the frailty index can potentially be used as a tool to estimate the increase in healthcare resources required for different levels of frailty. This information may be useful for quantifying the amount to invest in programs to reduce frailty in the community.

A 'cardio-geriatric' heart failure model of care was implemented to address the high rates of readmission in elderly acute decompensated heart failure patients. Despite demonstrably intensified management in both the cardiology and geriatric domains, this study did not demonstrate a positive effect on the primary outcome of all cause readmissions at 30 days.

Aims Urinary sodium concentration (UNa) is a simple test advocated to assess diuretics efficacy and predict outcomes in acute heart failure (AHF). We performed a systematic review and meta-analysis to examine the association of UNa with outcomes of AHF. Methods and results We searched Embase and Medline for eligible studies that reported the association between UNa and outcomes of urinary output, weight loss, worsening renal function, length of hospital stay, re-hospitalisation, worsening heart failure and all-cause mortality in AHF. Nineteen observational studies out of 1592 screened records were included. For meta-analyses of outcomes, we grouped patients into high vs low UNa, with most studies defining high UNa as >48-65 mmol/L. In the high UNa group, pooled data showed a higher urinary output (mean difference 502ml, 95%CI 323-681, p<0.01), greater weight loss (mean difference 1.6kg, 95%CI 0.3-2.9, p = 0.01), and a shorter length of stay (mean difference -1.4 days, 95%CI -2.8 to -0.1, p = 0.03). There was no significant difference in worsening kidney function (OR 0.54, 95%CI 0.25-1.16, p = 0.1). Due to the small number of studies, we did not report pooled estimates for re-hospitalisation and worsening heart failure. High UNa was associated with lower odds of 30-day (OR 0.27; 95%CI 0.14-0.49, p<0.01), 90-day (OR 0.39,95% CI 0.25-0.59, p<0.01) and 12-month (OR 0.35; 95%CI 0.20-0.61, p<0.01) mortality. Conclusion High UNa after diuretic administration is associated with higher urinary output, greater weight loss, shorter length of stay, and lower odds of death. UNa is a promising marker of diuretic efficacy in AHF which should be confirmed in randomised trials.

Background Handheld ultrasound could provide sufficient information to satisfy the clinical questions underlying ‘rarely appropriate’ echo requests, but there are limited data about its use as a gatekeeper to standard echocardiography. We sought to determine whether the use of handheld ultrasound could improve the appropriate use of echocardiography. Method A prospective study comparing handheld ultrasound strategy to standard echocardiography for studies deemed rarely appropriate, using a questionnaire based on appropriate use criteria was conducted across two hospitals, from October 2017 to April 2018. Results Groups undergoing Handheld ultrasound (n = 76, 58 (46.5–72.5) years, 53 males, 78% outpatients) and standard echocardiography (n = 72, 61 (49.0–71.5) years, 42 males, 76% outpatients) were comparable. There was a significant decrease in the time to scan from just over 1 month in standard group to a median of 12 days in handheld ultrasound group (P < 0.001). This difference was small for inpatients (from 1 day to a median of 10 min in handheld ultrasound, P = 0.014), but prominent in outpatients (from 1.5 months in the standard group to median of 2 weeks in the handheld ultrasound group, P < 0.001). There was no increase in the need for follow-up scan within 6 months and no significant differences in length of hospital stay for inpatients. Conclusion Handheld ultrasound can be an effective gatekeeper to standard echocardiography for requests deemed rarely appropriate, reducing time to echocardiography significantly and potentially decreasing the need for standard echocardiography by up to 20%.