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Introduction:Clinical, health economic and quality of life data supports the Direct Oral Anticoagulants (DOAC) over warfarin in patients at risk for thromboembolic events in the setting of non-valvulvar atrial fibrillation (AF). We sought to evaluate the rate and reasons for ongoing use of warfarin in this population.Methods:Baseline, follow up, medication reconciliation and insurance status data for all patients treated with warfarin at a large AF clinic were collected for this analysis. Contraindication to DOAC use were noted for all patients in the cohort. History of cardiovascular, renal, and hepatic disease, as well as the CHA2DS2-VASc score was obtained for all patients. Canadian Cardiovascular Society 2018 guidelines was used to assess treatment appropriateness.Results:553 patients treated with warfarin at the time of data collection (August 2018, Mean age: 76.0?9.6 years, 52% Male, Mean CHA2DS2-VASc score: 3.5?1.3) were identified and included in this analysis. Of those on warfarin 16% (88) did not have private insurance and were under the age of 65 (no public coverage), 18% (101) had a mechanical valve, 13% (74) had severe renal impairment, 3.4% (19) had a prior major bleeding episode, 10 of which occurred while patient was treated with a DOAC. Remaining 271 (49%) were eligible for treatment with a DOAC.Conclusion:Half of the patients seen at a large atrial fibrillation clinic treated with warfarin as of 2018 had no contraindications to a DOAC, but for reasons related to medication coverage, patient and physician comfort remain on warfarin. This population may derive further benefit from appropriate conversion to a DOAC.

Introduction:Ensuring adherence to evidence-based management of Heart Failure (HF) in a busy clinical practice is a challenge. An electronic medical records (EMR) system was enabled to alert physicians at the point of care prompting initiation of evidence based therapies in patients suffering from congestive heart failure (CHF). We sought to examine the impact of the point-of-care alerts on physician adherence to evidence based optimal medical therapy in these patients.Methods:Baseline, demographics, medication reconciliation, and follow-up data were collected for two groups of patients with diagnosis of HF - Group 1 were treated before (BI) and Group 2 after implementation (AI) of the alert module. Rates of Beta-Blocker (BB), Angiotensin Converting Enzyme Inhibitor (ACEi), Angiotensin II Receptor Antagonist (ARB), and Mineralocorticoid Receptor Antagonist (MRA) use were collected for each patient. Rates of medication use and uptitration to maximal tolerated guideline-indicated dose was examined for each Group. Independent sample T-Test was done to assess significance of change in PR and DC rate. All analysis was done by SPSS (v23).Results:Complete clinical data for 445 patients (Mean Age: 72.8?13.3 years, 70% male, mean LVEF: 34.8%?12.7, 65.4% BI) were included in the analysis. BB Prescription and MTDC adherence were increased by 3.2% (78.7% vs. 81.9%, P=0.11) and 51% respectively (24.4% vs. 75.4%, P<0.05). ACEi/ARB, and MRA use increased after the intervention (?=28.1% and ?=30%, p<0.05 respectively). Furthermore, double (BB + ACEi/ARB), and triple (BB + ACEi/ARB + MRA) therapy use increased by 13.2% and 23.7% respectively (P<0.05) (Table 1).Conclusion:Introduction of automated evidence-based EMR point-of-care alerts resulted in an increased rate of optimal medical therapy use and up-titration to the maximal tolerated guideline-indicated medication dose in patients with heart failure.

Introduction:Frequent Idiopathic Ventricular tachyarrhythmias (IVT) can lead to reversible ventricular dysfunction known as Tachycardia Induced Cardiomyopathy (TIC). Predicting factors that are associated with TIC are controversial. Therefore, we performed this study to determine incidence and predictors of TIC compared to patients with preserved ejection fraction (EF) who underwent catheter ablation.Methods:Overall, 204 patients with IVT, who underwent ablation (VTA) between 2011-2017 at a single tertiary care center were studied. After excluding all patients with structural heart diseases, history of syncope and implanted device, 130 patients were analyzed. Univariate, multivariate logistic regression, and ROC curve were used to determine the likelihood of TIC compared to patients with preserved LVEF (EF>50%).Results:Overall, 23 (17.6%) patients had EF under 50% of whom, 15 patients with more than 15% improvement in EF were considered as TIC (13(86.7%) male, with mean age of 59.50?19.04 years). Total of 103 patients with preserved EF more than 50% were considered as control. Mean Premature ventricular contraction (PVC)burden per day (30751.27? 16512.3 vs 16229.2? 15386.7, p=0.005) and PVC percentage (31.85?16.77 vs 15.01?13.19, p<0.001) before VTA was higher in patients with TIC than patients with preserved LVEF. ROC Curve Analysis showed PVC burden of 19x103per day and PVC percentage of 18.6% as the ideal cutoff point to differentiate TIC from patients with normal LVEF (Figure1). Multivariate logistic regression model showed higher PVC burden before VTA more than 19x103 per/day (OR=11.5, P=0.03) and PVC percentage more than 18.6% (OR=11.8, p=0.02) as the most significant predictor of TIC when adjusted for baseline characteristics.Conclusions:PVC burden greater than 19x103per day and PVC percentage greater than 18.6% are the most significant risk factors for tachycardia induced cardiomyopathy.

Introduction:Evidence supports utilization of Direct Oral Anticoagulants (DOAC) in patients at risk for stroke or thromboembolic events in the setting of non-valvular atrial fibrillation (AF) . Unfortunately, a number of patients may be at risk of adverse outcomes related to under treatment. We sought to describe DOAC prescribing patterns at a large AF clinic and understand the rate and reasons for subclinical DOAC dosing in these patients.Methods:Baseline, and follow up data for all patients on low dose Rivaroxaban (R) (15mg OD), Dabigatran (D) (110mg BiD), and Apixaban(A) (2.5mg BiD) was collected for analysis. Patients were then stratified into one of 3 groups based on the DOAC prescribed. History of cardiovascular, renal, and hepatic disease, as well as the HAS-BLED score was obtained for all patients.Results:629 patients were included in this analysis (Mean age: 82.3?7.6 years, 68.9% Male, A: 152, D: 242, R: 210). Average HAS-BLED score was 2.4 (A: 2.5?1.1, D: 2.2?0.8, R: 2.7?1.0) for all patients. Overall 63% (A: 52%, D:75%, R: 58%) were appropriately prescribed the lower dose of DOAC. Patients who were undertreated had an average HAS-BLED score of 2.5 (A: 2.5?0.9, D: 2?0.8, R: 2.5?1.0) vs. 2.4 (A: 2.5?1.0, D: 2.3?1.0, R: 2.9?1.0) P=0.16, for patients appropriately receiving the lower dose. Of the undertreated patients 12 had prior history of stroke (A: 3, D: 3, R: 6). Reasons for dose reduction included concomitant treatment with antiplatelet agents in 33 patients (A: 5, D: 7, R: 21), age greater than 80 as a sole factor in 93 patients (A: 56, D: 0, R: 37) and elevated creatinine (Scr>130umol/L) as a sole factor in 21 patients (A: 4, D: 4, R: 13). Of the patients on reduced dose of DOAC, those on Rivaroxaban were the most likely to be undertreated (P=0.03). The most significant factor for prescription of lower DOAC dose was age greater than 80 years (P=0.001).Conclusion:A significant number of patients with non-valvular AF who have clinical indications for oral anticoagulation therapy are undertreated with DOACs. Age greater than 80 appears to be the main reason for undertreatment. This pattern is not driven by objectively higher risk of bleeding according to the patient?s HAS-BLED score.

Introduction:Shocks delivered by Implantable cardioverter defibrillators (ICD), while life-saving, can affect patients? quality of life. Psychoeducational and Cognitive behavioral therapy (CBT) have been shown to offer a novel approach to reducing ICD shocks and improving quality of life (QOL) in ICD recipients. This systematic review and meta-analysis of randomized controlled trials (RCT) evaluated the pooled effect of CBT and psycho-education on QOL measures and ICD shocks.Methods:Systematic searches of literature were conducted for RCTs on the effectiveness of psycho-education and CBT in management of patients with ICD across Medline, PubMed, EMBASE, CINAHL and Web of Science from 1967 to April 2019. The meta-analysis was conducted using R statistical software.Results:Overall, 14 studies met inclusion criteria for meta-analysis. The meta-analysis of SF-12 components showed significance only in the physical component score (PCS). The mean difference for PCS across all studies was 2.14 [95% CI(1.2-3), p<0.001, i2 =0.00%, P=0.95], while the mean difference for Mental Component score (MCS) was 0.49 [95%CI(-1.97-2.95), P=0.6, i2=80.7%, P<0.001] favoring the intervention group. The number of ICD shocks during 12-months follow-up decreased compared to the baseline across all studies by -0.2 [95% CI (-0.4-0), p=0.04, i2 =0.00%, P=0.8] favoring the intervention group. Meta-regression analysis showed that the effect of treatment on the mean change in the number of ICD shocks during follow-up compared to the baseline did not vary significantly with the duration of follow-up(p=0.5).Conclusions:The Meta-analysis revealed that CBT and psychoeducation are associated with significant improvement in the Physical component of QOL measures and significant decrease in the number of ICD shocks during follow-up. However, there was no significant improvement in patients? Mental component of QOL post intervention.