scholarly journals Comparison of NICE and ESC proposed strategies on new onset chest pain and the contemporary clinical utility of pretest probability risk score

Open Heart ◽  
2020 ◽  
Vol 7 (1) ◽  
pp. e001081 ◽  
Author(s):  
Alexandros Papachristidis ◽  
George Frederick Vaughan ◽  
Sarah J Denny ◽  
Tamim Akbari ◽  
Edith Avornyo ◽  
...  
Keyword(s):  
Chest Pain ◽  
Coronary Angiography ◽  
Cost Analysis ◽  
Risk Score ◽  
Clinical Utility ◽  
De Novo ◽  
Invasive Coronary Angiography ◽  
Group A ◽  
Group B ◽  
New Onset

AimsPatients with de novo chest pain are usually investigated non-invasively. The new UK-National Institute for Health and Care Excellence (NICE) guidelines recommend CT coronary angiography (CTCA) for all patients, while European Society of Cardiology (ESC) recommends functional tests. We sought to compare the clinical utility and perform a cost analysis of these recommendations in two UK centres with different primary investigative strategies.Methods—resultsWe compared two groups of patients, group A (n=667) and group B (n=654), with new onset chest pain in two neighbouring National Health Service hospitals, each primarily following either ESC (group A) or NICE (group B) guidance. We assessed the clinical utility of each strategy, including progression to invasive coronary angiography (ICA) and revascularisation. We present a retrospective cost analysis in the context of UK tariff for stress echo (£176), CTCA (£220) and ICA (£1001). Finally, we sought to identify predictors of revascularisation in the whole population.Baseline characteristics in both groups were similar. The progression to ICA was comparable (9.9% vs 12.0%, p=0.377), with similar requirement for revascularisation (4.0% vs 5.0%.; p=0.532). The average cost of investigations per investigated patient was lower in group A (£279.66 vs £325.77), saving £46.11 per patient. The ESC recommended risk score (RS) was found to be the only predictor of revascularisation (OR 1.05, 95% CI 1.04 to 1.06; p<0.001).ConclusionBoth NICE and ESC-proposed strategies led to similar rates of ICA and need for revascularisation in discrete, but similar groups of patients. The SE-first approach had a lower overall cost by £46.11 per patient, and the ESC RS was the only variable correlated to revascularisation.

Left ventricular dysfunction causing ischemia in patients with patent coronary arteries

Perfusion ◽  
2017 ◽  
Vol 33 (2) ◽  
pp. 115-122
Author(s):  
Thach Nguyen ◽  
Hoang Do ◽  
Tri Pham ◽  
Loc T Vu ◽  
Marco Zuin ◽  
...  
Keyword(s):  
Chest Pain ◽  
Coronary Artery ◽  
Diastolic Pressure ◽  
Left Ventricular ◽  
T Wave ◽  
St Depression ◽  
Wave Inversion ◽  
Group A ◽  
Group B ◽  
New Onset

Background: New onset of heart failure (HF) is an indication for the assessment of coronary artery disease. The aim of this study was to clarify the mechanistic causes of new onset HF associated with ischemic electrocardiograph (EKG) changes and chest pain in patients with patent or minimally diseased coronary arteries. Methods: Twenty consecutive patients (Group A) were retrospectively reviewed if they had an history of new onset of HF, chest pain, electrocardiographic changes indicating ischemia (ST depression or T wave inversion in at least two consecutive leads and a negative coronary angiogram [CA]) and did not require percutaneous coronary intervention or coronary artery bypass grafting. A 1:1 matched cohort (Group B) was adopted to validate the results. Results: All patients had a negative CA. The majority of subjects in Group A had a higher left ventricular end diastolic pressure (LVEDP) when compared to the control group (p<0.05). Similarly, the aortic diastolic (AOD) pressure was lower in Group A than in Group B (p<0.05). In patients with elevated LVEDP and low AOD, with a coronary perfusion pressure (CPP) <20 mmHg, deep T wave inversion in two consecutive leads were more frequently observed. When the CPP was between 20-30 mmHg, a mild ST depression were more frequently recorded (p<0.05). Conversely, when the CPP was >30 mmHg, only mild non-specific ST-T changes or normal EKG were observed. Conclusions: In patients with HF and EKG changes suggestive of ischemia in at least two consecutive leads, a lower AOD could aggravate ischemia in patients with elevated left ventricular end diastolic pressure.

scholarly journals Integration of CTA in the Diagnostic Workup of New Onset Chest Pain in Clinical Practice

2019 ◽  
Vol 2019 ◽  
pp. 1-8
Author(s):  
Nazario Carrabba ◽  
Martina Berteotti ◽  
Giulia Taborchi ◽  
Francesca Ciatti ◽  
Manlio Acquafresca ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Chest Pain ◽  
Diagnostic Workup ◽  
Second Line ◽  
Functional Tests ◽  
First Line ◽  
Group A ◽  
Group B ◽  
The Impact ◽  
New Onset

Background. Recently, NICE guidelines recommend the use of computed tomographic angiography (CTA) as the first line of investigation for new onset chest pain. We sought to evaluate the impact of the integration of CTA in the diagnostic workup, as either a first- or second-line of investigation, in the clinical practice for patients presenting with new onset chest pain, with suspicion that it may be due to coronary artery disease (CAD). Method and Results. From 2014 to 2016, 208 outpatients (mean age 63.8 ± 12.7, 37% female) with an unknown CAD diagnosis were evaluated. About half (n=106, 51%) received usual testing care plus CTA as a second-line investigation (group A), while the other half (n=102, 49%) received CTA as a first-line investigation (group B). Care decisions and test interpretations were made by the attending physician. Obstructive CAD (O-CAD) was defined as >50% stenosis in the principal branch. As determined by CTA, the rates of CAD in group A vs. group B were the following (P=0.001): 31.1% vs. 27.4% for normal/minimal CAD; 42.5% vs. 63.7% for no O-CAD; and 26.4% vs. 8.8% with O-CAD. Based on a diagnostic result of no O-CAD, invasive angiography was cancelled in 42.6% (n=45) of group A patients, and additional functional tests were cancelled for the same reason in 63.7% (n=65) of group B patients, without adverse events at median 3-year. The average diagnostic cost for patients in our study was lower in group B (206 vs. 324.42 euro; P<0.0001). Conclusions. In clinical practice, CTA, as a first- or second-line investigation, most commonly detected no O-CAD in new onset chest pain patients, leading us to safely avoid unnecessary ICA or additional functional tests. The use of CTA as a first-line investigation also appears to be cost saving, but its cost-effectiveness remains to be demonstrated in larger studies.

scholarly journals Invasive Coronary Angiography after Chest Pain Presentations to Emergency Departments

2020 ◽  
Vol 17 (24) ◽  
pp. 9502
Author(s):  
Frank M. Sanfilippo ◽  
Graham S. Hillis ◽  
Jamie M. Rankin ◽  
Donald Latchem ◽  
Carl J. Schultz ◽  
...  
Keyword(s):  
Chest Pain ◽  
Coronary Angiography ◽  
Emergency Departments ◽  
Invasive Coronary Angiography ◽  
Patient Characteristics ◽  
Tertiary Hospital ◽  
Discharge Diagnosis ◽  
Coronary Syndrome ◽  
Interhospital Transfer ◽  
And Gender

We investigated patients presenting to emergency departments (EDs) with chest pain to identify factors that influence the use of invasive coronary angiography (ICA). Using linked ED, hospitalisations, death and cardiac biomarker data, we identified people aged 20 years and over who presented with chest pain to tertiary public hospital EDs in Western Australia from 1 January 2016 to 31 March 2017 (ED chest pain cohort). We report patient characteristics, ED discharge diagnosis, pathways to ICA, ICA within 90 days, troponin test results, and gender differences. Associations were examined with the Pearson Chi-squared test and multivariate logistic regression. There were 16,974 people in the ED chest pain cohort, with a mean age of 55.6 years and 50.7% males, accounting for 20,131 ED presentations. Acute coronary syndrome was the ED discharge diagnosis in 10.4% of presentations. ED pathways were: discharged home (57.5%); hospitalisation (41.7%); interhospital transfer (0.4%); and died in ED (0.03%)/inpatients (0.3%). There were 1546 (9.1%) ICAs performed within 90 days of the first ED chest pain visit, of which 59 visits (3.8%) had no troponin tests and 565 visits (36.6%) had normal troponin. ICAs were performed in more men than women (12.3% vs. 6.1%, p < 0.0001; adjusted OR 1.89, 95% CI 1.65, 2.18), and mostly within 7 days. Equal numbers of males and females present with chest pain to tertiary hospital EDs, but men are twice as likely to get ICA. Over one-third of ICAs occur in those with normal troponin levels, indicating that further investigation is required to determine risk profile, outcomes and cost effectiveness.

5965Perimatrial inflammation measured by fluoine-18-fluorodeoxyglucose-positron emission tomography/computed tomography to predict new-onset atrial fibrillation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
Y Hada ◽  
S Iwamiya ◽  
S Hijikata ◽  
T Yoshitake ◽  
H Sato ◽  
...  
Keyword(s):  
Blood Pool ◽  
Emission Tomography ◽  
Positron Emission ◽  
Pet Ct ◽  
Significant Difference ◽  
Group A ◽  
Arterial Inflammation ◽  
Group B ◽  
Fdg Pet Ct ◽  
New Onset

Abstract Background Fluoine-18-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) is a useful modality of inflammatory disease. Epicardial adipose tissue (EAT) contains abundant ganglionated plexi, therefore EAT inflammation may cause atrial arrhythmia, such as atrial premature contraction (APC) and atrial fibrillation (AF). Previous studies have shown that inflammatory activity of EAT has relation to the presence of AF. However, it is unknown whether EAT inflammation contributes to the occurrence of AF. Methods Out of 20720 examinees who underwent FDG-PET/CT for screening of cancer in the years 2012–2018, 151 (aged 65.6±12.0 years old, 62 females) had ambulatory electrocardiographic monitoring (Holter ECG) within a year and non-detection of AF. Standardized uptake value (SUV) was measured in fat adjacent to roof of left atrium (ROOF), atrioventricular groove (AV), left main coronary artery (LMT), and right ventricular blood pool (RV). In order to correct for blood pool activity, SUV of ROOF, AV, and LMT were divided by SUV of RV respectively, yielding target-to-background ratio (TBR). As regards to arterial inflammation, measurements were performed with SUV in ascending aorta (A-Ao) and in superior vena cava (SVC) as blood pool. In the same way, SUV of A-Ao was divided by SUV of SVC, yielding TBR. Results According to Holter ECG, APC≥100 beats per day was seen in 60 patients (Group A), but not in the other 91 (Group B). In Group A, TBR of ROOF, AV, and LMT were all significantly higher than Group B (p<0.001, p=0.004, and p=0.008, respectively). During a median follow-up of 179 days, new-onset AF was diagnosed in 7 patients (4 in Group A (6.7%), 3 in Group B (3.3%), p=0.046). There was significant difference in TBR of ROOF between patients with and without new-onset AF (p<0.001), but not in TBR of AV and LMT. In addition, no significant difference was observed in TBR of A-Ao between these two groups. In the Cox proportional hazard analysis, TBR of ROOF was found to be an independent predictor of new-onset AF (odds ratio 40.1, 95% confidence interval 6.05 to 265.9, p<0.001). Conclusions Although EAT inflammation evaluated by SUV is related to frequent APCs, only in fat adjacent to roof of left atrium is associated with and predicts future occurrence of AF. Arterial inflammation measured by SUV has no relation to atrial arrhythmia.

scholarly journals Variable use of amiodarone is associated with a greater risk of recurrence of atrial fibrillation in the critically ill

QJM ◽  
2020 ◽  
Vol 113 (Supplement_1) ◽  
Author(s):  
N A Fahmy ◽  
S M Alfawal ◽  
H S Abdelsamie ◽  
A M Hassan
Keyword(s):  
Atrial Fibrillation ◽  
Prospective Observational Study ◽  
P Value ◽  
Loading Dose ◽  
Inclusion Criteria ◽  
Reactive Protein ◽  
Group A ◽  
Group B ◽  
Af Recurrence ◽  
New Onset

Abstract Background Atrial fibrillation (AF) is the most common sustained arrhythmia affecting humans. It is an electrical disturbance that leads to rapid, disorganized, and asynchronous contraction of the atrial muscle. In clinical practice, it accounts for approximately one-third of hospitalizations for cardiac rhythm disturbances. The incidence of AF increases from less than 0.1% per year in those under 40 years old to exceed 1.5% per year in women and 2% per year in men older than 80 years. Aim of the Work: to discuss the effect of variation in amiodarone use (including dosage and duration) on dysrhythmia recurrence in patients with new-onset AF in ICU. Patients and Methods This was a prospective observational study conducted over 6 months, 60 patients who fulfilled inclusion criteria were included in the study divided in two groups according to amiodarone dosage, each group is 30 patients: Group (A): received a loading dose of amiodarone followed by an infusion (1200mg amiodarone). Group (B): received a loading dose of amiodarone not followed by an infusion (300mg amiodarone). Results a significant positive correlation was observed between level of C-reactive protein (CRP) and the rate of AF recurrence. As regard effect of CRP on AF recurrence; in AF recurrent patients, mean is (191±77.3) with range from 15 to 352 which significantly differed from Non-recurrent AF patients, mean is (89±63) with range from 20 to 223 (p value &lt;0.001). AF recurrence was higher in group (B) than group (A),. In group (A) 8 patients had recurrent AF representing 26.7 % and in group (B) 19 patients had AF recurrence representing 63.3% (p value =0.004). Conclusion Patients with new-onset AF in (ICU) who are treated with amiodarone should receive a loading dose, immediately followed by an infusion.

Relative clinical value of coronary computed tomography and stress echocardiography-guided management of stable chest pain patients: a propensity-matched analysis

2020 ◽  
Author(s):  
Anastasia Vamvakidou ◽  
Oleksandr Danylenko ◽  
Jiwan Pradhan ◽  
Mihir Kelshiker ◽  
Timothy Jones ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Chest Pain ◽  
Coronary Angiography ◽  
Stress Echocardiography ◽  
Invasive Coronary Angiography ◽  
Low Risk ◽  
Clinical Value ◽  
Coronary Computed Tomography ◽  
Stable Chest Pain

Abstract Aims The European Society of Cardiology recommends coronary computed tomography (CCT) for the assessment of low-risk patients with suspected stable angina. We aimed to assess in a real-life setting the relative clinical value of stress echocardiography (SE)- and CCT-guided management in this population. Methods and results Patients with stable chest pain and no prior history of coronary artery disease (CAD) who underwent CCT or SE as the initial investigative strategy were propensity-matched (990 patients each group-age: 59 ± 13.2 years, males: 47.9%) to account for baseline differences in cardiovascular risk factors. Inconclusive tests were 6% vs. 3% (P &lt; 0.005) in CCT vs. SE. Severe (≥70% stenosis) on CCT and inducible ischaemia on SE detected obstructive CAD by invasive coronary angiography in 63% vs. 57% patients (P = 0.33). Over the follow-up period (median 717, interquartile range 93–1069 days) more patients underwent invasive coronary angiography (21.5% vs. 7.3%, P &lt; 0.005), revascularization (7.3% vs. 3.5%, P &lt; 0.005), further functional testing 33.4% vs. 8.7% (P &lt; 0.005), but more patients were prescribed statins 8.8% vs. 3.8% (P &lt; 0.005) in the CCT vs. the SE arm, respectively. Combined all-cause mortality and acute myocardial infarction was low—CCT-2.3% and SE-3.3%—with no significant difference (P = 0.16). Conclusion Initial SE-guided management was similar for the detection of obstructive CAD, demonstrated better resource utilization, but was associated with reduced prescription of statins although with no difference in medium-term outcome compared to CCT in this very low-risk population. However, a randomized study with longer follow-up is needed to confirm the clinical value of our findings.

scholarly journals Comparison of the efficacy of Ivabradine and Nebivolol as Mono Therapy in the Treatment of Stable Angina Pectoris Patients with Mild Left Ventricular Dysfunction

2019 ◽  
Vol 15 (1) ◽  
pp. 8-11
Author(s):  
Harisul Hoque ◽  
Khurshed Ahmed ◽  
MRM Mandal ◽  
Faisal Ibn Kabir ◽  
Md Abdus Salam ◽  
...  
Keyword(s):  
Heart Rate ◽  
Chest Pain ◽  
Angina Pectoris ◽  
Left Ventricular Dysfunction ◽  
Stable Angina ◽  
Ventricular Dysfunction ◽  
Left Ventricular ◽  
Stable Angina Pectoris ◽  
Group A ◽  
Group B

This prospective study aimed to investigate the efficacy of ivabradine and nebivolol in treatment of stable angina pectoris (SAP) patients with mild left ventricular dysfunction. Heart rate decreased (78±6) to (65±5) in Group: A and ( 77± 7) to (70 ± 5) in Group: B. There was no change in Blood pressure reduction in Group:A but significant BP reduction in Nebivolol group. Chest pain was reduced by Ivabradine but in Group : B, chest pain decreased in long term after 6 weeks time. After 6 months’ treatment LVEF for the 15 patients of nebivolol group (50%; Group: A) improved by (48 ± 6.5) to (51 ± 3.2), (p>0.05) and for the 15 patients of Ivabradine group (50%; Group: B) (47 ± 5.4) to (51 ± 2.3), (p>0.05). Ivabradine can be considered as first choice in patient with tachycardia induced angina as this agent for reducing heart rate as well as chest pain. The hypertensive patient with tachycardia may be treated by Nebivolol. Among patients in which effective treatment could not be achieved at maximum nebivolol doses, more effective results were obtained in this study with Ivabradine. University Heart Journal Vol. 15, No. 1, Jan 2019; 8-11

scholarly journals The impact of mild renal dysfunction on isolated cardiopulmonary coronary artery bypass grafting: a retrospective propensity score matching analysis

2019 ◽  
Vol 14 (1) ◽  
Author(s):  
Xian Wang ◽  
Yifan Zhu ◽  
Wen Chen ◽  
Liangpeng Li ◽  
Xin Chen ◽  
...  
Keyword(s):  
Propensity Score ◽  
Propensity Score Matching ◽  
Artery Bypass ◽  
Term Survival ◽  
Group A ◽  
Group B ◽  
The Impact ◽  
New Onset

Abstract Background Mild preoperative renal dysfunction (RD) is not rare in patients receiving isolated cardiopulmonary coronary artery bypass grafting (CCABG). However, there are not too many studies about the impact of mild preoperative RD on in-hospital and follow-up outcomes after isolated CCABG. This single-centre, retrospective propensity score matching study designed to study the impact of mild preoperative RD on in-hospital and long-term outcomes after first isolated CCABG. Methods After propensity score matching, 1144 patients with preoperative estimated glomerular filtration rate (eGFR) of more than 60 ml/min/1.73 m2 receiving first isolated CCABG surgery from January 2012 to December 2015 entered the study, who were divided into 2 groups: A group (eGFR ≥90 ml/min/1.73 m2, n = 572) and B group (eGFR of 60–89 ml/min/1.73 m2, n = 572). The in-hospital and long-term outcomes were recorded and analyzed. The mean follow-up time was 54.4 ± 10.7 months. Acute kidney injury (AKI) was defined and classified according to the Acute Kidney Injury Network (AKIN) criteria. Results The 2 propensity score-matched groups had similar baseline and procedure except the baseline eGFR. There were 8 patients died in A group (mortality is 1.4%) and 14 died in B group (mortality is 2.5%) during the in hospital and 30-day postoperatively(χ2 = 1.159, p = 0.282). There were totally 38 patients lost to follow-up, 18 in group A and 20 in group B. 21 patients died in group A and 37 died in group B during the follow-up, and long-term survival in group A was higher than in group B (96.2% vs 93.1%, χ2 = 4.336, p = 0.037). Comparing with group A, group B was associated with an increased rates and severity of AKI postoperatively (total AKI: 62 vs 144. AKIN stageI: 54 vs 113; AKIN stageII: 6 vs 22; AKIN stageIII: 2 vs 9, p<0.0001). During follow-up, group B also had a higher rate of new onset of dialysis (0 vs 6, χ2 = 4.432, p = 0.039). Multivariable logistic regression showed that comparing with A group, the HR for long-term mortality and new onset of dialysis in B group was 1.67 and 1.52 respectively (95%CI 1.09–2.90, p = 0.035; 95%CI 1.14–2.49, p = 0.027). Conclusions Comparing with normal preoperative renal function, patients with mild preoperative RD had a similar in-hosptial mortality, but with an increased in-hosptial rates and severity of AKI, and with a decreased long-term survival and increased long-term new onset of dialysis.

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