Risultati per: Gestione e follow-up dei polipi della cistifellea (polipi della colecisti)

Introduction
Post-intensive care syndrome (PICS) seriously affects the quality of life of intensive care unit (ICU) survivors, their ability to return to work and society and the quality of life of their families, increasing overall care costs and healthcare expenditures. ICU follow-up services have important potential to improve PICS. However, the best clinical practice model of ICU follow-up service has not been fully defined and its benefits for ICU survivors are not clear. This review will synthesise and map the current types of follow-up services for ICU survivors and summarise the impact of follow-up services on PICS.

Methods and analysis
This scoping review will be conducted by applying the five-stage protocol proposed by Arksey and O’Malley in an updated version of the Joanna Briggs Institute. Eight academic databases including the Cochrane Library, MEDLINE, Web of Science, Embase, EBSCO Academic, CINAHL, PsycInfo and SinoMed (China Biology Medicine) will be systematically searched from inception to the present. Peer-reviewed literature and grey literature will be included. Qualitative, quantitative and mixed methods studies will be included. Studies published in English or Chinese will be included. There will be no time restriction. Two reviewers will screen and select the articles independently and if there is any disagreement, the two reviewers will discuss or invite a third reviewer to make decisions together. Descriptive analysis will be used to conduct an overview of the literature. The results will be presented in a descriptive format in response to the review questions accompanied by the necessary tables or charts.

Ethics and dissemination
Ethical approval is not required for this scoping review because data could be obtained by reviewing published primary study results and do not involve human participants. Findings should be disseminated at scientific meetings and published in peer-reviewed journals.

Circulation, Volume 150, Issue Suppl_1, Page A4142796-A4142796, November 12, 2024. Background:Peripartum cardiomyopathy (PPCM) is defined as a dilated form of cardiomyopathy that occurs within the last month of pregnancy and up to 5 months postpartum. Previous studies have shown that PPCM more often occurs in the Southern United States compared to other geographic locations. Although the etiology of PPCM is likely multifactorial, viral infections may account for up to a third of those cases. We aimed to examine the association of PPCM to active influenza infection in the Southern United States.Methods:National Inpatient Sample 2016-2021 was queried to identify women admitted with PPCM with (group A) and without (group B) concurrent influenza infection in the Southern United States.Results:A total of 13540 women were admitted with PPCM, of whom 3511 (35%) had concurrent influenza infection. Group A PPCM followed a seasonal pattern with peak incidence in winter (62%) followed by spring (25%), fall (13%) and summer (0) [p

Circulation, Volume 150, Issue Suppl_1, Page A4147647-A4147647, November 12, 2024. Background and Objectives:Yoga may be a promising form of mind-body rehabilitation for patients with long term illness. Digitally delivered yoga increases access to participation but has not previously been evaluated in the heart failure population. The aim of this study was to examine the effects of tele-yoga on cognition, sleep, health-related quality of life and exercise capacity in persons with heart failure.Methods:The Tele-yoga study (ClinicalTrials.gov, ID: NCT 03703609) was a parallel two-arm randomised controlled trial (RCT) with 1:1 distribution to an intervention and control group. Study participants were randomised to tele-yoga including live-streamed group-yoga for 60 minutes twice weekly during 12 weeks and yoga individually for 10 minutes/day using an app, or to a control group receiving individual exercise advice. Cognition (Montreal Cognitive Assessment: MoCA), sleep (minimal insomnia symptom scale; MISS), health-related quality of life (EQ-5D VAS) and sub-maximal exercise capacity (6 minute walk test; 6MWT) were assessed at baseline, after 3 and 6 months. Linear mixed model with random intercept for patients as the random effect and group-time interaction along with age was taken as the fixed effects to analyse outcomes.Results:A total of 311 participants were included (tele-yoga n=156 and active controls n=155), mean age 66 years, 70% men. Adherence to the group yoga was very good. The linear mixed models showed a significant change in cognition, health-related quality of life and exercise capacity favouring the tele-yoga group. No significant differences between the groups were seen regarding sleep. When analysing the fixed effects of all outcomes, age, group assignment and time-points interaction had significant effects on EQ-5D VAS score, 6MWT distance and MoCA scores. For EQ-5D VAS the tele-yoga group performed significantly better than the control group at 3 months, but not at 6 months. For the 6MWT distance, the tele-yoga group performed better than the control group at 3 months, but not at 6 months. The tele-yoga group had significantly higher MoCA scores than the control group at both 3 and 6 months.Conclusion:This adequately powered RCT showed that digitally delivered mind-body training in the format of group and individual yoga during 12 weeks lead to an improvement in cognition, quality of life and exercise capacity at the end of the intervention. The effect was sustained for cognition also after 6 months.

Circulation, Volume 150, Issue Suppl_1, Page A4140140-A4140140, November 12, 2024. Managing low-density lipoprotein (LDL) cholesterol is crucial for secondary cardiovascular prevention. Despite ACC/AHA recommendations for maintaining LDL below 70 mg/dL, achieving this target remains suboptimal. This study investigates the impact of consistent cardiologist involvement on LDL cholesterol management.Methods:We conducted a multicenter, cross-sectional cohort study within the Steward Healthcare System in Massachusetts, analyzing data from 10,211 patients hospitalized from January 2019 to March 2024. This study offers a detailed snapshot of data across the study period, capturing both recent and long-standing cases identified through ICD codes for conditions like NSTEMI, CAD, STEMI, or CABG, specifically as markers for secondary cardiovascular prevention. We utilized the most recent LDL cholesterol measurements for our analysis and compared the distribution of lipid-lowering medications across groups. Notably, follow-ups with cardiologists outside our network were not tracked, potentially omitting relevant data. Statistical analysis employed the Chi-square test for categorical variables and binary logistic regression to adjust for confounders.Results:showed that patients with regular cardiology visits more often achieved LDL levels below 70 mg/dL (57.45% vs. 46.67%; OR 1.54, 95% CI: 1.42-1.68; P

Circulation, Volume 150, Issue Suppl_1, Page A4140142-A4140142, November 12, 2024. Background:Cardiovascular-kidney metabolic (CKM) syndrome is exacerbated among individuals experiencing chronic exposure to both environmental and psychosocial stressors. Both neighborhood and individual-level stressors increase chronic inflammation resulting in worsened CKM factors, such as hypertension, diabetes, and dys/hyperlipidemia. However, associations between neighborhood perceptions (NP) and lipid profiles remain understudied. Therefore, we examined associations between NP domains and lipid profiles among African-American (AA) women with ≥Stage 1 CKM syndrome (overweight/obesity) residing in resource-limited neighborhoods within the Washington, DC area.Methods:Participants were enrolled in Step It Up, a technology-enabled, community-engaged physical activity (PA) intervention. Fasting blood samples were drawn at baseline to measure lipoproteins using Nuclear Magnetic Resonance (NMR) spectroscopy. Factor analysis of overall NP identified four perception sub-scores: disorder, social cohesion, violence, and safety (higher score=favorable perception). Associations between NP domains and lipoprotein particles were analyzed using multivariable regression adjusting for BMI, ASCVD 10-year risk score, and lipid-lowering therapy.Results:Participants (n=169) had mean age=57.16 ± 12.00 and BMI 35.99 ± 6.57. Perceptions of safety were positively associated with LDL concentrations (LDLc) and large LDL particles (L-LDLp) (β=4.70 [SD=2.41], p=0.05, β= 43.75 [17.70], p= 0.01), respectively). Perceptions about neighborhood violence were positively associated with L-LDLp (marginally) and very-low-density lipoprotein size (VLDLz) (β= 7.10 [3.96], p=0.08, β= 0.31 [0.14], p= 0.02, respectively). No associations were found between disorder and social cohesion with lipid biomarkers.Conclusions:After adjusting for BMI, ASCVD risk, and lipid-lowering therapy, there were significant associations between neighborhood perceptions of safety and violence with lipid profiles among AA women with CKM syndrome. Greater perceived safety was associated with higher LDLc and L-LDLp while more favorable perception about neighborhood violence was associated with higher L-LDLp. Future work should examine whether improving neighborhood resources and perceptions may improve CKM health among urban AA women.

Circulation, Volume 150, Issue Suppl_1, Page A4143142-A4143142, November 12, 2024. Introduction:Malonyl-CoA decarboxylase deficiency (MLYCDD) is a rare inherited metabolic disorder with multi-organ involvement, causing cognitive impairment, cardiomyopathy, seizures, hypotonia, and acidosis. Variants in MLYCCD, the gene for malonyl-CoA decarboxylase, disrupt long chain fatty acid synthesis in cardiac tissue. Prevalence is estimated to be less than 1 in 1,000,000, with cardiomyopathy being the leading cause of morbidity and mortality. Less than 40 cases have been documented, the majority of which detail newborns. No guidelines exist for treatment. A high-carbohydrate, low-fat diet, and levocarnitine reportedly improve cardiac function.Presentation:A 30-year-old Spanish-speaking male with MLYCDD, with resultant heart failure with reduced ejection fraction (EF) and cognitive delay, presented to a community hospital with malaise. He was diagnosed at age 9 and followed with an interdisciplinary team, receiving care in Spanish and English since diagnosis. His treatment consisted of levocarnitine and dietary restrictions that had led to cardiac recovery. At 24, his doctor retired, his insurance changed, and he was lost to follow-up, leading to dietary liberalization. On presentation, he was diagnosed with pneumonia complicated by atrial fibrillation (AF). AF was treated with a diltiazem infusion, resulting in cardiogenic shock with an EF of 15% from 39%. He was transferred to an academic center where diltiazem was stopped, inotropes started, and impella placed. He started enteral nutrition with liquid protein, dextrose infusion, medium-chain triglyceride (MCT) oil, and levocarnitine, along with supportive care for pneumonia. Given persistent shock he was transferred to our center for advanced therapies evaluation. Notable changes included replacing MCT oil with triheptanoin and stopping the dextrose infusion. A repeat echocardiogram showed recovery of EF to 40%Conclusions:MLYCDD exhibits a range of phenotypes, with limited data on long-term outcomes. This presentation is atypical: an adult with cardiomyopathy diagnosed in adolescence, successfully treated, who decompensated after stopping a modified diet in the setting of pneumonia and diltiazem. This case offers several clinical insights: (1) Restrictive diets with levocarnitine supplementation are instrumental in treating MLYCDD. (2) Avoid diltiazem in heart failure to prevent iatrogenic shock. (3) Language-concordant care ensures patients understanding and supports seamless care transitions.

Circulation, Volume 150, Issue Suppl_1, Page ASa308-ASa308, November 12, 2024. Background:Active compression-decompression (ACD) cardiopulmonary resuscitation (CPR), an impedance threshold device (ITD) and controlled, gradual, automated head and thorax elevation, collectively termed automated Head Up Position (AHUP) CPR, increases cerebral perfusion pressure (CerPP), brain blood flow, coronary perfusion pressure (CorPP), end tidal CO2 (ETCO2) and cerebral oximetry (rSO2) in animal models when compared with conventional (C) CPR. AHUP-CPR in patients is associated with increased neurologically favorable survival versus C-CPR. This study tested the hypothesis that AHUP CPR will increase cardiac stroke volume (SV) and other hemodynamics compared with C-CPR in a porcine model of cardiac arrest.Methods:Farm pigs (n=15) were sedated, anesthetized, and ventilated. Hemodynamics, including intracardiac conductance catheter based biventricular (BiV) pressure-volume (PV) loops, were continuously measured and recorded. After 10 minutes of untreated ventricular fibrillation, C-CPR was performed for 2 minutes in the supine position using an automated CPR device designed for pigs at a rate of 100 compressions/minute, depth of 21% of the chest antero-postero diameter, a 50% duty cycle, and no active decompression. ACD+ITD was then performed with 3 cm of active decompression for 2 minutes, followed by AHUP-CPR, where the head and thorax were initially raised to 10 cm and 8 cm for a 2-minute priming phase, followed by elevation over the next 2 minutes to 24 cm and 9 cm. A linear mixed-effects model with a random intercept for individual pigs was used for statistical analysis.Results:CerPP, CorPP, ETCO2, and rSO2, as well as BiV SV and cardiac output, increased progressively and significantly with implementation of AHUP-CPR (p

Circulation, Volume 150, Issue Suppl_1, Page A4146563-A4146563, November 12, 2024. Background:Secondary atrial fibrillation (AF) is triggered by acute illness and associated with adverse outcomes. Timely follow-up is recommended by the American Heart Association statement on acute AF.Hypotheses:Patients with secondary AF receive less follow-up and cardiac testing than those primarily hospitalized for AF (primary AF).Follow-up is lower for secondary AF patients hospitalized for noncardiac diagnoses.Methods:Population-based cohort study using linked administrative datasets of patients aged ≥66 yrs discharged alive after a new diagnosis of AF while hospitalized in Ontario between Apr 2013 – Mar 2019. Patients were classified as secondary or primary AF using a validated approach based on discharge diagnosis type and followed for 1yr. Outcomes included physician visits (family physicians [FP], internists, cardiologists), and cardiac testing (electrocardiograms [ECG], echocardiograms, ambulatory ECG monitoring). The cumulative incidence function was used to quantify the incidence of outcomes. Cause-specific hazards regression was used to estimate hazard ratios (HR) associated with hospitalization type in secondary AF patients. Regression analyses accounted for competing risks.Results:We studied 13,011 secondary AF (35.2% cardiac surgery, 9.6% cardiac medical, 17% noncardiac surgery, 38.1% noncardiac medical) and 11,065 primary AF patients. Secondary AF was associated with lower age, male sex, less heart failure, and greater prevalence of other comorbidities. Less than 50% of secondary AF patients had visits to internists, cardiologists, echocardiograms or ambulatory ECG monitoring (see Figure). The incidence of all outcomes was significantly lower for secondary than primary AF. Among secondary AF patients, specialist follow-up and cardiac testing rates were lowest after noncardiac diagnoses (see Table).Conclusion:Patients with secondary AF have less specialist follow-up and cardiac testing than primary AF, especially if hospitalized for noncardiac diagnoses.

Circulation, Volume 150, Issue Suppl_1, Page A4143109-A4143109, November 12, 2024. Background:The use of cardiac resynchronization therapy (CRT) devices has significantly increased in usage in recent years. Identifying predictors of mortality in CRT patients remains an area of investigation.Objective:To establish a relationship between timed up-and-go test time (TUGT) and mortality in heart failure patients (HF) with CRT devices.Methods:This retrospective study included 506 patients with heart failure with reduced ejection fraction (HFrEF) who underwent CRT implantation at our institution between 2017-2022. All patients were followed up with a multidisciplinary team, including electrophysiology and HF physicians about 6 months after CRT implantation, where frailty was assessed. We used TUGT as a measure of frailty and divided patients into 2 groups: TUGT: >15 seconds (n=73) and ≤15 seconds (n=433). The primary endpoint was a composite of left ventricular assist device implantation, transplant, or death at 2 years post-CRT. Data was collected retrospectively from electronic medical records.Results:The study population was 65.6% male, with a mean age of 69.1 years, and 79.4% of devices being CRT-D.Response was defined as an improvement in LVEF >5% with reduction in LVESV >10%; anybody not meeting this definition was classified as a non-responder. Responder and non-responder rates among TUGT >15 and TUGT15s have worse outcomes (Figure 1).Conclusion:Frailty testing using TUGT post-CRT implantation is a strong predictor of mortality in HFrEF patients after CRT implantation.

Circulation, Volume 150, Issue Suppl_1, Page A4136210-A4136210, November 12, 2024. Background:In the management of acute myocardial infarction (AMI) following percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) plays a crucial role in preventing recurrent ischemic events. Recent studies have explored the feasibility and safety of de-escalating DAPT from ticagrelor to clopidogrel.Methods:We conducted a systematic review and meta-analysis by searching several databases, including Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE (including MEDLINE InProcess) (OvidSP), Web of Science, Embase (OvidSP), and Scopus. We assessed the risk of bias using the ROB2 Cochrane tools for randomized controlled trials (RCTs). The analysis was performed using RevMan Cochrane software.Results:A total of ten studies including observational and clinical studies involving N=18,001patients (11,458 de-escalated from ticagrelor to clopidogrel after 12 months and 6,543 remained on ticagrelor after 12 months post-PCI) were included. There was no difference in the risk of all-cause death (RR 0.98; 95% CI 0.69 to 1.38; p=0.90), cardiovascular death (RR 1.09; 95% CI 0.68 to 1.74; p=0.73), myocardial infarction (RR 0.90; 95% CI 0.71 to 1.14; p=0.37) and stroke (RR 0.81; 95% CI 0.50 to 1.32; p=0.41) between the two groups.Conclusion:In conclusion, transitioning from ticagrelor to clopidogrel in acute myocardial infarction following percutaneous coronary intervention appears to be a feasible strategy for de-escalating dual antiplatelet therapy (DAPT). While maintaining efficacy in preventing adverse cardiovascular events, such as stent thrombosis, this approach may mitigate bleeding risks associated with prolonged ticagrelor use.

Circulation, Volume 150, Issue Suppl_1, Page A4140097-A4140097, November 12, 2024. Introduction:The MI-GENES randomized clinical trial (NCT01936675) assessed the effect of disclosing a polygenic risk score (PRS) for coronary heart disease (CHD), in addition to a clinical risk based on Framingham risk score (FRS), on LDL-C levels. The trial enrolled participants from Olmsted County, Minnesota, without cardiovascular disease, at intermediate CHD risk (10-y risk: 5-20%), and not on statins. There was a significant LDL-C reduction in the integrated risk score group (IRSg; received PRS information in addition to the FRS) compared to the FRS group (FRSg; received their risk based on FRS), due to more frequent statin initiation.Research Question:Does disclosure of an IRS for CHD lead to a lower rate of major adverse cardiovascular events (MACE)?Methods:Participants were followed from randomization beginning in October 2013 until September 2023 to ascertain cardiovascular events, testing for CHD, and risk factor changes, by blinded review of electronic health records. The primary outcome was time from randomization to the first MACE— defined as cardiovascular death, nonfatal MI, coronary revascularization, and nonfatal stroke. Analyses were done using Cox and linear mixed-effects models.Results:We followed all 203 participants, who completed the MI-GENES trial, 100 in FRSgand 103 in IRSg(mean age at the end of follow-up 68.2±5.2 years, 48% male). During a median follow-up of 9.5 years, 9 MACE occurred in FRSgand 2 in IRSg(HR, 0.20; 95% CI, 0.04 to 0.94;P=0.042, Figure 1A). In FRSg, 47 (47%) underwent at least one test for CHD, compared to 30 (29%) in IRSg(HR, 0.51; 95% CI, 0.32 to 0.81;P=0.004, Figure 1B). IRSgparticipants had a longer duration of statin therapy during the first four years post-randomization (Figure 1C) and a greater reduction in LDL-C for up to 3 years post-randomization (Figure 1D). No significant differences between the two groups were observed for hemoglobin A1C, blood pressure, weight, and smoking cessation rate during follow-up.Conclusion:The disclosure of 10-year CHD risk that included a PRS to those at intermediate risk was associated with lower incidence of MACE after a decade, likely due to more frequent and prolonged statin use, leading to lower LDL-C levels.

Circulation, Volume 150, Issue Suppl_1, Page A4135852-A4135852, November 12, 2024. Background:Vertebrobasilar artery stenosis (VBAS) can cause posterior circulation strokes (PCS). Optimal management is controversial, with options including medical therapy (MT), endovascular stenting (ES), and surgical revascularization (SR). This study compares outcomes of these treatments and evaluates the correlation between clinical features and medical history with 30-day outcome.Methods:Patients with VBAS were identified from the 2017-2018 National Inpatient Sample (NIS). Propensity scores adjusted for baseline differences. Outcomes included mortality, neurological complications (NC), discharge destination (DD), length of stay (LOS), total charges (TC), and procedural complications (PC). Predictive ability of clinical variables was assessed using logistic regression (LR) and machine learning techniques (MLT).Results:Of 1,343 patients, 1,061 (79.0%) received NI, 234 (17.4%) underwent ES, and 24 (1.8%) had SR. Mean age was 69.45 years, with 64.1% male. Demographics: 69.8% White, 14.9% Black, 10.0% Hispanic, and 5.3% other races. Hypertension (HTN, 85.4%) and diabetes (DM, 18.9%) were prevalent. After propensity weighting, ES was associated with higher odds of mortality, surgical/medical complications (SMC), and device/graft complications (DGC) compared to NI. SR showed a non-significant trend toward higher non-home discharges (NHD). ES and SR groups had higher resource utilization with longer LOS and greater TC. Clinical variables alone were weak predictors, with AUC values ranging from 0.454 to 0.71 across different outcomes and models.Conclusion:ES of VBAS was associated with higher mortality and complication rates compared to MT alone, with inconsistent benefits for NC. SR also carried elevated risks without clear advantages over MT. These results support that current clinical independent variables from the NIS are weak predictors. This highlights the limitation of the database in relying solely on clinical and medical history, and suggests that future use of radiological and anatomical features can improve predictions of outcomes and determination of subgroups that can benefit from certain treatment. More studies should be conducted, including post hoc analyses based on radiological and anatomical features, to better inform treatment decisions and determine subgroups that can benefit from intervention or surgery. These findings suggest a need for judicious patient selection and reinforce the role of optimal MT.

Circulation, Volume 150, Issue Suppl_1, Page A4143150-A4143150, November 12, 2024. Background:The FACTOR-64 study was a randomized controlled trial designed to assess whether routine screening for CAD by coronary computed tomography angiography (CCTA) in high-risk patients with diabetes followed by CCTA-directed therapy would reduce the risk of death and nonfatal coronary outcomes. Results at four years showed a lower revascularization rate (3.1% (14) vs. 8.9% (40), p

Circulation, Volume 150, Issue Suppl_1, Page A4146242-A4146242, November 12, 2024. Background:In 2021, the Food and Drug Administration approved the first Photon Counting Computed Tomography (PCCT) system, marking an extraordinary milestone in medical imaging. This advanced technology offers significant advantages in cardiac imaging, particularly in detecting severe calcification lesions and in-stent restenosis (ISR). Subsequently, in October 2023, our hospital became the first to implement a PCCT system. Leveraging the benefits of PCCT, we conducted a study to investigate ISR in patients who had undergone stenting over the course of a year.Methods:From October 2023 to January 2024, all high-risk stented patients, including those with multiple stents, bifurcation lesions, chronic total occlusions, and severe calcification lesions, were included in the study. The PCCT system (tube voltage 120 kV, collimation 120 x 0.2 mm, 50-70 ml Iohexol 300 mg/ml) was utilized to detect ISR. Intra-stent lesions with more than 50% narrowing were classified as ISR. Additionally, the quality of the PCCT images was assessed by two radiology experts using a five-point scale, where 1 indicated excellent quality (absence of artifacts) and 5 indicated non-diagnostic quality (severe artifacts).Results:Eighty patients (77.5% male) met the inclusion criteria, with a mean age of 64.7 ± 10.9 years. Among these patients, 56 had stents in the Left Anterior Descending (LAD) artery, while 27 and 34 had stents in the Left Circumflex Artery (LCx) and Right Coronary Artery (RCA), respectively. In total, 25 patients (31.2%) were identified with ISR. Specifically, ISR was most prevalent in the LCx at 25.9% (7/27), followed by the LAD at 21.4% (12/56), and the RCA at 17.7% (6/34). Nine patients underwent repeat percutaneous coronary intervention (PCI). The overall image quality was rated as excellent, with a median score of 1.5 [IQR, 1-2]. Additionally, 40 patients (50%) had a calcium score over 400.Conclusion:These findings represent the first results obtained using PCCT at our hospital. The results indicated a relatively high rate of ISR, particularly among high-risk patients. Given the excellent image quality, PCCT is a promising technique for the follow-up of patients post-PCI.

Circulation, Volume 150, Issue Suppl_1, Page A4137805-A4137805, November 12, 2024. Background:Many of the 1.4 million adults with congenital heart disease (CHD) are lost to follow up (LTF). We aimed to identify factors associated with LTF and compare to those who remained in care.Methods:In the Congenital Heart Disease Project to Understand Lifelong Survivor Experience (CHD PULSE), we performed a cross-sectional survey in 2021-2023 of CHD survivors with a history of intervention at 11 centers in the Pediatric Cardiac Care Consortium, a large US-based registry of CHD procedures. Participants reported their cardiac history, general health, education, income, health insurance, healthcare utilization, and marital status. LTF was defined as having seen a cardiologist three or more years ago.Results:Among the 3109 respondents with CHD (median age 33) there were 1157 (37%) LTF and 1952 (63%) in care. Age, sex, marital status, and household income were not risk factors for LTF; but lack of health insurance, lower severity of CHD, and increasing time since last heart surgery were. Notably, respondents who reported being told in adolescence about the lifelong need for a cardiologist were almost three times as likely to report being in care (79% vs 28%, p