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Introduction Many patients who present to E/D with low or intermediate risk cardiac presentations can be safely managed with out-patient ambulatory diagnostics strategy. The lack of definitive outpatient pathways to safely manage these patients has a significant impact on admissions and length of stay adding to the current bed crisis and overcrowding of Emergency Department (E/D). A novel collaborative approach to this problem involved the implementation of a Cardiology ANP led Virtual Clinic outpatient ambulatory pathway which facilitates the referral of non ACS chest discomfort, rate controlled atrial fibrillation/flutter/pSVT, stable heart failure, HTN, incidental murmur, low risk collapse/syncope from the ED and provides patients with rapid access to a comprehensive range of outpatient cardiology diagnostics prior to referral to OPD when necessary. Aims/Objectives To determine the benefit of an ANP-led Virtual Cardiology Clinic to the patient and the organisation. Methodology Clinic referrals from January 2017 - December 2017 were audited. Data was collected prospectively as patients were referred to the service and those referred patients underwent case review (History/exam/Bloods/CXR/ECG) and when required, were contacted by phone. If indicated, appropriate diagnostics were requested, results reviewed then referred on to consultant clinic only if indicated. Results/Discussion 894 patients were referred. 9 patients (1%) recalled to ED. A significant 254 (28%) were deemed not to require diagnostics and discharged to GP. 732 diagnostic tests were performed on 640 patients including 201 functional stress tests (13 abnormal), 38 coronary day case angiograms (10 of which required PCI), 292 Holters, 97 ECHOs (13 minor abnormalities), 68 CTCA, 12 DCCV, 73 24 hour BP. 186 patients were subsequently referred to cardiology OPD. There were 2,145 acute beds saved (based on 2.4 LOS) with estimated savings of €2,4000,000. Conclusion The Cardiology ANP led Virtual Clinic is a safe and efficient pathway that pre – filters ED referrals resulting in reduced waiting time in the Emergency Department, unnecessary travel back to the hospital (further reducing travel time, costs, waiting times), unnecessary referral to cardiology outpatients (reducing outpatient department overcrowding and waiting times). In a 12-month period, this initiative has saved Beaumont Hospital an estimated 2.4 million Euro and 2,145 acute hospital bed days. Implications Cardiology ANP led Virtual Clinics have the potential for a significant impact around the country with regards to the appropriate and efficient management of acute cardiology presentations to E/D with early access to outpatient cardiology ambulatory diagnostics and appropriate referral to outpatient consultant cardiology clinics or d/c to GP.

Current guidelines recommend anticoagulation prior to cardioversion in patients with atrial fibrillation of48 h or unknown duration to reduce thromboembolic risk. Therapeutic anticoagulation with warfarin, with INR between 2 and 3, is consistently achieved in approximately 60% of patients.We evaluated outcomes and assessed differences in direct current cardioversion (DCCV) in patients treated with warfarin and novel oral anticoagulants (NOAC) at our institution.A retrospective analysis of consecutive DCCV at a tertiary referral over 18 months was conducted. Analysis of cardioversion records allowed completion of a standardised dataset. Clinical variables recorded included (1) CHADSVASC score, (2) anticoagulant use, and (3) bleeding complications.During this period 187 DCCVs were scheduled; 119 on warfarin and 68 on NOAC. DCCV was deferred in 26% (n = 31) of the warfarin group and 4.4% (n = 3) of the NOAC group (p = 0.0002). The average time interval between referral and DCCV was 144.43 and 109.32 days for the warfarin and NOAC groups, respectively (p value = 0.023). 7.56% (n = 9) of the warfarin population had a bleeding event compared to a 2.94% total bleeding rate in NOAC group (p = 0.213). Deferral of elective DCCV and additional anticoagulant monitoring was estimated at €1160 per procedure.In elective cardioversions, the group anticoagulated with NOAC was less likely to have subtherapeutic anticoagulation and hence deferred procedures and had reduced health care consumption when compared to the group anticoagulated with warfarin.

Dilated cardiomyopathy is a global myocardial abnormality in which it is likely that there are relatively homogeneous electrical conditions. The pattern of arrhythmic complications, especially atrial ectopic beats, ventricular ectopic beats and the brief salvoes of polymorphic ventricular tachycardia which are characteristic of the condition, suggest that triggered automaticity is a more likely arrhythmia mechanism than reentry. Although treatment with 'conventional' antiarrhythmic agents has an important place, drugs which alter myocardial loading conditions (and thus, thereby, a possible mechanism of triggered automaticity) may be effective. Therapeutic strategies directed against the basic disease processes are in an early stage of clinical development but they hold great promise for the future.

The magnitude of tolerance to the anti-anginal efficacy of transdermal nitroglycerin and the efficacy and safety of short (4 h) and long (10 h) nitrate-free intervals for its prevention, were investigated in a randomized, double-blind, placebo-controlled crossover trial of 4 week-long treatment regimens: placebo, continuous therapy with a 50 mg patch (10 mg.24 h-1), and 4 h and 10 h nitrate-free periods. Only patients showing greater than 1 min increase in time to 1 mm ST depression after acute patch administration were eligible. Twelve men completed the study. One other anti-anginal medication (a beta-blocker in nine and calcium antagonist in two) was permitted in a constant dose throughout the study. Patients underwent exercise testing on days 1 and 7 of each treatment period, and 24 h ambulatory ECG monitoring on day 6. Compared to placebo, transdermal nitroglycerin on day 1 significantly improved time to 1 mm ST depression by 35%, and time to angina, exercise duration and maximal workload by 21%, 13% and 9% respectively. These improvements were totally lost after 7 days' continuous therapy, but completely maintained by a 10 h nitrate-free period (improvements of 35%, 25%, 16% and 11% respectively) but not by a 4 h nitrate-free period (non-significant improvements of 15%, 2%, 4% and 1% respectively). The differences between 10 and 4 h nitrate-free were significant for each end-point. Neither duration of ambulatory ischaemia, nor the proportion of patients experiencing greater than or equal to 5 min ischaemia during the scheduled nitrate-free interval differed between treatments.(ABSTRACT TRUNCATED AT 250 WORDS)