Michael P. O’sHea

Aims: Direct oral anticoagulants (DOACs) are widely used for stroke prevention in people with non-valvular atrial fibrillation/flutter (NVAF).Anticoagulants have different bleeding profiles. Apixaban is associated with the lowest bleeding risk. This study evaluates the interaction between DOAC use and right ventricular systolic pressure (RVSP) on echocardiogram and bleeding rates. It was hypothesized that elevated RVSP may be associated with excess bleeding based on anticoagulant-specific pharmacologic profiles. Methods& Results: A retrospective analysis of a database was conducted. Multivariable regression models for bleeding rates were developed using an analysis approach that adjusts for confounders among participants who had undergone an echocardiogram, and interaction terms for DOAC choice were incorporated. Stratum-specific estimates were calculated using linear computation. Patients taking apixaban had lower bleeding rates than those taking rivaroxaban and dabigatran. Among those without elevated RVSP, there was no difference in bleeding rates. Where RVSP was ≥45mmHg, there was a 90% increase in bleeding rates with use of dabigatran (HR 1.99, p=0.024) and rivaroxaban (HR 1.86, p=0.042) compared to apixaban (Table 1D). Conclusions: Elevated RVSP is associated with excess bleeding in patients taking rivaroxaban and dabigatran, but not apixaban, after controlling for confounding variables.

Introduction: Adults with congenital heart disease (CHD), particularly tetralogy of Fallot (ToF) and pulmonary atresia with intact ventricular septum (PA-IVS), are at increased risk for atrial fibrillation (AF) and its complications. We evaluated thromboembolic and bleeding risks in this population and assessed the predictive value of CHA ₂ DS ₂ -VASc and HAS-BLED scores. Methods: In this retrospective cohort study, patients with ToF-PS, ToF-PA, or PA-IVS and AF were identified across Mayo Clinic sites (1999–2023) were analyzed. Primary outcomes were thromboembolism (stroke, TIA, systemic embolism) and major bleeding. Cox regression controlled for age; anticoagulation exposure was treated as time-varying. Risk score performance was evaluated using ROC curves. Results: 300 patients with ToF-PS, ToF-PA, or PA-IVS were identified. Over 2,296 person-years, 12 thromboembolic events occurred (5.23/1000 person-years). Prior stroke, TIA, peripheral embolism, and Potts shunt were significant predictors. CHA ₂ DS ₂ -VASc had good discrimination (c-statistic 0.78); no events occurred in patients with a score of 0. Major bleeding occurred 69 times over 1,845 person-years (3.74/100 person-years), more frequently in ToF-PA (HR 2.05, p = 0.005), chronic AF, and those with Waterson shunts (HR 4.64, p = 0.013). DOAC use was associated with significantly higher bleeding risk than warfarin (HR 5.89, p < 0.001). The HAS-BLED score had limited predictive value (c-statistic 0.59) (figure 1). Discussion: In CHD patients with AF, thromboembolic risk was low with anticoagulation, and CHA ₂ DS ₂ -VASc performed well. However, bleeding risk, particularly with DOACs and in patients with specific anatomical features, was high. Warfarin may be the safer anticoagulant in this population. Figure 1: Graphical Abstract

Participation in scholarly activity is an essential component and outcome metric of clinical training. Residency research education curricula have been independently developed by many institutions, however results from these programs vary. We conducted a survey of Internal Medicine, Neurology and Transitional Residents to determine knowledge, attitudes, beliefs, and practices. Likert-style, open and closed questions were used. Results were analyzed using preference ranking, thematic analysis, descriptive statistics, and chi squared and fisher's exact test for association between categorical variables. Prior exposure to formal research opportunities in medical school significantly correlated with publication rates (OR 2.37, p = 0.022) but did not predict continued engagement in research during residency. Residents expressed confidence in critical appraisal skills but reported low confidence in statistical analysis and study design. Observational study designs, particularly chart review cohort studies, were ranked as the most desirable research focus areas, whereas outpatient and community-based research were of lower priority. Barriers to research productivity included time constraints, statistical analysis challenges, methodological concerns, and lack of mentorship. The findings underscore the need for structured approaches tailored to resident preferences to enhance scholarly engagement. Residents ranked observational study design and systematic reviews as their top priorities, indicating a preference for research methodologies that are practicable within residency timelines. Residency programs should enhance early mentorship, provide targeted research education, and facilitate access to statistical and methodological support to improve research productivity among trainees.

Coarctation of the aorta (CoA) comprises 5–7% of congenital heart disease and can present as an isolated narrowing in the aortic arch just distal to the left subclavian artery or can be associated with cardiac abnormalities such as a bicuspid aortic valve, aortopathy, or ventricular septal defects. With the advances in the medical field, intervention on CoA can either be via surgical repair or endovascular stenting. Echocardiography is the mainstay in diagnosing CoA, with tomographic imaging such as magnetic resonance imaging (MRI) or computed tomography providing supplementary assessment of the aorta, valves, and collateral vessels. We present a case of a young hypertensive male who was noted to have a continuous cardiac murmur with diagnostic Doppler pattern of CoA on echocardiography that normalized soon after percutaneous stenting.

Background: Immune checkpoint inhibitor (ICI) myocarditis is associated with significant mortality risk. Electrocardiogram (ECG) changes in ICI myocarditis have strong prognostic value. However the impact of complete heart block (CHB) is not well defined. This study sought to evaluate the impact of CHB on mortality in ICI myocarditis, and to identify clinical predictors of mortality and CHB incidence. Methods: We conducted a retrospective cohort study of patients with ICI myocarditis at three Mayo Clinic sites from 1^st January 2010 to 31^st September 2022 to evaluate mortality rates at 180 days. Clinical, laboratory, ECG, echocardiographic, and cardiac magnetic resonance imaging (CMR) characteristics were assessed. Cox and logistic regression were performed for associations with mortality and CHB respectively. Results: Of 34 identified cases of ICI myocarditis, 7 (20.6%) had CHB. CHB was associated with higher mortality (HR 7.41, p = 0.03, attributable fraction 86.5%). Among those with CHB, troponin T (TnT) < 1000 ng/dL, low white blood cell count and high ventricular rate at admission were protective. There was trend towards increased survival among patients who underwent permanent pacemaker insertion (p = 0.051), although most experienced device lead complications. Factors associated with development of CHB included prolonged PR and QRS intervals and low Sokolow Lyon Index. Where these were normal and TnT was < 1000 ng/dL, no deaths occurred. Impaired myocardial longitudinal strain was sensitive for ICI myocarditis but was not prognostically significant. Conclusion: There is a strong temporal association between CHB and early mortality in people with ICI myocarditis. Focusing on arrhythmogenic complications can be helpful in predicting outcomes for this group of critically ill individuals.

Aims:Increased left ventricular (LV) wall thickness is frequently encountered in transthoracic echocardiography (TTE). While accurate and early diagnosis is clinically important, given the differences in available therapeutic options and prognosis, an extensive workup is often required to establish the diagnosis. We propose the first echo-based, automated deep learning model with a fusion architecture to facilitate the evaluation and diagnosis of increased left ventricular (LV) wall thickness. Methods and Results: Patients with an established diagnosis of increased LV wall thickness (hypertrophic cardiomyopathy (HCM), cardiac amyloidosis (CA), and hypertensive heart disease (HTN)/others) between 1/2015 and 11/2019 at Mayo Clinic Arizona were identified. The cohort was divided into 80%/10%/10% for training, validation, and testing sets, respectively. Six baseline TTE views were used to optimize a pre-trained InceptionResnetV2 model. Each model output was used to train a meta-learner under a fusion architecture. Model performance was assessed by multiclass area under the receiver operating characteristic curve (AUROC). A total of 586 patients were used for the final analysis (194 HCM, 201 CA, and 191 HTN/others). The mean age was 55.0 years, and 57.8% were male. Among the individual view-dependent models, the apical 4-chamber model had the best performance (AUROC: HCM: 0.94, CA: 0.73, and HTN/other: 0.87). The final fusion model outperformed all the view-dependent models (AUROC: HCM: 0.93, CA: 0.90, and HTN/other: 0.92). Conclusion: The echo-based InceptionResnetV2 fusion model can accurately classify the main etiologies of increased LV wall thickness and can facilitate the process of diagnosis and workup.

BackgroundPrescribing error represent a significant source of preventable harm to patients. Prescribing error at discharge, including omission of pre-admission medications (PAM), are particularly harmful as they frequently propagate following discharge. This study assesses the impact of an educational intervention and introduction of an Electronic Patient Record (EPR) in the same centre on omission of PAM at discharge using a pragmatic design. A survey of newly qualified doctors is used to contextualise findings.Methods Discharge prescriptions and discharge summaries were reviewed at discharge, and compared to admission medicine reconciliation, using a paper-based chart system. Discrepancies were noted, using Health Information and Quality Authority guidelines for discharge prescribing. An educational intervention was conducted. Further review of discharge prescriptions and discharge summaries took place. Hospital-wide introduction of an EPR took place. Subsequently, review of discharge summaries and discharge prescriptions was repeated. A survey was administered to qualified doctors, and analysed using descriptive statistics and thematic analysis. Results Omission of PAM as prescribed or discontinued items at discharge occurs frequently. An educational intervention did not significantly change prescribing error rates. EPR introduction did significantly reduce omission of PAM on discharge prescribing, however there was also a reduction in the rate of deliberate discontinuation of PAM at discharge. Survey results demonstrated that multiple sources are required to develop a discharge prescription. Time pressure, access to documentation and lack of admission medicine reconciliation are frequently cited causes of discharge prescribing error.ConclusionThis study verified passive educational interventions alone do not improve discharge prescribing. Introduction of EPR improved discharge prescribing, but negatively impacted deliberate discontinuation of PAM at discharge. This is attributable to reduced access to key sources of information used in formulating discharge prescriptions, and separation of the discontinuation function from the prescribing function on the EPR discharge application.