Prevention of infective endocarditis in at-risk patients: how should dentists proceed in 2024?

National Institute for Health and Care Excellence (NICE) guidelines are ambiguous over the need for patients at increased risk of infective endocarditis (IE) to receive antibiotic prophylaxis (AP) prior to invasive dental procedures (IDPs), and this has caused confusion for patients and dentists alike. Moreover, the current law on consent requires clinicians to ensure that patients are made aware of any material risk they might be exposed to by any proposed dental treatment and what can be done to ameliorate this risk, so that the patient can decide for themselves how they wish to proceed. The aim of this article is to provide dentists with the latest information on the IE-risk posed by IDPs to different patient populations (the general population and those defined as being at moderate or high risk of IE), and data on the effectiveness of AP in reducing the IE risk in these populations. This provides the information dentists need to facilitate the informed consent discussions they are legally required to have with patients at increased risk of IE about the risks posed by IDPs and how this can be minimised. The article also provides practical information and advice for dentists on how to manage patients at increased IE risk who present for dental treatment.

New evidence calls into question NICE's endocarditis prevention guidance

In 2008, National Institute for Health and Care Excellence (NICE) guidelines recommended against the use of antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) to prevent infective endocarditis (IE). They did so because of lack of AP efficacy evidence and adverse reaction concerns. Consequently, NICE concluded AP was not cost-effective and should not be recommended. In 2015, NICE reviewed its guidance and continued to recommend against AP. However, it subsequently changed its wording to 'antibiotic prophylaxis against infective endocarditis is not routinely recommended'. The lack of explanation of what constituted routinely (and not routinely), or how to manage non-routine patients, caused enormous confusion and NICE remained out of step with all major international guideline committees who continued to recommend AP for those at high risk.Since the 2015 guideline review, new data have confirmed an association between IDPs and subsequent IE and demonstrated AP efficacy in reducing IE risk following IDPs in high-risk patients. New evidence also shows that in high-risk patients, the IE risk following IDPs substantially exceeds any adverse reaction risk, and that AP is therefore highly cost-effective. Given the new evidence, a NICE guideline review would seem appropriate so that UK high-risk patients can receive the same protection afforded high-risk patients in the rest of the world.

Bacteremia following different oral procedures: Systematic review and meta-analysis

To evaluate the timing, duration and incidence of bacteremia following invasive dental procedures (IDPs) or activities of daily living (ADL). Eight databases were searched for randomized (RCTs) and nonrandomized controlled trials (nRCTs) evaluating bacteremia before and after IDPs or ADL in healthy individuals. The risk of bias was assessed by RoB 2.0 and ROBINS-I. For the meta-analysis, the primary outcomes were the timing and duration of bacteremia. The secondary outcome was the incidence of bacteremia, measuring the proportion of patients with bacteremia within 5 min after the end of the procedure compared with baseline. We included 64 nRCTs and 25 RCTs. Peak bacteremia occurred within 5 min after the procedure and then decreased over time. Dental extractions showed the highest incidence of bacteremia (62%-66%), followed by scaling and root planing (SRP) (44%-36%) and oral health procedures (OHP) (e.g., dental prophylaxis and dental probing without SRP) (27%-28%). Other ADL (flossing and chewing) (16%) and toothbrushing (8%-26%) resulted in bacteremia as well. The majority of studies had some concerns RCTs or moderate risk of bias nRCTs. Dental extractions, SRP and OHP, are associated with the highest frequency of bacteremia. Toothbrushing, flossing, and chewing also caused bacteremia in lower frequency.

Evaluation of the prehospital use of a Valsalva assist device in the emergency treatment of supraventricular tachycardia (EVADE SVT): study protocol for a stepped wedge cluster randomised controlled trial

INTRODUCTION

Patients with episodes of supraventricular tachycardia (SVT), a common heart arrhythmia, are often attended by ambulance services. International guidelines advocate treatment with the Valsalva manoeuvre (VM), but this simple physical treatment has a low success rate, with most patients requiring conveyance to hospital. The Valsalva Assist Device (VAD) is a simple device that might help practitioners and patients perform a more effective VM and reduce the need for patients to be taken to hospital.

METHODS AND ANALYSIS

This stepped wedge cluster randomised controlled trial, conducted within a UK ambulance service, compares the current standard VM with a VAD-delivered VM in stable adult patients presenting to the ambulance service with SVT. The primary outcome is conveyance to hospital; secondary outcomes measures include cardioversion rates, duration of ambulance care and number of subsequent episodes of SVT requiring ambulance service care. We plan to recruit approximately 800 patients, to have 90% power to detect an absolute reduction in conveyance rate of 10% (from 90% to 80%) between the standard VM (control) and VAD-delivered VM (intervention). Such a reduction in conveyance would benefit patients, the ambulance service and receiving emergency departments. It is estimated potential savings would pay for devices for the entire ambulance trust within 7 months.

ETHICS AND DISSEMINATION

The study has been approved by the Oxford Research Ethics Committee (reference 22/SC/0032). Dissemination will be through peer-reviewed journal publication, presentation at national and international conferences and by the Arrhythmia Alliance, a patient support charity.

TRIAL REGISTRATION NUMBER

ISRCTN16145266.

Rapid Roll Out of a Pacemaker Home Monitoring Programme: A Patient Perspective

OBJECTIVE

To assess the safety, efficacy, and patient acceptability of a pacemaker home monitoring (HM) service.

METHODS

All patients receiving a new Biotronik (Biotronik, Berlin, Germany) pacemaker between March 2020 and February 2021 were contacted for participation. Participants were surveyed on their experience of pacemaker HM. HM alerts and remote wound monitoring rates were also assessed.

RESULTS

Of the patients contacted, 77% responded, with a mean age of 80.6±9.9 years. Of these, 95.8% agreed that the home monitoring (HM) has been beneficial. Two thirds preferred HM to face-to-face follow-up and two thirds felt safe with HM. Three themes were identified from the comments: reassurance, technology and data security. Forty-one percent (41%) of respondents would like more reassurance that their HM is working, 18% mentioned technology with mixed responses, and 4.7% cited cybersecurity or the use of their personal data as a concern. The average one-way patient journey saved was 24.3±16.7 km (15.1±10.4 miles). One in three HM alerts required action but only 3.4% were urgent. Remote wound review was successful in 59%.

CONCLUSIONS

The majority of patients prefer HM and almost all think it has been beneficial. It saves significant travel time and provides actionable alerts. The patient experience could be improved by reassuring patients that their device is being monitored.

Temporal association between invasive procedures and infective endocarditis

OBJECTIVE

Antibiotic prophylaxis has been recommended for patients at increased risk of infective endocarditis (IE) undergoing specific invasive procedures (IPs) despite a lack of data supporting its use. Therefore, antibiotic prophylaxis recommendations ceased in the mid-2000s for all but those at high IE risk undergoing invasive dental procedures. We aimed to quantify any association between IPs and IE.

METHODS

All 14 731 IE hospital admissions in England between April 2010 and March 2016 were identified from national admissions data, and medical records were searched for IP performed during the 15-month period before IE admission. We compared the incidence of IP during the 3 months immediately before IE admission (case period) with the incidence during the preceding 12 months (control period) to determine whether the odds of developing IE were increased in the 3 months after certain IP.

RESULTS

The odds of IE were increased following permanent pacemaker and defibrillator implantation (OR 1.54, 95% CI 1.27 to 1.85, p<0.001), extractions/surgical tooth removal (OR 2.14, 95% CI 1.22 to 3.76, p=0.047), upper (OR 1.58, 95% CI 1.34 to 1.85, p<0.001) and lower gastrointestinal endoscopy (OR 1.66, 95% CI 1.35 to 2.04, p<0.001) and bone marrow biopsy (OR 1.76, 95% CI 1.16 to 2.69, p=0.039). Using an alternative analysis, bronchoscopy (OR 1.33, 95% CI 1.06 to 1.68, p=0.049) and blood transfusions/red cell/plasma exchange (OR 1.2, 95% CI 1.07 to 1.35, p=0.012) were also associated with IE.

CONCLUSIONS

This study identifies a significant association between specific IPs (permanent pacemaker and defibrillator implantation, dental extraction, gastrointestinal endoscopy and bronchoscopy) and subsequent IE that warrants re-evaluation of current antibiotic prophylaxis recommendations to prevent IE in high IE risk individuals.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Very low event rate and few device implants in drug-induced brugada. A seven-year experience of ajmaline challenge at a district general hospital

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with a drug-induced Brugada electrocardiogram (ECG) are thought to have a lower risk of sudden cardiac death than those with a spontaneous type 1 ECG. Despite having a Brugada ECG, most patients do not need an implantable cardioverter defibrillator (ICD).

Purpose

To report a district general hospital experience on referral and outcomes of ajmaline challenge (AC) with medium term follow up.

Methods

92 consecutive patients (50 males, mean age 41 ±17) had an AC in a single centre from 2014-2021. High ventricular leads were used from 2015. Ajmaline (1m/kg) was administered intravenously over 10-minutes. Data were collected from the electronic health record.

Results

The AC was positive in 18 (20%) patients. The yield from high leads was higher (7% vs 22%) p=0.28) but not statistically significant. There were no deaths or documented ventricular arrhythmias (VA) in AC positive patients during a median follow up of 3.2 years (1.7-4.9).

The resting ECG was normal in 46.7%. A type 1 pattern had been provoked by fever or electrolyte derangements in 3.3%, type 2 pattern in 8.7% and a type 3 pattern in 5.4%. An RSR pattern (not in keeping with a BrS ECG) was seen in 26.4%. The test was stopped prematurely due to QRS widening &gt;150ms in 1 patient. No adverse arrhythmic events occurred (table 1).

In our cohort, positive AC patients were older (48y vs 37y p= 0.05) and more likely to have a type 2 (28% vs 4% p=0.007) or type 3 ECG (17% vs 3% p=0.05). Asymptomatic patients were more likely to have a normal ECG (22% vs 78% p=0.05)

Of those with a positive AC, nine patients had symptoms of palpitations or syncope (table 2). A subcutaneous ICD (S-ICD) was implanted for syncope in two patients. No device therapies have occurred during a follow up of 2.5 years and 3.9 years respectively. Of those with a positive AC but asymptomatic, one S-ICD was initially implanted due to patient preference. A second S-ICD was implanted in a patient who experienced a collapse and brief seizure in the context of modest alcohol consumption.

In seven positive patients (39%) and 18 negative patients (23%) an ILR was implanted. 1 episode of complete heart block was detected in an ajmaline negative patient during a median follow up of 2.7 years (1.7-3.9).

There were no device related complications or adverse events.

Conclusion

AC is safe with a low number of device implants and ICD shocks. The yield from ILR implants was very low. A single patient had a potentially adverse outcome after consuming alcohol, a known trigger for VA in BrS. Our findings are in keeping with contemporary evidence that suggests the risk of adverse cardiac events in drug-induced BrS is low. However, time to first ICD shock may occur after ten years or more from diagnosis so long term follow up is required.

Coenzyme Q10 to manage chronic heart failure with a reduced ejection fraction: a systematic review and economic evaluation

BACKGROUND

Chronic heart failure is a debilitating condition that accounts for an annual NHS spend of £2.3B. Low levels of endogenous coenzyme Q10 may exacerbate chronic heart failure. Coenzyme Q10 supplements might improve symptoms and slow progression. As statins are thought to block the production of coenzyme Q10, supplementation might be particularly beneficial for patients taking statins.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of coenzyme Q10 in managing chronic heart failure with a reduced ejection fraction.

METHODS

A systematic review that included randomised trials comparing coenzyme Q10 plus standard care with standard care alone in chronic heart failure. Trials restricted to chronic heart failure with a preserved ejection fraction were excluded. Databases including MEDLINE, EMBASE and CENTRAL were searched up to March 2020. Risk of bias was assessed using the Cochrane Risk of Bias tool (version 5.2). A planned individual participant data meta-analysis was not possible and meta-analyses were mostly based on aggregate data from publications. Potential effect modification was examined using meta-regression. A Markov model used treatment effects from the meta-analysis and baseline mortality and hospitalisation from an observational UK cohort. Costs were evaluated from an NHS and Personal Social Services perspective and expressed in Great British pounds at a 2019/20 price base. Outcomes were expressed in quality-adjusted life-years. Both costs and outcomes were discounted at a 3.5% annual rate.

RESULTS

A total of 26 trials, comprising 2250 participants, were included in the systematic review. Many trials were reported poorly and were rated as having a high or unclear risk of bias in at least one domain. Meta-analysis suggested a possible benefit of coenzyme Q10 on all-cause mortality (seven trials, 1371 participants; relative risk 0.68, 95% confidence interval 0.45 to 1.03). The results for short-term functional outcomes were more modest or unclear. There was no indication of increased adverse events with coenzyme Q10. Meta-regression found no evidence of treatment interaction with statins. The base-case cost-effectiveness analysis produced incremental costs of £4878, incremental quality-adjusted life-years of 1.34 and an incremental cost-effectiveness ratio of £3650. Probabilistic sensitivity analyses showed that at thresholds of £20,000 and £30,000 per quality-adjusted life-year coenzyme Q10 had a high probability (95.2% and 95.8%, respectively) of being more cost-effective than standard care alone. Scenario analyses in which the population and other model assumptions were varied all found coenzyme Q10 to be cost-effective. The expected value of perfect information suggested that a new trial could be valuable.

LIMITATIONS

For most outcomes, data were available from few trials and different trials contributed to different outcomes. There were concerns about risk of bias and whether or not the results from included trials were applicable to a typical UK population. A lack of individual participant data meant that planned detailed analyses of effect modifiers were not possible.

CONCLUSIONS

Available evidence suggested that, if prescribed, coenzyme Q10 has the potential to be clinically effective and cost-effective for heart failure with a reduced ejection fraction. However, given important concerns about risk of bias, plausibility of effect sizes and applicability of the evidence base, establishing whether or not coenzyme Q10 is genuinely effective in a typical UK population is important, particularly as coenzyme Q10 has not been subject to the scrutiny of drug-licensing processes. Stronger evidence is needed before considering its prescription in the NHS.

FUTURE WORK

A new independent, well-designed clinical trial of coenzyme Q10 in a typical UK heart failure with a reduced ejection fraction population may be warranted.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018106189.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 4. See the NIHR Journals Library website for further project information.

The resuscitation status of implantable cardioverter-defibrillator patients according to electronic health records: are we ignoring the device?

Introduction/Background

The Care Quality Commission (CQC) has recently raised concerns around resuscitation decisions in the UK. In our hospital an early resuscitation decision is made on admission, often by junior doctors, and documented in electronic notes. Concerns have been raised about the veracity of these discussions in patients with implantable cardioverter-defibrillators (ICD's). We investigated resuscitation status as documented on the electronic record for our ICD population.

Methods

The ICD database was interrogated in 2020 for patients under current follow-up. Baseline demographics, hospital admissions over the past 5 years and ICD indications were documented from the electronic hospital records. All patients with an electronic do-not-resuscitate (DNR) flag on the electronic system were recorded, as were any documented resuscitation discussions and ICD deactivations between 2015 and 2020. Any patient deaths were recorded and correlated with resuscitation status and ICD status at the time of death.

Results

Six-hundred and thirty-six patients with ICD's (transvenous, subcutaneous and CRT defibrillators) were identified under follow-up for the study period. The mean age of the population was 68 years old. 251 had an ischaemic cardiomyopathy, 209 had dilated cardiomyopathy, 50 prior ventricular fibrillation or tachycardia, 40 hypertrophic cardiomyopathy, 26 ARVC and the rest a channelopathy, congenital heart disease, sarcoidosis or valvular heart disease.

Thirty-seven of the 636 patients were flagged on the electronic record as being not for resuscitation (5.9%). They had a mean age of 79 and 54% had an ischaemic cardiomyopathy. Of these, only 15 (39%) had their ICD deactivated and only 12 of those at the time of the resuscitation decision (32%). 15 of the 37 (39%) patients made DNR have subsequently died. Six of these (40%) had an active ICD at the time of death.

In the 257 patients who had had a hospital admission in the study period, 34 were made not for resuscitation during the admission (13%) of whom 11 had their ICD deactivated at the time of discussion (32%). Patients with a DNR flag and an “active” ICD were contacted about deactivation of their ICD and offered discussion with a cardiologist or specialist nurse about ICD deactivation. Of these 9/27 (33%) stated that they wanted resuscitation and the alert was removed and the ICD kept on, although 3 subsequently had the device deactivated.

Conclusions

In this study the majority of patients with ICD's who were made not for resuscitation on admission to hospital did not have their ICD therapies switched off, therefore putting them at risk of unnecessary ICD shocks. In addition, one third these patients subsequently chose to be for resuscitation after discussion. These complex decisions would be improved with the early involvement of cardiologists and specialist nurses.

Funding Acknowledgement

Type of funding sources: None.

Rapid rollout of a pacemaker home monitoring service during the 2020 COVID-19 pandemic

Introduction

In an effort to reduce non-essential face to face contact during the COVD pandemic our pacemaker service was restructured in March 2020 to home monitoring only. Home monitors were issued at implant and wound reviews were done remotely via photo messages at one month or if prompted by the patient. Existing patients were given monitors on an ad hoc basis. A dedicated physiologist worked off site on home monitoring clinics. We assessed the impact on our service and on patient experience of these changes one year after implementation.

Methods

Baseline characteristics of age at implant and distance of home address from hospital were collected from all patients undergoing pacemaker home monitoring. Patients were surveyed using an adapted version of the Generic Short Patient Experiences Questionnaire (GS-PEQ). Comparison was made with our standard face-to-face follow-up model (1, 3, and 12 months).

Results

Data was collected for 326 patients. 233 received a new permanent pacemaker from March 2020 onwards and 93 existing patients were issued with a home monitor. Average age at pacemaker implant was 80.6 years (±9.9 years). The average one-way distance from home to outpatient clinic saved was 15.1 miles (±10.4 miles). 567 face-to-face appointments were saved. On an average day the off-site physiologist reviewed over 100 patient records a day, contacted 10 patients by phone and dictated reports on 20 patients (14 clinic patients and 6 alerts).

Of patients surveyed 88% agreed with the statement “I feel safe being cared for solely with a remote monitoring service” and 84% agreed with the statement “I receive the same standard of care via remote monitoring and face-to-face appointments”. Time saved by avoiding a face to face appointment was more than 1 hour for 90% of respondents. Respondents requested communication of reassuring monitoring, the ability to contact the pacing team in the event of concerns and clearer instructions for the home monitoring device.

Only 34% of newly implanted patients were able to send a photo message of their wound without prompting. We did not get a post procedure photo in 38% and the rest either spoke to us about the wound or had a face-to face visit. There was a significant difference in mean age between those who sent a photo (73.7 years) and those who didn't (81.4 years) (P=0.0006).

Conclusion

Rapid role out of a remote monitoring service for permanent pacemakers across a large county was feasible, produced significant savings in clinic time and was well received by patients. There were significant time savings for physiologists and patients. However remote wound monitoring in elderly patients was problematic due to the difficulty of sending photo messages.

Funding Acknowledgement

Type of funding sources: None.

The effect of a standardised protocol for CIED insertion on complications and infection rates in a DGH

Cardiac implantable electronic device (CIED)-related complications and infections typically lead to prolonged hospital stays and, very occasionally, death. A new CIED insertion protocol was implemented in a district general hospital. The primary objective of this study was to determine whether a significant reduction in complication and infection rates occurred after implementation of the new protocol. Medical records were reviewed for patients who had a CIED inserted in the two years pre- and post-protocol implementation, and any complications were identified in a one-year follow-up period. An increase in the complexity of the devices implanted after introduction of the protocol was observed. The number of complications was significantly reduced from 6.86% to 3.95% (p<0.0001). In the two years prior to protocol implementation, 14 of 871 (1.6%) patients suffered a CIED-related infection. In contrast, four of 683 (0.44%) patients suffered a CIEDrelated infection in the two years postimplementation. This was not statistically significant (p=0.093). In conclusion, implementing a standardised protocol for CIED insertion significantly reduced the rate of complications, and also reduced the rate of infection, but this was not statistically significant.

The central nervous system and heart failure

The view that chronic heart failure was exclusively a disease of the heart dominated the cardiovascular literature until relatively recently. However, over the last 40 years it has increasingly come to be seen as a multisystem disease. Aside from changes in the sympathetic and parasympathetic nervous systems and the renin-angiotensin-aldosterone system, adaptations to the lungs, muscles and gastrointestinal tract have been clearly documented. It is clear that the brain and CNS are also affected in patients with heart failure, although this is often under recognized. The purpose of this review is to summarize the changes in the structure and biochemical function of the CNS in patients with chronic heart failure and to discuss their potential importance.

Factors influencing digital review of pathology test results in an inpatient setting: a cross-sectional study

BACKGROUND

Delay or failure to view test results in a hospital setting can lead to delayed diagnosis, risk of patient harm, and represents inefficiency. Factors influencing this were investigated to identify how timeliness and completeness of test review could be improved through an evidence-based redesign of the use of clinical test review software.

METHODS

A cross-section of all abnormal hematology and biochemistry results which were published on a digital test review platform over a 3-year period were investigated. The time it took for clinicians to view these results, and the results that were not viewed within 30 days, were analyzed relative to time of the week, the detailed type of test, and an indicator of patient record data quality.

RESULTS

The majority of results were viewed within 90 min, and 93.9% of these results viewed on the digital platform within 30 days. There was significant variation in results review throughout the week, shown to be due to an interplay between technical and clinical workflow factors. Routine results were less likely to be reviewed, as were those with patient record data quality issues.

CONCLUSION

The evidence suggests that test result review would be improved by stream-lining access to the result platform, differentiating between urgent and routine results, improving handover of responsibility for result review, and improving search for temporary patient records. Altering the timing of phlebotomy rounds and a review of the appropriateness of routine test requests at the weekend may also improve result review rates.

A comparison of different antibiotic regimens for the treatment of infective endocarditis

BACKGROUND

Infective endocarditis is a microbial infection of the endocardial surface of the heart. Antibiotics are the cornerstone of treatment, but due to the differences in presentation, populations affected, and the wide variety of micro-organisms that can be responsible, their use is not standardised. This is an update of a review previously published in 2016.

OBJECTIVES

To assess the existing evidence about the clinical benefits and harms of different antibiotics regimens used to treat people with infective endocarditis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase Classic and Embase, LILACS, CINAHL, and the Conference Proceedings Citation Index - Science on 6 January 2020. We also searched three trials registers and handsearched the reference lists of included papers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) assessing the effects of antibiotic regimens for treating definitive infective endocarditis diagnosed according to modified Duke's criteria. We considered all-cause mortality, cure rates, and adverse events as the primary outcomes. We excluded people with possible infective endocarditis and pregnant women.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, 'Risk of bias' assessment, and data extraction in duplicate. We constructed 'Summary of findings' tables and used GRADE methodology to assess the quality of the evidence. We described the included studies narratively.

MAIN RESULTS

Six small RCTs involving 1143 allocated/632 analysed participants met the inclusion criteria of this first update. The included trials had a high risk of bias. Three trials were sponsored by drug companies. Due to heterogeneity in outcome definitions and different antibiotics used data could not be pooled. The included trials compared miscellaneous antibiotic schedules having uncertain effects for all of the prespecified outcomes in this review. Evidence was either low or very low quality due to high risk of bias and very low number of events and small sample size. The results for all-cause mortality were as follows: one trial compared quinolone (levofloxacin) plus standard treatment (antistaphylococcal penicillin (cloxacillin or dicloxacillin), aminoglycoside (tobramycin or netilmicin), and rifampicin) versus standard treatment alone and reported 8/31 (26%) with levofloxacin plus standard treatment versus 9/39 (23%) with standard treatment alone; risk ratio (RR) 1.12, 95% confidence interval (CI) 0.49 to 2.56. One trial compared fosfomycin plus imipenem 3/4 (75%) versus vancomycin 0/4 (0%) (RR 7.00, 95% CI 0.47 to 103.27), and one trial compared partial oral treatment 7/201 (3.5%) versus conventional intravenous treatment 13/199 (6.53%) (RR 0.53, 95% CI 0.22 to 1.31). The results for rates of cure with or without surgery were as follows: one trial compared daptomycin versus low-dose gentamicin plus an antistaphylococcal penicillin (nafcillin, oxacillin, or flucloxacillin) or vancomycin and reported 9/28 (32.1%) with daptomycin versus 9/25 (36%) with low-dose gentamicin plus antistaphylococcal penicillin or vancomycin; RR 0.89, 95% CI 0.42 to 1.89. One trial compared glycopeptide (vancomycin or teicoplanin) plus gentamicin with cloxacillin plus gentamicin (13/23 (56%) versus 11/11 (100%); RR 0.59, 95% CI 0.40 to 0.85). One trial compared ceftriaxone plus gentamicin versus ceftriaxone alone (15/34 (44%) versus 21/33 (64%); RR 0.69, 95% CI 0.44 to 1.10), and one trial compared fosfomycin plus imipenem versus vancomycin (1/4 (25%) versus 2/4 (50%); RR 0.50, 95% CI 0.07 to 3.55). The included trials reported adverse events, the need for cardiac surgical interventions, and rates of uncontrolled infection, congestive heart failure, relapse of endocarditis, and septic emboli, and found no conclusive differences between groups (very low-quality evidence). No trials assessed quality of life.

AUTHORS' CONCLUSIONS

This first update confirms the findings of the original version of the review. Limited and low to very low-quality evidence suggests that the comparative effects of different antibiotic regimens in terms of cure rates or other relevant clinical outcomes are uncertain. The conclusions of this updated Cochrane Review were based on few RCTs with a high risk of bias. Accordingly, current evidence does not support or reject any regimen of antibiotic therapy for the treatment of infective endocarditis.

A cross-sectional audit of the risk of burnout among senior medical staff in a UK district general hospital

OBJECTIVE

The objective was to assess burnout in senior hospital doctors (consultants and staff grade, associate specialist and specialty (SAS) doctors) within a UK-based NHS district general hospital (DGH).

METHOD

A web-based survey was created using the validated abbreviated Maslach Burnout Inventory (aMBI) with consultants and SAS doctors in a DGH.

PRIMARY AND SECONDARY OUTCOME MEASURES

We measured scores on aMBI subscales: depersonalisation, emotional exhaustion, personal accomplishment and efficacy.

RESULTS

One-hundred and seventy-eight senior clinicians (60% of consultant and SAS doctors) completed the survey with 85% of these being substantive consultants. Forty-nine per cent of senior clinicians were found to be at high risk of burnout using metrics from the aMBI.

CONCLUSIONS

Burnout is prevalent among senior clinicians at this DGH.

P3792The impact of elective cardioversion for atrial fibrillation in heart failure patients

Introduction

Severe left ventricular systolic dysfunction (LVSD) is associated with worse outcomes in heart failure (HF) patients. Persistent atrial fibrillation (AF) is common in this patient group. As part of a nurse-led cardioversion service at a district general hospital we assessed the impact of elective cardioversion (DCCV) for AF in patients with LVSD on their ejection fraction (EF), and compared outcomes in patients selectively pre-treated with amiodarone for their DCCV.

Methods

A retrospective analysis was undertaken of DCCV for AF over 5 years, recording demographic, medication, serial echocardiogram (TTE), and outcome data. Significant LVSD was classified as moderate (ejection fraction [EF] 35–45%) or severe (EF<35%). All patients treated with amiodarone had baseline and serial thyroid, liver, renal function monitored, were counselled on side effects and followed up.

Results

103 patients with significant LVSD and follow-up TTE underwent DCCV, with a median age of 66 (IQR 58–73) and mean CHA2DS2-VASc 2.5. Overall mean baseline EF was 30% (SD ±11), overall follow-up EF (regardless of repeat TTE rhythm) was 42% (SD ±12), and the mean delta EF +12% improvement (SD ±11). At follow-up TTE, 66% (68/103) of patients were in sinus rhythm (SR) and 34% (35/103) in AF. 62/68 (91%) patients in SR at follow-up TTE were also treated with HF medications, vs 33/35 (94%) of those in AF. 61/68 (90%) of patients in SR at follow-up TTE had any improvement in EF vs 21/35 (60%) patients in AF (p=0.0007). For patients in SR the mean baseline EF was 31% (SD ±10) and mean follow-up EF 47% (SD ±9), vs the AF at repeat TTE patients' mean baseline EF 27% (SD ±12) and mean follow-up EF 35% (SD ±13). The mean delta EF of patients still in SR at follow-up scan was 15% (SD ±10) vs 8% (SD ±11) for patients who had reverted to AF (p=0.0004). Prior analysis of our data-set including patients awaiting repeat TTE demonstrated a significant improvement in 6 month AF recurrence rate.

Table 1. Comparing outcomes with amiodarone pre-treatment for patient with follow-up EF data Acute DCCV Success Mean Baseline EF Mean Repeat EF Mean Delta EF AF Recurrence to 6 months Amiodarone 17/17 (100%) 29% (SD 11) 45% (SD 11) 15% (SD 13) 6/17 (35%) No Amiodarone 80/86 (93%) 30% (SD 11) 42% (SD 12) 12% (SD 10) 50/86 (58%) P value 0.59 0.22 0.11

Conclusion

Restoration of SR in a cohort of patients with AF, severe LVSD, on good medical therapy significantly improves left ventricular EF. This reinforces the importance of maintaining SR for HF patients. There was also a trend towards improved medium term outcomes in patients pre-treated with amiodarone. Further study into long-term rhythm control and ablation outcomes is needed.

P766The impact of a nurse-led heart failure service on complex device need

Introduction

The prevalence of left ventricular systolic dysfunction (LVSD) continues to rise. It is recognised that optimal medical therapy can improve ejection fraction (EF) in a proportion of patients. A nurse-led Heart Failure Service (HFS) was established in a district general hospital to deliver this, and previous analysis has demonstrated its efficacy in optimising HF drugs to recognised therapeutic doses.

Complex devices (Implantable Cardiac Defibrillators [ICDs] or Cardiac Re-synchronisation Therapy Devices [CRTs]) are established treatments for HF patients if on Optimal Medical Therapy (OMT). The European Society of Cardiology (ESC) and National Institute for Clinical Excellence (NICE) guidelines have expanded their role with a broad cohort of patients eligible for this therapy.

Aim

We sought to determine how many patients, who at baseline had an indication for device therapy, improved after OMT to an extent that they no longer had an indication for device therapy.

Methods

A retrospective analysis was undertaken of the HFS database over a 5 year period recording ECG for QRS duration & morphology, surveillance of EF, device outcome. Exclusion criteria: Baseline EF >35%; device in-situ or listed for prior to HFS referral; no identifiable baseline EF or ECG.

Results

502 patients were analysed and 264 patients met criteria for a new device or upgrade at baseline – 191 male (72%), 73 female (28%), median age 73 (IQR 64–80).

76/97 (78%) of potential CRT candidates (Pacing or Defibrillator component) were male. 16/97 (16%) improved to an EF >35% (median age 68 [IQR 64–72], 14 male [88%], 2 female [12%]). 4/16 (25%) of these patients underwent pharmacological or electrical cardioversion, which can contribute to EF improvement.

There were 167 potential ICD candidates (115 male [69%]). 53 /167 (32%) improved to an EF >35% (median age 68 [IQR 56–75], 33 male [61%]). 7/53 (13%) of these patients had other treatments that can also improve EF (cardioversion, 4; re-vascularisation, 2; valvuloplasty, 1).

69/264 (26.1%) patients did not require a device after optimal therapy had been delivered.

Conclusions

We have demonstrated that in a significant proportion of HFS patients, the delivery of high quality OMT translates into an improvement in EF.

Not all patients that strictly “meet guideline criteria” will be offered a device, nor will all patients take up offer of a device. However, this improvement in EF is likely to benefit the patient symptomatically and prognostically, and carry a significant cost saving to healthcare institutions. A cost analysis study will be undertaken to further assess this.

B-type natriuretic peptide-guided therapy for heart failure (HF): a systematic review and meta-analysis of individual participant data (IPD) and aggregate data

BACKGROUND

We estimated the effectiveness of serial B-type natriuretic peptide (BNP) blood testing to guide up-titration of medication compared with symptom-guided up-titration of medication in patients with heart failure (HF).

METHODS

Systematic review and meta-analysis of randomised controlled trials (RCTs). We searched: MEDLINE (Ovid) 1950 to 9/06/2016; Embase (Ovid), 1980 to 2016 week 23; the Cochrane Library; ISI Web of Science (Citations Index and Conference Proceedings). The primary outcome was all-cause mortality; secondary outcomes were death related to HF, cardiovascular death, all-cause hospital admission, hospital admission for HF, adverse events, and quality of life. IPD were sought from all RCTs identified. Random-effects meta-analyses (two-stage) were used to estimate hazard ratios (HR) and confidence intervals (CIs) across RCTs, including HR estimates from published reports of studies that did not provide IPD. We estimated treatment-by-covariate interactions for age, gender, New York Heart Association (NYHA) class, HF type; diabetes status and baseline BNP subgroups. Dichotomous outcomes were analysed using random-effects odds ratio (OR) with 95% CI.

RESULTS

We identified 14 eligible RCTs, five providing IPD. BNP-guided therapy reduced the hazard of hospital admission for HF by 19% (13 RCTs, HR 0.81, 95% CI 0.68 to 0.98) but not all-cause mortality (13 RCTs; HR 0.87, 95% CI 0.75 to 1.01) or cardiovascular mortality (5 RCTs; OR 0.88, 95% CI 0.67 to 1.16). For all-cause mortality, there was a significant interaction between treatment strategy and age (p = 0.034, 11 RCTs; HR 0.70, 95% CI 0.53-0.92, patients < 75 years old and HR 1.07, 95% CI 0.84-1.37, patients ≥ 75 years old); ejection fraction (p = 0.026, 11 RCTs; HR 0.84, 95% CI 0.71-0.99, patients with heart failure with reduced ejection fraction (HFrEF); and HR 1.33, 95% CI 0.83-2.11, patients with heart failure with preserved ejection fraction (HFpEF)). Adverse events were significantly more frequent with BNP-guided therapy vs. symptom-guided therapy (5 RCTs; OR 1.29, 95% CI 1.04 to 1.60).

CONCLUSION

BNP-guided therapy did not reduce mortality but reduced HF hospitalisation. The overall quality of the evidence varied from low to very low. The relevance of these findings to unselected patients, particularly those managed by community generalists, are unclear.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013005335.

Effectiveness and cost-effectiveness of serum B-type natriuretic peptide testing and monitoring in patients with heart failure in primary and secondary care: an evidence synthesis, cohort study and cost-effectiveness model

BACKGROUND

Heart failure (HF) affects around 500,000 people in the UK. HF medications are frequently underprescribed and B-type natriuretic peptide (BNP)-guided therapy may help to optimise treatment.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of BNP-guided therapy compared with symptom-guided therapy in HF patients.

DESIGN

Systematic review, cohort study and cost-effectiveness model.

SETTING

A literature review and usual care in the NHS.

PARTICIPANTS

(a) HF patients in randomised controlled trials (RCTs) of BNP-guided therapy; and (b) patients having usual care for HF in the NHS.

INTERVENTIONS

Systematic review: BNP-guided therapy or symptom-guided therapy in primary or secondary care. Cohort study: BNP monitored (≥ 6 months' follow-up and three or more BNP tests and two or more tests per year), BNP tested (≥ 1 tests but not BNP monitored) or never tested. Cost-effectiveness model: BNP-guided therapy in specialist clinics.

MAIN OUTCOME MEASURES

Mortality, hospital admission (all cause and HF related) and adverse events; and quality-adjusted life-years (QALYs) for the cost-effectiveness model.

DATA SOURCES

Systematic review: Individual participant or aggregate data from eligible RCTs. Cohort study: The Clinical Practice Research Datalink, Hospital Episode Statistics and National Heart Failure Audit (NHFA).

REVIEW METHODS

A systematic literature search (five databases, trial registries, grey literature and reference lists of publications) for published and unpublished RCTs.

RESULTS

Five RCTs contributed individual participant data (IPD) and eight RCTs contributed aggregate data (1536 participants were randomised to BNP-guided therapy and 1538 participants were randomised to symptom-guided therapy). For all-cause mortality, the hazard ratio (HR) for BNP-guided therapy was 0.87 [95% confidence interval (CI) 0.73 to 1.04]. Patients who were aged < 75 years or who had heart failure with a reduced ejection fraction (HFrEF) received the most benefit [interactions (p = 0.03): < 75 years vs. ≥ 75 years: HR 0.70 (95% CI 0.53 to 0.92) vs. 1.07 (95% CI 0.84 to 1.37); HFrEF vs. heart failure with a preserved ejection fraction (HFpEF): HR 0.83 (95% CI 0.68 to 1.01) vs. 1.33 (95% CI 0.83 to 2.11)]. In the cohort study, incident HF patients (1 April 2005-31 March 2013) were never tested (n = 13,632), BNP tested (n = 3392) or BNP monitored (n = 71). Median survival was 5 years; all-cause mortality was 141.5 out of 1000 person-years (95% CI 138.5 to 144.6 person-years). All-cause mortality and hospital admission rate were highest in the BNP-monitored group, and median survival among 130,433 NHFA patients (1 January 2007-1 March 2013) was 2.2 years. The admission rate was 1.1 patients per year (interquartile range 0.5-3.5 patients). In the cost-effectiveness model, in patients aged < 75 years with HFrEF or HFpEF, BNP-guided therapy improves median survival (7.98 vs. 6.46 years) with a small QALY gain (5.68 vs. 5.02) but higher lifetime costs (£64,777 vs. £58,139). BNP-guided therapy is cost-effective at a threshold of £20,000 per QALY.

LIMITATIONS

The limitations of the trial were a lack of IPD for most RCTs and heterogeneous interventions; the inability to identify BNP monitoring confidently, to determine medication doses or to distinguish between HFrEF and HFpEF; the use of a simplified two-state Markov model; a focus on health service costs and a paucity of data on HFpEF patients aged < 75 years and HFrEF patients aged ≥ 75 years.

CONCLUSIONS

The efficacy of BNP-guided therapy in specialist HF clinics is uncertain. If efficacious, it would be cost-effective for patients aged < 75 years with HFrEF. The evidence reviewed may not apply in the UK because care is delivered differently.

FUTURE WORK

Identify an optimal BNP-monitoring strategy and how to optimise HF management in accordance with guidelines; update the IPD meta-analysis to include the Guiding Evidence Based Therapy Using Biomarker Intensified Treatment (GUIDE-IT) RCT; collect routine long-term outcome data for completed and ongoing RCTs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN37248047 and PROSPERO CRD42013005335.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 40. See the NIHR Journals Library website for further project information. The British Heart Foundation paid for Chris A Rogers' and Maria Pufulete's time contributing to the study. Syed Mohiuddin's time is supported by the NIHR Collaboration for Leadership in Applied Health Research and Care West at University Hospitals Bristol NHS Foundation Trust. Rachel Maishman contributed to the study when she was in receipt of a NIHR Methodology Research Fellowship.

Is antibiotic prophylaxis to prevent infective endocarditis worthwhile?

Infective endocarditis (IE) is a rare condition which is associated with considerable morbidity and mortality. Almost 100 years ago, the links between endocarditis and procedures, particularly dental procedures, were postulated. Over 50 years ago the first guidelines recommending antibiotic prophylaxis (AP), with the aim of preventing IE developing after procedures, were proposed. However, there has only ever been circumstantial evidence in humans that AP prevents IE. The rarity of IE has made a randomised controlled clinical trial impractical to date. This article outlines the history of AP and reviews the evidence base for the use of AP to prevent IE.

Homocysteine-lowering interventions for preventing cardiovascular events

BACKGROUND

Cardiovascular disease, which includes coronary artery disease, stroke and peripheral vascular disease, is a leading cause of death worldwide. Homocysteine is an amino acid with biological functions in methionine metabolism. A postulated risk factor for cardiovascular disease is an elevated circulating total homocysteine level. The impact of homocysteine-lowering interventions, given to patients in the form of vitamins B6, B9 or B12 supplements, on cardiovascular events has been investigated. This is an update of a review previously published in 2009, 2013, and 2015.

OBJECTIVES

To determine whether homocysteine-lowering interventions, provided to patients with and without pre-existing cardiovascular disease are effective in preventing cardiovascular events, as well as reducing all-cause mortality, and to evaluate their safety.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 5), MEDLINE (1946 to 1 June 2017), Embase (1980 to 2017 week 22) and LILACS (1986 to 1 June 2017). We also searched Web of Science (1970 to 1 June 2017). We handsearched the reference lists of included papers. We also contacted researchers in the field. There was no language restriction in the search.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of homocysteine-lowering interventions for preventing cardiovascular events with a follow-up period of one year or longer. We considered myocardial infarction and stroke as the primary outcomes. We excluded studies in patients with end-stage renal disease.

DATA COLLECTION AND ANALYSIS

We performed study selection, 'Risk of bias' assessment and data extraction in duplicate. We estimated risk ratios (RR) for dichotomous outcomes. We calculated the number needed to treat for an additional beneficial outcome (NNTB). We measured statistical heterogeneity using the I2 statistic. We used a random-effects model. We conducted trial sequential analyses, Bayes factor, and fragility indices where appropriate.

MAIN RESULTS

In this third update, we identified three new randomised controlled trials, for a total of 15 randomised controlled trials involving 71,422 participants. Nine trials (60%) had low risk of bias, length of follow-up ranged from one to 7.3 years. Compared with placebo, there were no differences in effects of homocysteine-lowering interventions on myocardial infarction (homocysteine-lowering = 7.1% versus placebo = 6.0%; RR 1.02, 95% confidence interval (CI) 0.95 to 1.10, I2 = 0%, 12 trials; N = 46,699; Bayes factor 1.04, high-quality evidence), death from any cause (homocysteine-lowering = 11.7% versus placebo = 12.3%, RR 1.01, 95% CI 0.96 to 1.06, I2 = 0%, 11 trials, N = 44,817; Bayes factor = 1.05, high-quality evidence), or serious adverse events (homocysteine-lowering = 8.3% versus comparator = 8.5%, RR 1.07, 95% CI 1.00 to 1.14, I2 = 0%, eight trials, N = 35,788; high-quality evidence). Compared with placebo, homocysteine-lowering interventions were associated with reduced stroke outcome (homocysteine-lowering = 4.3% versus comparator = 5.1%, RR 0.90, 95% CI 0.82 to 0.99, I2 = 8%, 10 trials, N = 44,224; high-quality evidence). Compared with low doses, there were uncertain effects of high doses of homocysteine-lowering interventions on stroke (high = 10.8% versus low = 11.2%, RR 0.90, 95% CI 0.66 to 1.22, I2 = 72%, two trials, N = 3929; very low-quality evidence).We found no evidence of publication bias.

AUTHORS' CONCLUSIONS

In this third update of the Cochrane review, there were no differences in effects of homocysteine-lowering interventions in the form of supplements of vitamins B6, B9 or B12 given alone or in combination comparing with placebo on myocardial infarction, death from any cause or adverse events. In terms of stroke, this review found a small difference in effect favouring to homocysteine-lowering interventions in the form of supplements of vitamins B6, B9 or B12 given alone or in combination comparing with placebo.There were uncertain effects of enalapril plus folic acid compared with enalapril on stroke; approximately 143 (95% CI 85 to 428) people would need to be treated for 5.4 years to prevent 1 stroke, this evidence emerged from one mega-trial.Trial sequential analyses showed that additional trials are unlikely to increase the certainty about the findings of this issue regarding homocysteine-lowering interventions versus placebo. There is a need for additional trials comparing homocysteine-lowering interventions combined with antihypertensive medication versus antihypertensive medication, and homocysteine-lowering interventions at high doses versus homocysteine-lowering interventions at low doses. Potential trials should be large and co-operative.

Antibiotic prophylaxis for infective endocarditis: a systematic review and meta-analysis

OBJECTIVE

The use of antibiotic prophylaxis (AP) for prevention of infective endocarditis (IE) is controversial. In recent years, guidelines to cardiologists and dentists have advised restriction of AP to high-risk groups (in Europe and the USA) or against its use at all (in the UK). The objective of this systematic review was to appraise the evidence for use of AP for prevention of bacteraemia or IE in patients undergoing dental procedures.

METHODS

We conducted electronic searches in Medline, Embase, Cochrane Library and ISI Web of Science. We assessed the methodological characteristics of included studies using the Strengthening the Reporting of Observational Studies in Epidemiology criteria for observational studies and the Cochrane Risk of Bias Tool for trials. Two reviewers independently determined the eligibility of studies, assessed the methodology of included studies and extracted the data.

RESULTS

We identified 178 eligible studies, of which 36 were included in the review. This included 10 time-trend studies, 5 observational studies and 21 trials. All trials identified used bacteraemia as an endpoint rather than IE. One time-trend study suggests that total AP restriction may be associated with a rising incidence of IE, while data on the consequences of relative AP restriction are conflicting. Meta-analysis of trials indicates that AP is effective in reducing the incidence of bacteraemia (risk ratio 0.53, 95% CI 0.49 to 0.57, p<0.01), but case-control studies suggest this may not translate to a statistically significant protective effect against IE in patients at low risk of disease.

CONCLUSIONS

The evidence base for the use of AP is limited, heterogeneous and the methodological quality of many studies is poor. Postprocedural bacteraemia is not a good surrogate endpoint for IE. Given the logistical challenges of a randomised trial, high-quality case-control studies would help to evaluate the role of dental procedures in causing IE and the efficacy of AP in its prevention.

Antibiotic Prophylaxis of Infective Endocarditis

Links between infective endocarditis (IE) and dental and other invasive procedures were first identified in the 1920s, and the use of antibiotic prophylaxis (AP) to prevent IE was first recommended by the American Heart Association in 1955. Recognising the weak evidence to support this practice and the wider risks of anaphylaxis and antibiotic resistance, guidelines in the USA and Europe have been rationalised in the last decade with restriction of AP to those patients perceived to be at the highest risk. In the UK, the National Institute for Health and Care Excellence controversially recommended the complete cessation of AP for all invasive procedures in 2008 and subsequent epidemiological studies have suggested a significant increase in cases above the baseline trend. AP appears to be safe and is likely to be cost-effective. Until further data are available, we recommend continued adherence to US and European guidelines.

Model-based cost-effectiveness analysis of B-type natriuretic peptide-guided care in patients with heart failure

OBJECTIVE

Monitoring B-type natriuretic peptide (BNP) to guide pharmacotherapy might improve survival in patients with heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). However, the cost-effectiveness of BNP-guided care is uncertain and guidelines do not uniformly recommend it. We assessed the cost-effectiveness of BNP-guided care in patient subgroups defined by age and ejection fraction.

METHODS

We used a Markov model with a 3-month cycle length to estimate the lifetime health service costs, quality-adjusted life years (QALYs) and incremental net monetary benefits (iNMBs) of BNP-guided versus clinically guided care in 3 patient subgroups: (1) HFrEF patients <75 years; (2) HFpEF patients <75 years; and (3) HFrEF patients ≥75 years. There is no evidence of benefit in patients with HFpEF aged ≥75 years. We used individual patient data meta-analyses and linked primary care, hospital and mortality data to inform the key model parameters. We performed probabilistic analysis to assess the uncertainty in model results.

RESULTS

In younger patients (<75 years) with HFrEF, the mean QALYs (5.57 vs 5.02) and costs (£63 527 vs £58 139) were higher with BNP-guided care. At the willingness-to-pay threshold of £20 000 per QALY, the positive iNMB (£5424 (95% CI £987 to £9469)) indicates that BNP-guided care is cost-effective in this subgroup. The evidence of cost-effectiveness of BNP-guided care is less strong for younger patients with HFpEF (£3155 (-£10 307 to £11 613)) and older patients (≥75 years) with HFrEF (£2267 (-£1524 to £6074)). BNP-guided care remained cost-effective in the sensitivity analyses, albeit the results were sensitive to assumptions on its sustained effect.

CONCLUSIONS

We found strong evidence that BNP-guided care is a cost-effective alternative to clinically guided care in younger patients with HFrEF. It is potentially cost-effective in younger patients with HFpEF and older patients with HFrEF, but more evidence is required, particularly with respect to the frequency, duration and BNP target for monitoring. Cost-effectiveness results from trials in specialist settings cannot be generalised to primary care.

A comparison of different antibiotic regimens for the treatment of infective endocarditis

BACKGROUND

Infective endocarditis is a microbial infection of the endocardial surface of the heart. Antibiotics are the cornerstone of treatment, but their use is not standardised, due to the differences in presentation, populations affected and the wide variety of micro-organisms that can be responsible.

OBJECTIVES

To assess the existing evidence about the clinical benefits and harms of different antibiotics regimens used to treat people with infective endocarditis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE Classic and EMBASE, LILACS, CINAHL and the Conference Proceedings Citation Index on 30 April 2015. We also searched three trials registers and handsearched the reference lists of included papers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of antibiotic regimens for treating possible infective endocarditis diagnosed according to modified Duke's criteria. We considered all-cause mortality, cure rates and adverse events as the primary outcomes. We excluded people with possible infective endocarditis and pregnant women.

DATA COLLECTION AND ANALYSIS

Three review authors independently performed study selection, 'Risk of bias' assessment and data extraction in duplicate. We constructed 'Summary of findings' tables and used GRADE methodology to assess the quality of studies. We described the included studies narratively.

MAIN RESULTS

Four small randomised controlled trials involving 728 allocated/224 analysed participants met our inclusion criteria. These trials had a high risk of bias. Drug companies sponsored two of the trials. We were unable to pool the data due to the heterogeneity in outcome definitions and the different antibiotics used.The included trials compared the following antibiotic schedules. The first trial compared quinolone (levofloxacin) plus standard treatment (anti-staphylococcal penicillin (cloxacillin or dicloxacillin), aminoglycoside (tobramycin or netilmicin) and rifampicin) versus standard treatment alone reporting uncertain effects on all-cause mortality (8/31 (26%) with levofloxacin plus standard treatment versus 9/39 (23%) with standard treatment alone; RR 1.12, 95% CI 0.49 to 2.56, very low quality evidence). The second trial compared daptomycin versus low-dose gentamicin plus an anti-staphylococcal penicillin (nafcillin, oxacillin or flucloxacillin) or vancomycin. This showed uncertain effects in terms of cure rates (9/28 (32.1%) with daptomycin versus 9/25 (36%) with low-dose gentamicin plus anti-staphylococcal penicillin or vancomycin, RR 0.89 95% CI 0.42 to 1.89; very low quality evidence). The third trial compared cloxacillin plus gentamicin with a glycopeptide (vancomycin or teicoplanin) plus gentamicin. In participants receiving gentamycin plus glycopeptide only 13/23 (56%) were cured versus 11/11 (100%) receiving cloxacillin plus gentamicin (RR 0.59, 95% CI 0.40 to 0.85; very low quality evidence). The fourth trial compared ceftriaxone plus gentamicin versus ceftriaxone alone and found no conclusive differences in terms of cure (15/34 (44%) with ceftriaxone plus gentamicin versus 21/33 (64%) with ceftriaxone alone, RR 0.69, 95% CI 0.44 to 1.10; very low quality evidence).The trials reported adverse events, need for cardiac surgical interventions, uncontrolled infection and relapse of endocarditis and found no conclusive differences between comparison groups (very low quality evidence). No trials assessed septic emboli or quality of life.

AUTHORS' CONCLUSIONS

Limited and very low quality evidence suggested that there were no conclusive differences between antibiotic regimens in terms of cure rates or other relevant clinical outcomes. However, because of the very low quality evidence, this needs confirmation. The conclusion of this Cochrane review was based on randomised controlled trials with high risk of bias. Accordingly, current evidence does not support or reject any regimen of antibiotic therapy for treatment of infective endocarditis.

Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial

BACKGROUND

The Valsalva manoeuvre is an internationally recommended treatment for supraventricular tachycardia, but cardioversion is rare in practice (5-20%), necessitating the use of other treatments including adenosine, which patients often find unpleasant. We assessed whether a postural modification to the Valsalva manoeuvre could improve its effectiveness.

METHODS

We did a randomised controlled, parallel-group trial at emergency departments in England. We randomly allocated adults presenting with supraventricular tachycardia (excluding atrial fibrillation and flutter) in a 1:1 ratio to undergo a modified Valsalva manoeuvre (done semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain), or a standard semi-recumbent Valsalva manoeuvre. A 40 mm Hg pressure, 15 s standardised strain was used in both groups. Randomisation, stratified by centre, was done centrally and independently, with allocation with serially numbered, opaque, sealed, tamper-evident envelopes. Patients and treating clinicians were not masked to allocation. The primary outcome was return to sinus rhythm at 1 min after intervention, determined by the treating clinician and electrocardiogram and confirmed by an investigator masked to treatment allocation. This study is registered with Current Controlled Trials (ISRCTN67937027).

FINDINGS

We enrolled 433 participants between Jan 11, 2013, and Dec 29, 2014. Excluding second attendance by five participants, 214 participants in each group were included in the intention-to-treat analysis. 37 (17%) of 214 participants assigned to standard Valsalva manoeuvre achieved sinus rhythm compared with 93 (43%) of 214 in the modified Valsalva manoeuvre group (adjusted odds ratio 3·7 (95% CI 2·3-5·8; p<0·0001). We recorded no serious adverse events.

INTERPRETATION

In patients with supraventricular tachycardia, a modified Valsalva manoeuvre with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients.

FUNDING

National Institute for Health Research.

Protocol for a systematic review and individual participant data meta-analysis of B-type natriuretic peptide-guided therapy for heart failure

BACKGROUND

Several aggregate data meta-analyses suggest that treatment guided by the serum concentration of natriuretic peptides (B-type natriuretic peptide (BNP) or its derivative N-terminal pro-B-type natriuretic peptide (NT-BNP)) reduces all-cause mortality compared with usual care in patients with heart failure (HF). We propose to conduct a meta-analysis using individual participant data (IPD) to estimate the effect of BNP-guided therapy on clinical outcomes, and estimate the extent of effect modification for clinically important subgroups.

METHODS

We will use standard systematic review methods to identify relevant trials and assess study quality. We will include all randomized controlled trials (RCTs) of BNP-guided treatment for HF that report a clinical outcome. The primary outcome will be time to all-cause mortality. We will collate anonymized, individual patient data into a single database, and carry out appropriate data checks. We will use fixed-effects and random-effects meta-analysis methods to combine hazard ratios (HR) estimated within each RCT, across all RCTs. We will also include a meta-analysis and meta-regression analyses based on aggregate data, and combine IPD with aggregate data if we obtain IPD for a subset of trials.

DISCUSSION

The IPD meta-analysis will allow us to estimate how patient characteristics modify treatment benefit, and to identify relevant subgroups of patients who are likely to benefit most from BNP-guided therapy. This is important because aggregate meta-analyses have suggested that clinically relevant subgroup effects exist, but these analyses have been unable to quantify the effects reliably or precisely.

TRIALS REGISTRATION

PROSPERO 2013: CRD42013005335.