institute , Cape Town , South Africa
| | - A Hohlfeld
- South African Medical Research Council , Cape Town , South Africa
| | - M Boehm
- Saarland University Hospital, Department of Cardiology , Homburg , Germany
| | - K Sliwa
- University of Cape Town, Cape Heart Institute , Cape Town , South Africa
| | - C A Viljoen
- University of Cape Town, Division of Cardiology , Cape Town , South Africa
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Hoevelmann J, Viljoen CA, Jermy S, Cirota J, Kraus S, Sliwa K, Ntusi NAB. Diagnostic value of cardiovascular magnetic resonance in acute peripartum cardiomyopathy (PPCM). Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Peripartum cardiomyopathy (PPCM) is characterised by left ventricular (LV) dilatation and systolic dysfunction developing towards the end of pregnancy or in the first five months postpartum. Cardiovascular magnetic resonance (CMR) allows for comprehensive evaluation of myocardial structure, function, and tissue characteristics. There is a dearth of studies investigating utility of CMR in PPCM.
Purpose
To evaluate diagnostic benefit of multiparametric assessment of myocardial oedema, fibrotic burden, and strain impairment in PPCM using CMR.
Methods
Eighteen consenting women with newly diagnosed PPCM and 20 female, age-matched healthy controls (HCs) underwent CMR imaging on a 3T MR scanner. A comprehensive, contrast-enhanced CMR protocol was used including cines, native T1 and T2 mapping, myocardial strain analysis, and extracellular volume (ECV). Images were evaluated qualitatively and semi-quantitively for the presence of late gadolinium enhancement (LGE)
Results
Patients with PPCM (median age of 34.5 years [IQR 25–38]) presented with severely impaired LV ejection fraction (LVEF) of 31.4% (IQR 19.6–37.9) and reduced right ventricular (RV) ejection fraction (RVEF) of 37.2% (IQR 21.6–51.7). Global longitudinal strain (GLS) was significantly reduced in PPCM patients (−8.9% [IQR −10.8 to −5.6] vs. −19.7 [−21.9 to −16.3], p<0.001) compared to HCs. LGE was present in 13 (81.2%) PPCM patients and included linear or circumferential mid-wall, patchy and diffuse patterns (LGE mass 19.1g [IQR 15.0–26.5] vs. 11.4g [8.8–13.2] in HCs, p<0.001). Patients with PPCM had significantly higher T1 times (1369.3ms [IQR 1343.7–1409.7 vs. 1207.8ms [IQR 1194.8–1241.3], p<0.001) and ECV (36.5% [32.7–37.0] vs. 27.5 [26.3–28.5], p<0.001) compared to HCs. ECV, native T1 and T2 times did not differ between PPCM patients presenting with LVEF ≤35% and >35%. RV dysfunction (present in 61.1% of PPCM cohort) was associated with significantly higher ECV (37.0% [IQR 36.5–38.4] vs 33.4% [IQR 28.5–37.0], p=0.05 and higher T1 (1409.0ms [IQR 1349.0–1443.0] vs. 1311.3ms [IQR 1299.3–1369.3], p=0.015) compared to those with preserved RV function. LV fibrosis was not significantly different between PPCM patients with and without RV dysfunction. LGE mass correlated negatively with LVEF and RVEF (r=−0.540, p=0.001; r=−0.568, p<0.001), respectively. There was a strong positive correlation between LGE mass and native T1 (r=0.619, p<0.001), LGE mass and GLS (r=0.638, p<0.001) and moderate correlation with ECV (r=0.528, p=0.001) (Figure 1). Small, sub-centimetre pericardial effusions were noted in 83.3% of PPCM patients vs. 10% in HCs (p<0.001).
Conclusion
For the first time, we report a high prevalence of myocardial fibrosis in well-phenotyped patients with newly diagnosed PPCM. Increased LGE mass was associated with severe impairments in LV strain, LVEF and RVEF. RV dysfunction was associated with significantly higher ECV and native T1 times.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- J Hoevelmann
- Saarland University Hospital, Department of Cardiology , Homburg , Germany
| | - C A Viljoen
- University of Cape Town, Division of Cardiology , Cape Town , South Africa
| | - S Jermy
- University of Cape Town, Cape Universities Body Imaging Centre , Cape Town , South Africa
| | - J Cirota
- University of Cape Town, Division of Cardiology , Cape Town , South Africa
| | - S Kraus
- University of Cape Town, Division of Cardiology , Cape Town , South Africa
| | - K Sliwa
- University of Cape Town, Cape Heart Institute , Cape Town , South Africa
| | - N A B Ntusi
- University of Cape Town, Cape Universities Body Imaging Centre , Cape Town , South Africa
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Uys F, Beeton AT, van der Walt S, Lamprecht M, Verryn M, Vallie Y, Stokes D, Millar RS, Viljoen CA. Profile and management of acute coronary syndromes at primary- and secondary-level healthcare facilities in Cape Town. Cardiovasc J Afr 2021; 33:138-144. [PMID: 34851354 DOI: 10.5830/cvja-2021-054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 10/26/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Little is known about the clinical profile and management of patients with acute coronary syndromes (ACS) in the South African public sector. METHODS We conducted a retrospective study of patients presenting with ACS to a secondary-level healthcare facility in Cape Town during a one-year period to study the clinical profile and management of these patients. RESULTS Among the 214 patients in this cohort, 48 (27.5%) had ST-segment elevation myocardial infarction (STEMI), 43 (24.7%) had non-ST-segment elevation myocardial infarction and 83 (47.7%) unstable angina pectoris. We identified high rates of >12-hour delays in first medical contact after symptom onset (46%) and inaccurate ECG diagnosis of STEMI (29.2%), which were associated with low rates of thrombolysis (39.6%). High rates of non-adherence and ACS recurrence were also observed. CONCLUSION To address the local challenges in ACS management highlighted in this study, we propose the development of a regional referral network prioritising access to expedited care and primary reperfusion interventions in ACS.
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Affiliation(s)
- F Uys
- Department of Medicine, New Somerset Hospital, Cape Town, South Africa.
| | - A T Beeton
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - S van der Walt
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - M Lamprecht
- Department of Medicine, New Somerset Hospital, Cape Town, South Africa
| | - M Verryn
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Y Vallie
- Department of Medicine, New Somerset Hospital, Cape Town, South Africa
| | - D Stokes
- New Somerset Hospital, Cape Town, South Africa
| | - R S Millar
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa; Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - C A Viljoen
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa; Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa; Cape Heart Institute, University of Cape Town, Cape Town, South Africa
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Abstract
INTRODUCTION Peripartum cardiomyopathy (PPCM) remains a major contributor to maternal morbidity and mortality worldwide. The disease is associated with various complications, which occur predominantly during the early stages of the disease. Adverse outcomes include decompensated heart failure, thromboembolic complications, arrhythmias and death. We present a protocol for a systematic review and meta-analysis to summarise the available data on the complications and outcomes of women with PPCM. METHODS AND ANALYSIS A comprehensive search of all articles published between 2000 (the year in which the first universal definition of PPCM was used) and 1 June 2021 will be performed on PubMed/MEDLINE, Web of Science, Scopus and EBSCO Host, including Academic Search Premier, Africa-Wide Information, Cumulative Index to Nursing and Allied Health Literature. All cohort and cross-sectional studies, as well as control arms of randomised control trials (RCTs) reporting on the complications and outcomes of PPCM will be included in the review. Methodological quality assessment of included studies will be done by assessing the risk of bias. Heterogeneity of the data will be tested by visual inspection of the forest plot and I2 and χ2 tests. This study will report the burden of complications occurring around the time of diagnosis as well as the 6-month or 12-month outcomes of women with PPCM. A summarised description in form of a pooled analysis of across multiple centres, regions and continents would help us to better understand the estimates of complications and outcomes of women with PPCM. ETHICS AND DISSEMINATION As this research is a systematic review of published literature, ethical approval is not required. The results will be reported according to the latest guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement, and will be submitted to a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021255654.
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Affiliation(s)
- Julian Hoevelmann
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Homburg (Saar), Saarland, Germany
| | - Elani Muller
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Ameer Hohlfeld
- Cohrane South Africa, South African Medical Research Council, Cape Town, Western Cape, South Africa
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Michael Böhm
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Homburg (Saar), Saarland, Germany
| | - Karen Sliwa
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Mark E Engel
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Charle André Viljoen
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
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Hoevelmann J, Viljoen CA, Chin A, Briton O, Sliwa K. Effectiveness of implanted cardiac rhythm recorders with electrocardiographic monitoring for detecting arrhythmias in peripartum cardiomyopathy (PPCM). Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy that occurs within the last months of pregnancy or up to 5 months postpartum. Previous studies have shown that up to 30% of deaths in PPCM are related to sudden cardiac death (SCD). However, little is known about the burden of arrythmias in PPCM and their contribution to SCD.
Purpose
We aimed to compare implantable loop recorder (ILR) plus 24-hour Holter monitoring to 24h Holter monitoring alone to assess its utility in the detection of arrhythmias in PPCM.
Methods
In this single-centre, prospective clinical trial, 20 consecutive patients with PPCM were randomized to either standard care (SC cohort: ECG & 24-hour Holter) or SC plus ILR (SC-ILR cohort: ECG, 24-hour Holter, ILR). Follow-up included the first six months after ILR implantation.
Results
The median age of this cohort was 31.7 years with a parity of 2 (IQR 1–4). They presented with a median left ventricular ejection fraction (LVEF) of 28% (IQR 24–35) and LVEDD of 60mm (IQR 55–66). The 12-lead ECG recorded sinus tachycardia in half of the patients, with median heart rate of 90bpm (IQR 79–106) compared to 94.5bpm (IQR 85–99) on 24h-Holter-monitoring. The median QTc-interval was 464ms (IQR 424–494). Ambulatory ECG monitoring detected major arrhythmias in three women (one in SC cohort, two in SC-ILR cohort). One patient (5%) died shortly after ILR implantation. Her ILR detected sinus arrest with an escape rhythm (figure 1A) that failed and resulted in an out of hospital cardiac arrest. Non-sustained ventricular tachycardia (nsVT) occurred in two women (10%), one of which was detected by Holter monitoring and the other on ILR (figure 1B, 1C). Both women presented with acute heart failure with severely impaired systolic function (LVEF 12% and 21% respectively). One of these patients had persistent LV systolic dysfunction despite optimal medical therapy and received an implantable cardioverter-defibrillator (ICD). The other patient had intractable heart failure requiring recurrent intensive-care treatment and underwent heart transplantation. There was no atrial fibrillation or atrioventricular block detected in any patient by ECG, Holter or ILR monitoring throughout the study period.
Conclusion
This study on ambulatory ECG monitoring in PPCM showed a high prevalence of potentially fatal arrhythmias, which occurred predominantly in the acute phase of the disease. One patient had sinus arrest and asystole detected by ILR as the terminal arrhythmia. Both Holter monitoring and ILR played an important role in ventricular arrhythmia detection, which in two cases had a direct influence on clinical decision making. ILR is more effective than 24-hour Holter monitoring in paroxysmal arrhythmia detection because of extended monitoring.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Medtronic South Africa Ambulatory ECG monitoring in PPCM
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Affiliation(s)
- J Hoevelmann
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa
| | - C A Viljoen
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa
| | - A Chin
- University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - O Briton
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa
| | - K Sliwa
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa
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Viljoen CA, Millar RS, Manning K, Hoevelmann J, Burch VC. Clinically contextualised ECG interpretation: the impact of prior clinical exposure and case vignettes on ECG diagnostic accuracy. BMC Med Educ 2021; 21:417. [PMID: 34344375 PMCID: PMC8336410 DOI: 10.1186/s12909-021-02854-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/26/2021] [Indexed: 05/29/2023]
Abstract
BACKGROUND ECGs are often taught without clinical context. However, in the clinical setting, ECGs are rarely interpreted without knowing the clinical presentation. We aimed to determine whether ECG diagnostic accuracy was influenced by knowledge of the clinical context and/or prior clinical exposure to the ECG diagnosis. METHODS Fourth- (junior) and sixth-year (senior) medical students, as well as medical residents were invited to complete two multiple-choice question (MCQ) tests and a survey. Test 1 comprised 25 ECGs without case vignettes. Test 2, completed immediately thereafter, comprised the same 25 ECGs and MCQs, but with case vignettes for each ECG. Subsequently, participants indicated in the survey when last, during prior clinical clerkships, they have seen each of the 25 conditions tested. Eligible participants completed both tests and survey. We estimated that a minimum sample size of 165 participants would provide 80% power to detect a mean difference of 7% in test scores, considering a type 1 error of 5%. RESULTS This study comprised 176 participants (67 [38.1%] junior students, 55 [31.3%] senior students, 54 [30.7%] residents). Prior ECG exposure depended on their level of training, i.e., junior students were exposed to 52% of the conditions tested, senior students 63.4% and residents 96.9%. Overall, there was a marginal improvement in ECG diagnostic accuracy when the clinical context was known (Cohen's d = 0.35, p < 0.001). Gains in diagnostic accuracy were more pronounced amongst residents (Cohen's d = 0.59, p < 0.001), than senior (Cohen's d = 0.38, p < 0.001) or junior students (Cohen's d = 0.29, p < 0.001). All participants were more likely to make a correct ECG diagnosis if they reported having seen the condition during prior clinical training, whether they were provided with a case vignette (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.24-1.71) or not (OR 1.58, 95% CI 1.35-1.84). CONCLUSION ECG interpretation using clinical vignettes devoid of real patient experiences does not appear to have as great an impact on ECG diagnostic accuracy as prior clinical exposure. However, exposure to ECGs during clinical training is largely opportunistic and haphazard. ECG training should therefore not rely on experiential learning alone, but instead be supplemented by other formal methods of instruction.
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Affiliation(s)
- Charle André Viljoen
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
- Cape Heart Institute, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
| | - Rob Scott Millar
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Kathryn Manning
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Julian Hoevelmann
- Cape Heart Institute, University of Cape Town, Observatory, Cape Town, 7925, South Africa
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Hospital, Homburg/Saar, Germany
| | - Vanessa Celeste Burch
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
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Viljoen CA, Millar RS, Hoevelmann J, Muller E, Hähnle L, Manning K, Naude J, Sliwa K, Burch VC. Utility of mobile learning in Electrocardiography. Eur Heart J Digit Health 2021; 2:202-214. [PMID: 36712390 PMCID: PMC9707875 DOI: 10.1093/ehjdh/ztab027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/18/2021] [Accepted: 02/18/2021] [Indexed: 02/01/2023]
Abstract
Aims Mobile learning is attributed to the acquisition of knowledge derived from accessing information on a mobile device. Although increasingly implemented in medical education, research on its utility in Electrocardiography remains sparse. In this study, we explored the effect of mobile learning on the accuracy of electrocardiogram (ECG) analysis and interpretation. Methods and results The study comprised 181 participants (77 fourth- and 69 sixth-year medical students, and 35 residents). Participants were randomized to analyse ECGs with a mobile learning strategy [either searching the Internet or using an ECG reference application (app)] or not. For each ECG, they provided their initial diagnosis, key supporting features, and final diagnosis consecutively. Two weeks later, they analysed the same ECGs, without access to any mobile device. ECG interpretation was more accurate when participants used the ECG app (56%), as compared to searching the Internet (50.3%) or neither (43.5%, P = 0.001). Importantly, mobile learning supported participants in revising their initial incorrect ECG diagnosis (ECG app 18.7%, Internet search 13.6%, no mobile device 8.4%, P < 0.001). However, whilst this was true for students, there was no significant difference amongst residents. Internet searches were only useful if participants identified the correct ECG features. The app was beneficial when participants searched by ECG features, but not by diagnosis. Using the ECG reference app required less time than searching the Internet (7:44 ± 4:13 vs. 9:14 ± 4:34, P < 0.001). Mobile learning gains were not sustained after 2 weeks. Conclusion Whilst mobile learning contributes to increased ECG diagnostic accuracy, the benefits were not sustained over time.
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Affiliation(s)
- Charle André Viljoen
- Division of Cardiology, New Main Building, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa,Department of Medicine, Old Main Building, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa,Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Chris Barnard Building, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa,Corresponding author. Tel: +27214046088,
| | - Rob Scott Millar
- Division of Cardiology, New Main Building, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa,Department of Medicine, Old Main Building, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa
| | - Julian Hoevelmann
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Chris Barnard Building, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa,Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Hospital, Homburg/Saar, Deutschland, Germany
| | - Elani Muller
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Chris Barnard Building, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa
| | - Lina Hähnle
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Chris Barnard Building, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa
| | - Kathryn Manning
- Department of Medicine, Old Main Building, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa
| | - Jonathan Naude
- Department of Medicine, Old Main Building, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Chris Barnard Building, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa
| | - Vanessa Celeste Burch
- Department of Medicine, Old Main Building, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa
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Hoevelmann J, Muller E, Azibani F, Kraus S, Cirota J, Briton O, Ntsekhe M, Ntusi NAB, Sliwa K, Viljoen CA. Prognostic value of NT-proBNP for myocardial recovery in peripartum cardiomyopathy (PPCM). Clin Res Cardiol 2021; 110:1259-1269. [PMID: 33555408 PMCID: PMC8318939 DOI: 10.1007/s00392-021-01808-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/16/2021] [Indexed: 11/25/2022]
Abstract
Introduction Peripartum cardiomyopathy (PPCM) is an important cause of pregnancy-associated heart failure worldwide. Although a significant number of women recover their left ventricular (LV) function within 12 months, some remain with persistently reduced systolic function. Methods Knowledge gaps exist on predictors of myocardial recovery in PPCM. N-terminal pro-brain natriuretic peptide (NT-proBNP) is the only clinically established biomarker with diagnostic value in PPCM. We aimed to establish whether NT-proBNP could serve as a predictor of LV recovery in PPCM, as measured by LV end-diastolic volume (LVEDD) and LV ejection fraction (LVEF). Results This study of 35 women with PPCM (mean age 30.0 ± 5.9 years) had a median NT-proBNP of 834.7 pg/ml (IQR 571.2–1840.5) at baseline. Within the first year of follow-up, 51.4% of the cohort recovered their LV dimensions (LVEDD < 55 mm) and systolic function (LVEF > 50%). Women without LV recovery presented with higher NT-proBNP at baseline. Multivariable regression analyses demonstrated that NT-proBNP of ≥ 900 pg/ml at the time of diagnosis was predictive of failure to recover LVEDD (OR 0.22, 95% CI 0.05–0.95, P = 0.043) or LVEF (OR 0.20 [95% CI 0.04–0.89], p = 0.035) at follow-up. Conclusions We have demonstrated that NT-proBNP has a prognostic value in predicting LV recovery of patients with PPCM. Patients with NT-proBNP of ≥ 900 pg/ml were less likely to show any improvement in LVEF or LVEDD. Our findings have implications for clinical practice as patients with higher NT-proBNP might require more aggressive therapy and more intensive follow-up. Point-of-care NT-proBNP for diagnosis and risk stratification warrants further investigation.
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Affiliation(s)
- J Hoevelmann
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University Hospital, Homburg (Saar), Deutschland
| | - E Muller
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - F Azibani
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - S Kraus
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - J Cirota
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - O Briton
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - M Ntsekhe
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - N A B Ntusi
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Cape Universities Body Imaging Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - K Sliwa
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - C A Viljoen
- Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Viljoen CA, Millar RS, Manning K, Burch VC. Effectiveness of blended learning versus lectures alone on ECG analysis and interpretation by medical students. BMC Med Educ 2020; 20:488. [PMID: 33272253 PMCID: PMC7713171 DOI: 10.1186/s12909-020-02403-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 11/24/2020] [Indexed: 05/29/2023]
Abstract
BACKGROUND Most medical students lack confidence and are unable to accurately interpret ECGs. Thus, better methods of ECG instruction are being sought. Current literature indicates that the use of e-learning for ECG analysis and interpretation skills (ECG competence) is not superior to lecture-based teaching. We aimed to assess whether blended learning (lectures supplemented with the use of a web application) resulted in better acquisition and retention of ECG competence in medical students, compared to conventional teaching (lectures alone). METHODS Two cohorts of fourth-year medical students were studied prospectively. The conventional teaching cohort (n = 67) attended 4 hours of interactive lectures, covering the basic principles of Electrocardiography, waveform abnormalities and arrhythmias. In addition to attending the same lectures, the blended learning cohort (n = 64) used a web application that facilitated deliberate practice of systematic ECG analysis and interpretation, with immediate feedback. All participants completed three tests: pre-intervention (assessing baseline ECG competence at start of clinical clerkship), immediate post-intervention (assessing acquisition of ECG competence at end of six-week clinical clerkship) and delayed post-intervention (assessing retention of ECG competence 6 months after clinical clerkship, without any further ECG training). Diagnostic accuracy and uncertainty were assessed in each test. RESULTS The pre-intervention test scores were similar for blended learning and conventional teaching cohorts (mean 31.02 ± 13.19% versus 31.23 ± 11.52% respectively, p = 0.917). While all students demonstrated meaningful improvement in ECG competence after teaching, blended learning was associated with significantly better scores, compared to conventional teaching, in immediate (75.27 ± 16.22% vs 50.27 ± 17.10%, p < 0.001; Cohen's d = 1.58), and delayed post-intervention tests (57.70 ± 18.54% vs 37.63 ± 16.35%, p < 0.001; Cohen's d = 1.25). Although diagnostic uncertainty decreased after ECG training in both cohorts, blended learning was associated with better confidence in ECG analysis and interpretation. CONCLUSION Blended learning achieved significantly better levels of ECG competence and confidence amongst medical students than conventional ECG teaching did. Although medical students underwent significant attrition of ECG competence without ongoing training, blended learning also resulted in better retention of ECG competence than conventional teaching. Web applications encouraging a stepwise approach to ECG analysis and enabling deliberate practice with feedback may, therefore, be a useful adjunct to lectures for teaching Electrocardiography.
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Affiliation(s)
- Charle André Viljoen
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
- Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
| | - Rob Scott Millar
- Division of Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Kathryn Manning
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Vanessa Celeste Burch
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
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11
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Viljoen CA, Millar RS, Manning K, Burch VC. Determining electrocardiography training priorities for medical students using a modified Delphi method. BMC Med Educ 2020; 20:431. [PMID: 33198726 PMCID: PMC7670661 DOI: 10.1186/s12909-020-02354-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/02/2020] [Indexed: 05/02/2023]
Abstract
BACKGROUND Although electrocardiography is considered a core learning outcome for medical students, there is currently little curricular guidance for undergraduate ECG training. Owing to the absence of expert consensus on undergraduate ECG teaching, curricular content is subject to individual opinion. The aim of this modified Delphi study was to establish expert consensus amongst content and context experts on an ECG curriculum for medical students. METHODS The Delphi technique, an established method of obtaining consensus, was used to develop an undergraduate ECG curriculum. Specialists involved in ECG teaching were invited to complete three rounds of online surveys. An undergraduate ECG curriculum was formulated from the topics of ECG instruction for which consensus (i.e. ≥75% agreement) was achieved. RESULTS The panellists (n = 131) had a wide range of expertise (42.8% Internal Medicine, 22.9% Cardiology, 16% Family Medicine, 13.7% Emergency Medicine and 4.6% Health Professions Education). Topics that reached consensus to be included in the undergraduate ECG curriculum were classified under technical aspects of performing ECGs, basic ECG analysis, recognition of the normal ECG and abnormal rhythms and waveforms and using electrocardiography as part of a clinical diagnosis. This study emphasises that ECG teaching should be framed within the clinical context. Course conveners should not overload students with complex and voluminous content, but rather focus on commonly encountered and life-threatening conditions, where accurate diagnosis impacts on patient outcome. A list of 23 "must know" ECG diagnoses is therefore proposed. CONCLUSION A multidisciplinary expert panel reached consensus on the ECG training priorities for medical students.
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Affiliation(s)
- Charle André Viljoen
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
- Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Observatory, Cape Town, 7925, South Africa.
| | - Rob Scott Millar
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Kathryn Manning
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Vanessa Celeste Burch
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7925, South Africa
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Hoevelmann J, Viljoen CA, Millar RS, Manning K, Ntsekhe M, Sliwa K. Reply to '12‑lead ECG as an emerging risk stratifier in peripartum cardiomyopathy'. Int J Cardiol 2019; 297:91. [PMID: 31431295 DOI: 10.1016/j.ijcard.2019.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/31/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
Affiliation(s)
- J Hoevelmann
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa; Hannover Medical School, Department of Cardiology and Angiology, Hannover, Germany
| | - C A Viljoen
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa; University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - R S Millar
- University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - K Manning
- University of Cape Town, Department of Medicine, Cape Town, South Africa
| | - M Ntsekhe
- University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - K Sliwa
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa.
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13
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Viljoen CA, Scott Millar R, Engel ME, Shelton M, Burch V. Is computer-assisted instruction more effective than other educational methods in achieving ECG competence amongst medical students and residents? A systematic review and meta-analysis. BMJ Open 2019; 9:e028800. [PMID: 31740464 PMCID: PMC6886915 DOI: 10.1136/bmjopen-2018-028800] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES It remains unclear whether computer-assisted instruction (CAI) is more effective than other teaching methods in acquiring and retaining ECG competence among medical students and residents. DESIGN This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES Electronic literature searches of PubMed, databases via EBSCOhost, Scopus, Web of Science, Google Scholar and grey literature were conducted on 28 November 2017. We subsequently reviewed the citation indexes for articles identified by the search. ELIGIBILITY CRITERIA Studies were included if a comparative research design was used to evaluate the efficacy of CAI versus other methods of ECG instruction, as determined by the acquisition and/or retention of ECG competence of medical students and/or residents. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data from all eligible studies and assessed the risk of bias. After duplicates were removed, 559 papers were screened. Thirteen studies met the eligibility criteria. Eight studies reported sufficient data to be included in the meta-analysis. RESULTS In all studies, CAI was compared with face-to-face ECG instruction. There was a wide range of computer-assisted and face-to-face teaching methods. Overall, the meta-analysis found no significant difference in acquired ECG competence between those who received computer-assisted or face-to-face instruction. However, subanalyses showed that CAI in a blended learning context was better than face-to-face teaching alone, especially if trainees had unlimited access to teaching materials and/or deliberate practice with feedback. There was no conclusive evidence that CAI was better than face-to-face teaching for longer-term retention of ECG competence. CONCLUSION CAI was not better than face-to-face ECG teaching. However, this meta-analysis was constrained by significant heterogeneity amongst studies. Nevertheless, the finding that blended learning is more effective than face-to-face ECG teaching is important in the era of increased implementation of e-learning. PROSPERO REGISTRATION NUMBER CRD42017067054.
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Affiliation(s)
| | | | - Mark E Engel
- Medicine, Unversity of Cape Town, Cape Town, South Africa
| | - Mary Shelton
- Health Sciences Library, University of Cape Town, Cape Town, South Africa
| | - Vanessa Burch
- Medicine, Unversity of Cape Town, Cape Town, South Africa
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Viljoen CA, Sliwa K, Azibani F, Johnson MR, Baard J, Osman A, Briton O, Ntsekhe M, Anthony J, Chin A. P2533Prospective randomized study on implanted cardiac rhythm recorders in pregnant women with symptomatic arrhythmia and/or structural heart disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Cardiac arrhythmia is an important cause of maternal morbidity and mortality in pregnancy, but is difficult to diagnose.
Purpose
The aim of this single-centre, prospective, randomized pilot study was to compare the implantable loop recorder (ILR) with standard assessment of arrhythmia (12-lead ECG; 24-hour Holter ECG) in terms of acceptability, detection of arrhythmias and impact on outcome in pregnant women with symptomatic arrhythmias and/or structural heart disease (SHD).
Methods
The study recruited 40 consecutive patients from a weekly, dedicated cardiac obstetric clinic. Inclusion criteria: symptoms of arrhythmia and/or having SHD at risk of arrhythmia. Patients were randomized to either standard care (SC) or standard care plus ILR (SC-ILR). ILR recordings were read at the monthly visits and/or when presenting with symptoms.
Results
There were no demographic differences between the study groups. Seventeen patients consented to ILR insertion, all of whom found the procedure acceptable. No arrhythmias were recorded by the 12-lead ECGs. Holter monitoring detected arrhythmias in 10 of 23 patients (43%) from the SC group. In the SC-ILR group, 8 of 17 patients (47%) had arrhythmias detected by Holter, whereas 13 of 17 patients (76%) patients had arrhythmias detected by ILR (p=0.157). One of 4 patients with supraventricular tachycardia, 2 of 3 patients with premature ventricular complexes and 2 patients with paroxysmal atrial fibrillation (AF) recorded by ILR did not have the arrhythmias detected by Holter monitoring (Figure 1A shows a scatter plot of the variable R-R intervals seen in AF and 1B a rhythm strip of AF with irregular RR intervals and the absence of P waves, both downloaded from the ILR). Four of these 5 patients (80%) had a change in management as a direct result of their ILR recordings. There were no maternal deaths up to 42 days postpartum in either of the study groups. Nine babies were born with a low birthweight (<2500g), 5 stillbirth/neonatal deaths and 1 pregnancy termination occurred (5 in the Holter group and 1 in ILR group, p=0.37).
Figure 1
Conclusion(s)
This study suggests that an ILR is an acceptable diagnostic modality in pregnant women with a suspected or at risk of arrhythmia. The ILR increased the diagnostic yield to detect arrhythmias that were not detected by routine ECG and Holter monitoring which led to a change in management in the SC-ILR group and was associated with better maternal and neonatal outcomes. The impact of ILR monitoring should be further assessed in larger studies with longer follow up.
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Affiliation(s)
- C A Viljoen
- University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - K Sliwa
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa
| | - F Azibani
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa
| | - M R Johnson
- Imperial College London, London, United Kingdom
| | - J Baard
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa
| | - A Osman
- University of Cape Town, Division of Obstetrics and Gynaecology, Cape Town, South Africa
| | - O Briton
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa
| | - M Ntsekhe
- University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - J Anthony
- University of Cape Town, Division of Obstetrics and Gynaecology, Cape Town, South Africa
| | - A Chin
- University of Cape Town, Division of Cardiology, Cape Town, South Africa
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Hoevelmann J, Viljoen CA, Manning K, Baard J, Hahnle L, Ntsekhe M, Bauersachs J, Sliwa K. The prognostic significance of the 12-lead ECG in peripartum cardiomyopathy. Int J Cardiol 2018; 276:177-184. [PMID: 30497895 DOI: 10.1016/j.ijcard.2018.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 10/24/2018] [Accepted: 11/05/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Peripartum cardiomyopathy (PPCM) is an important cause of pregnancy-associated heart failure, which appears in previously healthy women towards the end of pregnancy or within five months following delivery. Although the ECG is widely used in clinical practice, its prognostic value has not been established in PPCM. METHODS We analysed 12-lead ECGs of patients with PPCM, taken at index presentation and follow-up visits at 6 and 12 months. Poor outcome was determined by the composite endpoint of death, readmission, NYHA functional class III/IV or left ventricular ejection fraction (LVEF) of ≤35% at follow-up. RESULTS This cohort of 66 patients had a median age of 28.59 (IQR 25.43-32.19). The median LVEF at presentation (33%, IQR 25-40) improved significantly at follow-up (LVEF 49%, IQR 38-55, P < 0.001 at 6 months; 52% IQR 38-57, P = 0.001 at 12 months). Poor outcome occurred in 27.91% at 6 months and 41.18% at 1 year. Whereas sinus tachycardia at baseline was an independent predictor of poor outcome at 12 months (OR 6.56, 95% CI 1.17-20.41, P = 0.030), sinus arrhythmia was associated with event free survival (log rank P = 0.013). T wave inversion was associated with an LVEF ≤35% at presentation (P = 0.038), but did not predict poor outcome. A prolonged QTc interval at presentation (found in almost half of the cohort) was an independent predictor of poor outcome at 6 months (OR 6.34, 95% CI 1.06-37.80, P = 0.043). CONCLUSION(S) A prolonged QTc and sinus tachycardia at baseline were independent predictors of poor outcome in PPCM at 6 months and 1 year respectively.
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Affiliation(s)
- J Hoevelmann
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa; Hannover Medical School, Department of Cardiology and Angiology, Hannover, Germany
| | - C A Viljoen
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa; University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - K Manning
- University of Cape Town, Department of Medicine, Cape Town, South Africa
| | - J Baard
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa
| | - L Hahnle
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa; University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - M Ntsekhe
- University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - J Bauersachs
- Hannover Medical School, Department of Cardiology and Angiology, Hannover, Germany
| | - K Sliwa
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa.
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Viljoen CA, Scott Millar R, Engel ME, Shelton M, Burch V. Is computer-assisted instruction more effective than other educational methods in achieving ECG competence among medical students and residents? Protocol for a systematic review and meta-analysis. BMJ Open 2017; 7:e018811. [PMID: 29282268 PMCID: PMC5988085 DOI: 10.1136/bmjopen-2017-018811] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Although ECG interpretation is an essential skill in clinical medicine, medical students and residents often lack ECG competence. Novel teaching methods are increasingly being implemented and investigated to improve ECG training. Computer-assisted instruction is one such method under investigation; however, its efficacy in achieving better ECG competence among medical students and residents remains uncertain. METHODS AND ANALYSIS This article describes the protocol for a systematic review and meta-analysis that will compare the effectiveness of computer-assisted instruction with other teaching methods used for the ECG training of medical students and residents. Only studies with a comparative research design will be considered. Articles will be searched for in electronic databases (PubMed, Scopus, Web of Science, Academic Search Premier, CINAHL, PsycINFO, Education Resources Information Center, Africa-Wide Information and Teacher Reference Center). In addition, we will review citation indexes and conduct a grey literature search. Data extraction will be done on articles that met the predefined eligibility criteria. A descriptive analysis of the different teaching modalities will be provided and their educational impact will be assessed in terms of effect size and the modified version of Kirkpatrick framework for the evaluation of educational interventions. This systematic review aims to provide evidence as to whether computer-assisted instruction is an effective teaching modality for ECG training. It is hoped that the information garnered from this systematic review will assist in future curricular development and improve ECG training. ETHICS AND DISSEMINATION As this research is a systematic review of published literature, ethical approval is not required. The results will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement and will be submitted to a peer-reviewed journal. The protocol and systematic review will be included in a PhD dissertation. PROSPERO REGISTRATION NUMBER CRD42017067054; Pre-results.
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Affiliation(s)
- Charle André Viljoen
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Rob Scott Millar
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Mark E Engel
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Mary Shelton
- Health Sciences Library, University of Cape Town, Cape Town, South Africa
| | - Vanessa Burch
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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