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Heartbeat: Anatomy versus physiology for diagnosis of coronary artery disease

2017-06-14T05:54:05-07:00

The optimal approach to the initial diagnosis of coronary artery disease (CAD) in patients with chest pain symptoms is controversial. Historically, graded treadmill exercise stress testing for diagnosis of CAD was proposed in 1963 by Robert A. Bruce in Seattle because direct visualisation of the coronary arteries was expensive and risky at that time. Over the intervening five decades, a plethora of stress testing and imaging approaches have been developed, with persuasive advocates for each type of testing and guidelines stating that each is ‘appropriate’ but with little guidance for clinicians as to which test is best or should be performed first.

This controversy is addressed in this issue of Heart with an original research paper, a review article and two editorials. To investigate whether direct anatomic imaging of coronary anatomy improves outcomes in patients with suspected angina, The Scottish COmputed Tomography of the HEART (SCOT-HEART) Trial Investigators




The National Institute for Health and Care Excellence update for stable chest pain: poorly reasoned and risky for patients

2017-06-14T05:54:05-07:00

For nearly two decades, the National Institute for Health and Care Excellence (NICE) has been admired as a reliable and authoritative source for evidence-based practice pathways. Unfortunately, in the latest iteration of the stable chest pain guidelines, NICE has veered dangerously off course by advocating that we abandon Bayesian analysis and simply order CT  coronary angiography (CTCA) in all patients with typical or atypical chest pain.1 The clinician should no longer consider a patient’s pretest probability, whether any imaging is necessary, and if so, which imaging test is best. These recommendations are not supported by high quality scientific evidence and put patients at risk for serious harm. At its foundation, the NICE guideline is antithetical to the current focus on a more personalised approach to medicine with conscientious use of diagnostic imaging, particularly when it involves ionising radiation. Moreover, given that cardiovascular events have dramatically decreased with...




Management of coronary artery disease with cardiac CT beyond gatekeeping

2017-06-14T05:54:05-07:00

This journal reports an analysis of symptoms and quality of life (QOL) of patients enrolled in the Scottish COmputed Tomography of the HEART (SCOT-HEART).1

Last year the results of the two major trials on cardiovascular imaging strategies for the diagnosis of coronary artery disease (CAD) were published (ie, PROMISE/PROspective Multicenter Imaging Study for Evaluation of chest pain—performed in North America and SCOT-HEART—performed in Scotland).2–4 They were structured to analyse the impact of cardiac CT (CCT) on current standards of care.

The PROMISE trial ultimately showed a diagnostic and prognostic equivalence of anatomical strategy versus the North American standard of care; although more patients in the CCT group underwent cardiac catheterisation within 3 months after randomisation, the secondary end point of the frequency of catheterisation showing no obstructive CAD was significantly lower in the CCT group.

The SCOT-HEART investigated the incremental value of...




Oral anticoagulation for elderly patients with non-valvular atrial fibrillation: recent insights from randomised trials and the 'real world

2017-06-14T05:54:05-07:00

The year 2009 was a turning point for thromboprophylaxis for the patients with non-valvular atrial fibrillation (NVAF). The first randomised control trial (RCT) for a currently licensed non-vitamin K antagonist oral anticoagulant (NOAC), the RE-LY trial comparing the oral direct throkbin inhibitor dabigatran with warfarin, was published.1 This trial led to the global approval of dabigatran as an alternative to vitamin K antagonists (VKAs; eg, warfarin) for the prevention of stroke and thromboembolic events in patients with NVAF.

Since the RE-LY trial, three more NOACs (ie, rivaroxaban, apixaban and edoxaban) supported by their respective RCTs against VKAs, have gained approval and the NOACs are now recommended by international guidelines as the treatment of choice for stroke prevention in NVAF. Due to the availability of additional treatment options and the minor but significant differences in some outcomes between the NOACs, guidelines recommend a more individualised patient approach regarding...




Sex-related differences in atrial fibrillation: can we discern true disparities from biases?

2017-06-14T05:54:05-07:00

The deleterious health effects of atrial fibrillation (AF), including impaired quality of life and significantly increased risks of stroke, heart failure and all-cause mortality, can be attenuated using the therapies for AF symptoms management and/or reduction in adverse cardiovascular outcomes. As certain consistently reported sex-related differences in the epidemiology, pathophysiology, clinical presentation and prognosis of AF (table 1)1–3 may affect ultimate effectiveness of AF treatment, these differences should be well appreciated in the personalised, individual patient-centred approach to AF management in clinical practice.

Table 1

Sex-related differences in the epidemiology, pathophysiology, clinical presentation and prognosis of atrial fibrillation, and sex-related differences in utilisation and outcomes of AF-directed therapies1 3 4 6–8

CategorySpecific featuresSex-related differenceEpidemiology



National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm

2017-06-14T05:54:05-07:00

In the 2016 update of the stable chest pain guideline, the National Institute for Health and Care Excellence (NICE) has made radical changes to the diagnostic paradigm that it—like other international guidelines—had previously placed at the centre of its recommendations. No longer are quantitative assessments of the disease probability considered necessary to determine the need for diagnostic testing and the choice of test. Instead, the recommendation is for no diagnostic testing if chest pain is judged to be ‘non-anginal’ and CT coronary angiography (CTCA) in patients with ‘typical’ or ‘atypical’ chest pain with additional perfusion imaging only if there is uncertainty about the functional significance of coronary lesions. The new emphasis on anatomical—as opposed to functional—testing is driven in large part by cost-effectiveness analysis and despite inevitable resource implications NICE calculates that annual savings for the population of England will be significant. In making CTCA the default diagnostic testing strategy in its updated chest pain guideline, NICE has responded emphatically to calls from trialists for CTCA to have a greater role in the diagnostic pathway of patients with suspected angina.




Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside

2017-06-14T05:54:05-07:00

The development of hand-carried, battery-powered ultrasound devices has created a new practice in ultrasound diagnostic imaging, called ‘point-of-care’ ultrasound (POCUS). Capitalising on device portability, POCUS is marked by brief and limited ultrasound imaging performed by the physician at the bedside to increase diagnostic accuracy and expediency. The natural evolution of POCUS techniques in general medicine, particularly with pocket-sized devices, may be in the development of a basic ultrasound examination similar to the use of the binaural stethoscope. This paper will specifically review how POCUS improves the limited sensitivity of the current practice of traditional cardiac physical examination by both cardiologists and non-cardiologists. Signs of left ventricular systolic dysfunction, left atrial enlargement, lung congestion and elevated central venous pressures are often missed by physical techniques but can be easily detected by POCUS and have prognostic and treatment implications. Creating a general set of repetitive imaging skills for these entities for application on all patients during routine examination will standardise and reduce heterogeneity in cardiac bedside ultrasound applications, simplify teaching curricula, enhance learning and recollection, and unify competency thresholds and practice. The addition of POCUS to standard physical examination techniques in cardiovascular medicine will result in an ultrasound-augmented cardiac physical examination that reaffirms the value of bedside diagnosis.




Symptoms and quality of life in patients with suspected angina undergoing CT coronary angiography: a randomised controlled trial

2017-06-14T05:54:05-07:00

Background

In patients with suspected angina pectoris, CT coronary angiography (CTCA) clarifies the diagnosis, directs appropriate investigations and therapies, and reduces clinical events. The effect on patient symptoms is currently unknown.

Methods

In a prospective open-label parallel group multicentre randomised controlled trial, 4146 patients with suspected angina due to coronary heart disease were randomised 1:1 to receive standard care or standard care plus CTCA. Symptoms and quality of life were assessed over 6 months using the Seattle Angina Questionnaire and Short Form 12.

Results

Baseline scores indicated mild physical limitation (74±0.4), moderate angina stability (44±0.4), modest angina frequency (68±0.4), excellent treatment satisfaction (92±0.2) and moderate impairment of quality of life (55±0.3). Compared with standard care alone, CTCA was associated with less marked improvements in physical limitation (difference –1.74 (95% CIs, –3.34 to –0.14), p=0.0329), angina frequency (difference –1.55 (–2.85 to –0.25), p=0.0198) and quality of life (difference –3.48 (–4.95 to –2.01), p<0.0001) at 6 months. For patients undergoing CTCA, improvements in symptoms were greatest in those diagnosed with normal coronary arteries or who had their preventative therapy discontinued, and least in those with moderate non-obstructive disease or had a new prescription of preventative therapy (p<0.001 for all).

Conclusions

While improving diagnosis, treatment and outcome, CTCA is associated with a small attenuation of the improvements in symptoms and quality of life due to the detection of moderate non-obstructive coronary artery disease.

Trial registration number:

NCT01149590.




Long-term (8-10 years) outcomes after biodegradable polymer-coated biolimus-eluting stent implantation

2017-06-14T05:54:05-07:00

Objective

Efficacy and safety data on biodegradable polymer-coated biolimus-eluting stent (BP-BES) are currently limited to 5 years. We evaluated longer term (8–10 years) clinical and angiographic outcomes after BP-BES implantation.

Methods

Between 2005 and 2008, 243 patients (301 lesions) underwent BP-BES implantation. The primary clinical outcome measure was defined as any target lesion revascularisation (TLR). Absolute serial angiographic studies without any concomitant TLR within 2 years after the procedure were performed in 55 patients (65 lesions) at postprocedure, mid-term (within 1 year), late term (between 1 and 2 years) and very late term (beyond 2 years).

Results

The median follow-up duration was 9.4 years (IQR 8.2–10.2 years). The 8-year cumulative incidence of any TLR was 20.3%. The increase rate was approximately 7% per year in the first 2 years, but decelerated to approximately 1.2% per year beyond 2 years after the procedure. The minimal lumen diameter significantly decreased from postprocedure (2.63±0.44 mm) to mid-term (2.43±0.59 mm, p=0.002) and from late term (2.27±0.63 mm) to very late term (1.98±0.73 mm, p=0.002). The 8-year cumulative incidences of definite or probable stent thrombosis (ST) and major bleeding (Bleeding Academic Research Consortium (BARC) ≥3) were 0.5% and 12.0%, respectively. Definite ST was none within 10 years in the entire cohort.

Conclusions

The long-term clinical outcomes after BP-BES implantation were favourable, although angiographic late progression of luminal narrowing did not reach a plateau. The incidence of ST remained notably low, whereas that of major bleeding gradually increased.




Association between bariatric surgery and rate of hospitalisations for stable angina pectoris in obese adults

2017-06-14T05:54:05-07:00

Objective

Obesity and stable angina pectoris (SAP) are important public health problems in the USA. However, little is known about whether weight reduction affects the rate of SAP-related morbidities. This study was designed to test the hypothesis that bariatric surgery is associated with a lower rate of hospitalisations for SAP in obese adults.

Methods

We performed a self-controlled case series study of obese adults with SAP who underwent bariatric surgery using a population-based inpatient database in three states (California, Florida and Nebraska) from 2005 to 2011. The primary outcome was hospitalisation for SAP. We used conditional logistic regression to compare the rate of the outcome event during sequential 12-month periods, using presurgery months 13–24 as a reference period.

Results

Our sample consisted of 953 patients with SAP who underwent bariatric surgery. The median age was 57 years, 51% were women, and 78% were non-Hispanic white. During the reference period, 25.3% (95%CI, 22.5% to 28.1%) had a hospitalisation for SAP. The rate remained stable in the subsequent 12-month presurgery period (adjusted OR (aOR) 0.84 (95% CI, 0.69 to 1.02); p=0.07). In the first 12-month period after bariatric surgery, we observed a significantly lower rate (9.1% (95% CI, 7.3% to 11.0%); aOR 0.33 (95% CI, 0.26 to 0.43); p<0.0001). Similarly, the rate remained significantly lower in the subsequent 13–24 months after bariatric surgery (8.7% (95% CI, 6.9% to 10.5%); aOR 0.31 (95% CI, 0.24 to 0.41); p<0.0001).

Conclusion

In this population-based study of obese adults with SAP, we found that the rate of hospitalisations for SAP was lower by two-thirds after bariatric surgery.




Effects of dabigatran according to age in atrial fibrillation

2017-06-14T05:54:05-07:00

Objective

The prevalence of atrial fibrillation (AF) and the risk of stroke and bleeding vary according to age. To estimate effects of dabigatran, compared with warfarin, on stroke, bleeding and mortality in patients with AF in the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) trial according to age, we analysed treatment effects using age as a continuous variable and using age categories.

Methods

RE-LY included 10 855 (59.9%) patients aged <75 years, 4231 patients (23.4%) aged 75–79 years, 2305 (12.7%) aged 80–84 years and 722 (4.0%) aged ≥85 years at baseline.

Results

Benefits of dabigatran versus warfarin regarding stroke (HR range 0.63 (95% CI 0.46 to 0.86) to 0.70 (0.31 to 1.57) for dabigatran 150 mg twice daily), HR range 0.52 (0.21 to 1.29) to 1.08 (0.73 to 1.60) for dabigatran 110 mg twice daily) and intracranial bleeding were maintained across all age groups (interaction p values all not significant). There was a highly significant interaction (p value interaction <0.001) between age and treatment for extracranial major bleeding, with lower rates with both doses of dabigatran compared with warfarin in younger patients (HR 0.78 (0.62 to 0.97) for 150 mg twice daily, HR 0.72 (0.57 to 0.90) for 110 mg twice daily) but similar (HR 1.50 (1.03 to 2.18) for 110 mg twice daily) or higher rates (HR 1.68 (1.18 to 2.41) for 150 mg twice daily) in older patients (≥80 years).

Conclusion

Effects of dabigatran compared with warfarin on stroke prevention and intracranial bleeding are consistent across all age groups. Effects of dabigatran on extracranial major bleeding are age dependent, supporting selection of dabigatran 110 mg twice daily for elderly patients (age ≥80 years).

Trial registration number

Clinical trial registration number: https://clinicaltrials.gov NCT00262600.




Gender differences in clinical presentation and 1-year outcomes in atrial fibrillation

2017-06-14T05:54:05-07:00

Objectives

Our objective was to examine gender differences in clinical presentation, management and prognosis of atrial fibrillation (AF) in a contemporary cohort.

Methods

In 6412 patients, 39.7% women, of the PREvention oF thromboembolic events – European Registry in Atrial Fibrillation, we examined gender differences in symptoms, risk factors, therapies and 1-year incidence of adverse outcomes.

Results

Men with AF were on average younger than women (mean±SD: 70.1±10.7 vs 74.1±9.7 years, p<0.0001). Women more frequently had at least one AF-related symptom at least occasionally compared with men (95.4% in women, 89.8% in men, p<0.0001). Prescription of oral anticoagulation was similar, with an increase of non-vitamin K antagonist oral anticoagulants from 5.9% to 12.6% in women and from 6.2% to 12.6% in men, p<0.0001 for both.

Men were more frequently treated with electrical cardioversion and ablation (20.6% and 6.3%, respectively) than women (14.9% and 3.3%, respectively), p<0.0001. Women had 65% (OR: 0.35; 95% CI (0.22 to 0.56)) lower age-adjusted and country-adjusted odds of coronary revascularisation, 40% (OR: 0.60; (0.38 to 0.93)) lower odds of acute coronary syndrome and 20% (OR: 0.80; (0.68 to 0.96)) lower odds of heart failure at 1 year. There were no statistically significant gender differences in 1-year stroke/transient ischaemic attack/arterial thromboembolism and major bleeding events.

Conclusion

In a ‘real-world’ European AF registry, women were more symptomatic but less likely to receive invasive rhythm control therapy such as electrical cardioversion or ablation. Further study is needed to confirm that these differences do not disadvantage women with AF.




Clinical information has low sensitivity for postmortem diagnosis of heart valve disease

2017-06-14T05:54:05-07:00

Background

Accuracy of routinely collected information concerning cause of death is essential for public health and health systems planning. Since clinical examination has relatively low sensitivity for detection of valvular heart disease (VHD), mortality data based on clinical information alone might routinely underestimate the number of deaths due to VHD.

Methods

We compared autopsy findings against premortem clinical information for 8198 consecutive adult postmortems (mean age 69.1 years, 61.3% men), performed in a single UK tertiary referral centre with on-site cardiac surgical facilities over a 10-year period (2004–2013) during which 21% of the adult population underwent postmortem examination.

Results

Following postmortem, VHD was the principal cause of death in 165 individuals (2.0%), a principal or contributory cause (‘any cause’) of death in 326 (4.0%) and an incidental (ie, non-causal) finding in a further 346 (4.2%). Clinical documentation of VHD before death was highly specific but relatively insensitive for postmortem identification of VHD as the principal (specificity 96.8%; 95% CI 96.4% to 97.2%; sensitivity 69.7%, 95% CI 62.1% to 76.6%) or any (specificity 98.1%; 95% CI 97.8% to 98.4%; sensitivity 68.4%, 95% CI 63.1% to 73.4%) cause of death. VHD (principally aortic stenosis, endocarditis and rheumatic heart disease) was newly noted at postmortem and listed as a cause of death in 142 individuals (1.7%).

Conclusions

Clinical information recorded premortem is highly specific but relatively insensitive for the cause of death established at autopsy. Population-based mortality statistics that depend on premortem clinical information are likely to routinely underestimate the mortality burden of VHD.




Appearance of QRS fragmentation late after Mustard/Senning repair is associated with adverse outcome

2017-06-14T05:54:05-07:00

Objective

To evaluate if development of fragmented QRS (fQRS) complexes, a marker of inhomogeneous ventricular activation due to myocardial fibrosis, is associated with adverse outcome in adults after Mustard/Senning repair for d-transposition of the great arteries (d-TGA).

Methods

Adults with atrial switch repair for d-TGA were selected from the database of a tertiary care hospital. Exclusion criteria were systemic right ventricular (RV) assist device or heart transplantation (HTx) before the age of 16, or fQRS already present at first visit to the Adult Congenital Heart Disease clinic. A blinded expert reader retrospectively analysed all available ECGs after the age of 16 for the presence of fQRS. The appearance of fQRS was modelled for each patient as a time-dependent variable. Cox regression was performed to assess the relationship between covariates and the composite endpoint of cardiovascular mortality, HTx or systemic RV assist device.

Results

Records of 89 patients (34% female, 42% Mustard repair) were analysed. At latest follow-up, fQRS was noted in 26 patients (29%). Over a median follow-up time of 16.9 (IQR 12.6–22.9) years, the composite endpoint occurred in nine patients (10%). In multivariable Cox analysis, appearance of fQRS (HR 14.11; 95% CI 1.42 to 140.12) and development of severe RV dysfunction (HR 11.36; 95% CI 2.08 to 62.17) were significantly associated with the composite endpoint.

Conclusions

Appearance of fQRS complexes on a 12-lead ECG is associated with adverse outcome in adults after atrial switch repair for d-TGA. In this population, fQRS detection might be a promising and easily implementable tool to identify patients at risk for adverse events.




Spontaneous coronary artery dissection

2017-06-14T05:54:05-07:00

Learning objectives

  • To recognise spontaneous coronary artery dissection (SCAD) as a cause of myocardial infarction in low-risk, predominantly female, patients and to understand that although SCAD is an important cause of peripartum myocardial infarction, ~90% of incident cases are not pregnant.

  • To be aware that a visible dissection flap at angiography is absent in the majority of cases.

  • To understand the rationale for an ‘as conservative as possible’ approach to revascularisation and key challenges in medical treatment.

  • Introduction

    Spontaneous coronary artery dissection (SCAD) is an increasingly recognised cause of non-atherosclerotic acute coronary syndromes leading to myocardial infarction. It is characterised by the presence of blood entering and separating the layers of the coronary arterial wall to form a false lumen. This leads to external compression of the true coronary lumen restricting coronary blood flow and leading to coronary insufficiency (figure 1). SCAD...




    A middle-aged woman with a heavy heart

    2017-06-14T05:54:05-07:00

    Clinical introduction

    A 51-year-old woman was referred to our hospital with a 4-month history of progressive dyspnoea on exertion (New York Heart Association Functional Classification III), chest heaviness, dry cough, weight loss and tiredness. She worked as cleaning woman and had no relevant medical history, apart from an Epstein-Barr Virus (EBV) infection 2 months before symptom onset. She did not smoke and family history was negative.

    On examination, blood pressure was 104/80 mm Hg and heart rate was regular at 145 bpm. On auscultation, heart sounds were distant, muffled and there was no murmur. Minimal, bilateral pitting oedema was observed. Laboratory findings were unremarkable. During hospitalisation, cardiac monitoring revealed paroxysmal new-onset atrial fibrillation.

    Chest radiography from a previous hospital had revealed cardiomegaly and subsequent echocardiography had shown pericardial effusion with diastolic dysfunction, for which she had received percutaneous pericardiocentesis. However, repeated echocardiography at our hospital showed recurrence of pericardial effusion...




    Cardiovascular highlights from non-cardiology journals

    2017-06-14T05:54:05-07:00

    Adolescent body mass index predicts future cardiovascular risk

    One-third of the adolescent population in Western countries is now considered to be overweight or obese. The implications of this epidemic remain unclear but may well lead to an increased prevalence of cardiovascular disease and an erosion in the mortality and morbidity gains that have been apparent in the last few decades. To further explore this question, records from an Israeli national database containing the BMIs of adolescents was analysed. Data for a total of 2.3 million individuals (mean age 17 years.) was available between 1967 and 2010 compromising a total of over 42 000 000 years of person follow-up. Body mass index (BMI) was assessed by centiles and linked to mortality data for the population. 9.1% of deaths in this young cohort were attributable to cardiovascular causes with 1497 from coronary disease, 528 from stroke and 893 from sudden death. Using a multivariable...




    Re: The National Institute for Health and Care Excellence update for stable chest pain: poorly reasoned and risky for patients

    2017-06-14T05:54:05-07:00

    Dear Editor, Cremer and Nissen have chosen to traduce the National Institute for Health and Care Excellence (NICE) guideline update in their editorial.1 The views they express are inaccurate and biased as summarised in the bulleted comments that follow:

  • Contrary to the assertion by Cremer and Nissen, the NICE guideline emphasises the importance of a careful history to guide the need for further diagnostic testing.

  • Nowhere does the NICE guideline state that assessing pretest probability (PTP) of disease is ‘useless’ or that Bayesian analysis should be ‘abandoned’. It merely observes that regardless of age and gender, nearly all patients with atypical or typical chest pain have a PTP of disease between 10% and 90% by Genders’ updated diagnostic model. In all such patients, therefore, non-invasive testing can usefully modify disease probability according to Bayesian principles. Accordingly, NICE recommends testing in all patients with atypical or typical chest pain.

  • ...



  • The true value of The National Institute for Health and Care Excellence guidance

    2017-06-14T05:54:05-07:00

    To the Editor: We read with interest the Editorial on the recently updated National Institute for Health and Care Excellence (NICE) guidance for the assessment of suspected stable angina.1 The authors raise some salient points regarding the importance of careful history taking, the vexed question of the exercise ECG and the relative merits of the myriad non-invasive tests for diagnosing coronary artery disease (CAD). However, we believe they have adopted an unnecessarily alarmist tone in their criticisms and feel obliged to respond to several issues.

    Although they suggest that the assessment of pretest probability (PTP) has been disregarded, this process has merely been made implicit rather than explicit. The guidelines emphasise the pivotal importance of the clinical history and, in the setting of suspected angina, the nature of the presenting symptoms is the dominant predictor of CAD. Existing risk tables2 show that either typical or atypical angina...