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Roifman I, Chu A, Austin PC, Rashid M, Douglas PS, Wijeysundera HC. Comparing Costs of Noninvasive Cardiac Diagnostic Tests-a Population-Based Study. J Am Soc Echocardiogr 2024; 37:288-299. [PMID: 37972792 DOI: 10.1016/j.echo.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 11/05/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Noninvasive cardiac diagnostic tests (NITs) for the diagnosis of coronary artery disease have been estimated to cost >$3 billion annually in the United States alone and have recently undergone scrutiny over concerns of overuse. Consequently, comparing costs of different NIT testing strategies is of urgent importance to health care planning. METHODS We utilized population-based administrative and clinical data from Ontario, Canada, to compare downstream costs between 4 available NIT testing strategies (graded exercise stress testing [GXT], stress echocardiography, cardiac computed tomography angiography [CCTA], and myocardial perfusion imaging [MPI] as well as no testing), among patients evaluated for chest pain. To compare costs among the tested (overall and by testing strategy) and nontested groups, we used a log-gamma generalized linear model to account for the skewed distribution of health care cost data, adjusting for relevant clinical covariates. RESULTS A total of 2,340,699 patients were included in our cohort, of whom 481,170 (21%) patients received 1 of the 4 NITs. Among patients who received a NIT, 254,492 (53%) received a GXT as their initial test, 154,137 (32%) received MPI, 69,160 (14%) received a stress echo, and 3,381 (<1%) received a CCTA. After adjustment for differences in baseline patient characteristics, receipt of any NIT was associated with an approximate 12% reduction in downstream 1-year mean costs (cost ratio = 0.88; 95% CI, 0.87, 0.89) compared with those without any testing. Comparing the different testing strategies with no testing, both GXT (cost ratio = 0.80; 95% CI, 0.79-0.81) and stress echocardiography (cost ratio = 0.82; 95% CI, 0.81-0.83) were associated with the lower downstream costs, while both MPI (cost ratio = 1.26; 95% CI, 1.25, 1.27) and CCTA (cost ratio = 1.29; 95% CI, 1.23, 1.35) were associated with higher downstream costs. CONCLUSIONS In a large population-based cohort consisting of >2 million people evaluated for chest pain, we report that receipt of noninvasive testing was associated with a 12% reduction in downstream costs when compared with no testing. Graded exercise stress testing and stress echocardiography were associated with the least downstream costs, whereas CCTA and MPI were associated with higher costs when compared with no testing. These findings may help inform testing decisions in chest pain patients.
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Affiliation(s)
- Idan Roifman
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| | | | - Peter C Austin
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | | | - Pamela S Douglas
- Duke University Medical Centre, Duke University, Durham, North Carolina
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
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Jaffer S, Noble M, Pozgay A, Randhawa V, Gulati M, Mensour E, Parast N, Tegg N, Theberge E, Harchaoui EK, Mulvagh SL. The Development of a Chest-Pain Protocol for Women Presenting to the Emergency Department. CJC Open 2024; 6:517-529. [PMID: 38487055 PMCID: PMC10935692 DOI: 10.1016/j.cjco.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/02/2023] [Indexed: 03/17/2024] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death in women worldwide, and of premature death in women in Canada. Despite improvements in cardiovascular care over the past 15-20 years, acute coronary syndrome (ACS) and CVD mortality continue to increase among women in Canada. Chest pain is a common symptom leading to emergency department visits for both men and women. However, women with ACS experience worse outcomes. compared with those of men, due to misdiagnosis or lack of diagnosis resulting in delayed care and underuse of guideline-directed medical therapies. CVD mortality rates are highest in Indigenous and racialized women and those with a disproportionately high number of adverse social determinants of health. CVD remains underrecognized, underdiagnosed, undertreated, and underresearched in women. Moreover, a lack of awareness of unique symptoms, clinical presentations, and sex-and-gender specific CVD risk factors, by healthcare professionals, leads to outcome disparities. In response to this knowledge gap, in acute recognition and management of chest-pain syndromes in women, the Canadian Women's Heart Health Alliance performed a needs assessment and review of CVD risk factors and ACS pathophysiology, through a sex and gender lens, and then developed a unique chest-pain assessment protocol utilizing modified dynamic programming algorithmic methodology. The resulting algorithmic protocol is presented. The output is intended as a quick reference algorithm that could be posted in emergency departments and other acute-care settings. Next steps include protocol implementation evaluation and impact assessment on CVD outcomes in women.
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Affiliation(s)
- Shahin Jaffer
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Anita Pozgay
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Varinder Randhawa
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Martha Gulati
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Emma Mensour
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Nazli Parast
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Nicole Tegg
- Faculty of Nursing, University of Alberta, Alberta, Ontario, Canada
| | - Emilie Theberge
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Sharon L. Mulvagh
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Clavel MA, Van Spall HG, Mantella LE, Foulds H, Randhawa V, Parry M, Liblik K, Kirkham AA, Cotie L, Jaffer S, Bruneau J, Colella TJ, Ahmed S, Dhukai A, Gomes Z, Adreak N, Keeping-Burke L, Limbachia J, Liu S, Jacques KE, Mullen KA, Mulvagh SL, Norris CM. The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 8: Knowledge Gaps and Status of Existing Research Programs in Canada. CJC Open 2024; 6:220-257. [PMID: 38487042 PMCID: PMC10935691 DOI: 10.1016/j.cjco.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 11/14/2023] [Indexed: 03/17/2024] Open
Abstract
Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women.
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Affiliation(s)
- Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Harriette G.C. Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact, McMaster University, Toronto, Ontario, Canada
| | - Laura E. Mantella
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Heather Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Varinder Randhawa
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Kiera Liblik
- Department of Medicine, Kingston Health Science Center, Kingston, Ontario, Canada
| | - Amy A. Kirkham
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Lisa Cotie
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Shahin Jaffer
- General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jill Bruneau
- Faculty of Nursing, Memorial University of Newfoundland and Labrador, St John, Newfoundland and Labrador, Canada
| | - Tracey J.F. Colella
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Sofia Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abida Dhukai
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Zoya Gomes
- Faculty of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Najah Adreak
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Keeping-Burke
- Department of Nursing and Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Jayneel Limbachia
- Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Shuangbo Liu
- Section of Cardiology, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Karen E. Jacques
- Person with lived experience, Canadian Women’s Heart Health Alliance, Ottawa, Ontario, Canada
| | - Kerri A. Mullen
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sharon L. Mulvagh
- Faculty of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Sun YL, Yao YL, Jia MJ, Sun YY, Li HL, Ruan XF, Wang XL. Evaluation of the efficacy and safety of Suxiao Jiuxin Pill in the treatment of stable angina: A randomized, double-blind, placebo-controlled, multi-center clinical trial. JOURNAL OF ETHNOPHARMACOLOGY 2024; 318:116959. [PMID: 37487965 DOI: 10.1016/j.jep.2023.116959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/22/2023] [Accepted: 07/21/2023] [Indexed: 07/26/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE The Suxiao Jiuxin Pill (SJP) has been used for treating chronic stable angina (SA) for more than 40 years in China. SJP is composed of two Chinese herbs and has the effect of activating blood and promoting qi, according to traditional Chinese medicine (TCM) theory. AIM OF THE STUDY The study aims to determine the effects of adjunct SJP on conventional therapy in patients with SA which provides a complementary choice and its evidence for clinical medication for treating SA. MATERIALS AND METHODS Participants with SA were recruited and randomized 1:1 to either the SJP group or the control group for 24 weeks. Both groups received conventional treatment according to local tertiary hospital protocols, and the participants received additional SJP (composed of Ligusticum wallichii and Borneol) or placebo in treatment and control groups respectively. The primary outcome was the curative efficacy rate at week 4. Secondary outcomes are the curative efficacy rate, the total score of angina pectoris symptoms, CCS Angina Classification improvement, Seattle Angina Questionnaire (SAQ) score, TCM syndrome scores (TCMSS), and the curative efficacy rate of TCMSS. Adverse events and adverse drug reactions were observed and recorded for safety analysis. RESULTS A total of 324 participants with SA from 13 hospitals in China were enrolled in this trial. Compared with the control group, the curative efficacy rate of SA, the curative efficacy rate of TCMSS significantly increased, and the total score of angina pectoris symptoms and TCMSS significantly reduced in the SJP group at week 4, 12, and 24, accompanied by the statistically significant improvement in the curative efficacy rate based on CCS grade reduction (all P < 0.05). Furthermore, the SAQ score (physical limitation, angina stability, and treatment satisfaction) was evaluated as the quality of life significantly improved after treatment (P < 0.05). The medication compliance, concomitant medication, and rates of adverse events were similar between the two groups (P > 0.05). CONCLUSION The present prospective, multicenter, randomized, double-blind, placebo-controlled, clinical trial confirms that adjunct SJP to conventional treatment increased the curative efficacy and life quality of SA patients with no significant adverse drug reactions during the clinical application. CLINICAL TRIAL REGISTRATION (ID, ChiCTR1900021876, URL = http://www.chictr.org.cn/showproj.aspx?proj=34955).
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Affiliation(s)
- Yuan-Long Sun
- Cardiovascular Department, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Cardiovascular Research Institute of Traditional Chinese Medicine, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Yi-Li Yao
- Cardiovascular Department, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Cardiovascular Research Institute of Traditional Chinese Medicine, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Mei-Jun Jia
- Cardiovascular Department, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Cardiovascular Research Institute of Traditional Chinese Medicine, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Yuan-Yuan Sun
- Cardiovascular Disease Drug Research Committee, China Association of Traditional Chinese Medicine, China
| | - He-Lin Li
- Beijing Yaohai Ningkang Pharmaceutical Technology Co., LTD, China
| | - Xiao-Fen Ruan
- Cardiovascular Department, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Cardiovascular Research Institute of Traditional Chinese Medicine, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Xiao-Long Wang
- Cardiovascular Department, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China; Cardiovascular Research Institute of Traditional Chinese Medicine, Shuguang Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
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Sebastian SA, Co EL, Tidd-Johnson A, Chowdhury S, Jain E, Davidson M, Johal G. Usefulness of Carotid Ultrasound Screening in Primary Cardiovascular Prevention: A Systematic Review. Curr Probl Cardiol 2024; 49:102147. [PMID: 37863454 DOI: 10.1016/j.cpcardiol.2023.102147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/14/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide, and its prevention is more cost-effective than the treatment of its complications. Although cardiovascular (CV) risk assessment based on conventional risk factors is the general recommendation, a significant percentage of the population, irrespective of these risk factors, present with subclinical atherosclerosis during carotid Doppler ultrasound (US) imaging. Subclinical atherosclerotic lesions at the carotid bifurcations may be related to the incidence of future CV events and occult atherosclerotic coronary disease. Such patients might benefit from preventive measures if the carotid Doppler US is allowed as a screening tool to detect the extent of carotid stenosis. We aimed to conduct a comprehensive and systematic evaluation of the impact of carotid US screening on CV risk stratification. METHODS We searched PubMed, Scopus, and ScienceDirect from inception until July 2023. We included literature that examined the impact of carotid US screening on cardiovascular risk factor (CVRF) prevention, CV events, and mortality in adults of all age groups free of symptomatic carotid artery disease. RESULTS We identified 2 randomized controlled trials (RCTs) and 9 observational studies, including 21,046 participants. The mean age of the participants was 49, and 53% were female. Two RCTs, with 7,064 participants, examined the impact of pictorial knowledge about subclinical carotid atherosclerosis using carotid US versus traditional CVD risk evaluation without any US evidence in primary cardiovascular prevention. Both studies reported remarkable improvement in medication adherence at 1 to 3-year follow-up after carotid US screening with a decrease in Framingham risk score (FRS). Nine observational studies with 13, 982 participants analyzed the evidence of atherosclerosis on carotid US screening and demonstrated that it is a beneficial tool in the early identification of subclinical atherosclerosis and effective therapeutic intervention. CONCLUSION This systematic review found that pictorial presentation of silent atherosclerosis using carotid US screening has a contributory role in CV risk stratification and prevention of CVD.
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Affiliation(s)
| | - Edzel Lorraine Co
- Department of Internal Medicine, University of Santo Tomas Faculty of Medicine and Surgery, Manila, Philippines
| | | | - Selia Chowdhury
- Department of Medicine, Dhaka Medical College, Dhaka, Bangladesh
| | - Esha Jain
- Department of Family Medicine, Cooper University Hospital, Camden, NJ, USA
| | | | - Gurpreet Johal
- Department of Cardiology, University of Washington, Valley Medical Center, Seattle, USA
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Chow BJ, Galiwango P, Poulin A, Raggi P, Small G, Juneau D, Kazmi M, Ayach B, Beanlands RS, Sanfilippo AJ, Chow CM, Paterson DI, Chetrit M, Jassal DS, Connelly K, Larose E, Bishop H, Kass M, Anderson TJ, Haddad H, Mancini J, Doucet K, Daigle JS, Ahmadi A, Leipsic J, Lim SP, McRae A, Chou AY. Chest Pain Evaluation: Diagnostic Testing. CJC Open 2023; 5:891-903. [PMID: 38204849 PMCID: PMC10774086 DOI: 10.1016/j.cjco.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/01/2023] [Indexed: 01/12/2024] Open
Abstract
Chest pain/discomfort (CP) is a common symptom and can be a diagnostic dilemma for many clinicians. The misdiagnosis of an acute or progressive chronic cardiac etiology may carry a significant risk of morbidity and mortality. This review summarizes the different options and modalities for establishing the diagnosis and severity of coronary artery disease. An effective test selection algorithm should be individually tailored to each patient to maximize diagnostic accuracy in a timely fashion, determine short- and long-term prognosis, and permit implementation of evidence-based treatments in a cost-effective manner. Through collaboration, a decision algorithm was developed (www.chowmd.ca/cadtesting) that could be adopted widely into clinical practice.
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Affiliation(s)
- Benjamin J.W. Chow
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Paul Galiwango
- Department of Medicine, Scarborough Health Network and Lakeridge Health, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Poulin
- Department of Medicine, Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Paolo Raggi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Gary Small
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Daniel Juneau
- Department of Radiology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Mustapha Kazmi
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Bilal Ayach
- Department of Medicine, Lakeridge Health, Queen’s University, Kingston, Ontario, Canada
| | - Rob S. Beanlands
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Anthony J. Sanfilippo
- Department of Medicine, Lakeridge Health, Queen’s University, Kingston, Ontario, Canada
| | - Chi-Ming Chow
- Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D. Ian Paterson
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael Chetrit
- Department of Cardiovascular Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Davinder S. Jassal
- Department of Physiology and Pathophysiology, Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kim Connelly
- Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eric Larose
- Department of Medicine, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Quebec, Canada
| | - Helen Bishop
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Malek Kass
- Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Todd J. Anderson
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Haissam Haddad
- Division of Cardiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - John Mancini
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Katie Doucet
- Peterborough Regional Health Centre, Kawartha Cardiology Clinic, Peterborough, Ontario, Canada
| | - Jean-Sebastien Daigle
- Department of Internal Medicine, Dr Everett Chalmers Hospital, Fredericton, New Brunswick, Canada
| | - Amir Ahmadi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Leipsic
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Siok Ping Lim
- Mayfair Diagnostics, Saskatoon, Saskatchewan, Canada
| | - Andrew McRae
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Annie Y. Chou
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Radiology, St. Paul’s Hospital, Vancouver, British Columbia, Canada
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Marquis-Gravel G, Samuel M. Can We Define the Role of Cardiac Stress Testing After Percutaneous Coronary Intervention With the Use of Observational Data? Can J Cardiol 2023; 39:1522-1524. [PMID: 37468119 DOI: 10.1016/j.cjca.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 07/21/2023] Open
Affiliation(s)
- Guillaume Marquis-Gravel
- Montréal Heart Institute, Montréal, Québec, Canada; Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.
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MacDonald BJ, Turgeon RD. Incorporation of Shared Decision-Making in International Cardiovascular Guidelines, 2012-2022. JAMA Netw Open 2023; 6:e2332793. [PMID: 37676658 PMCID: PMC10485733 DOI: 10.1001/jamanetworkopen.2023.32793] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/01/2023] [Indexed: 09/08/2023] Open
Abstract
Importance Shared decision-making (SDM) is a key component of the provision of ethical care, but prior reviews have indicated that clinical practice guidelines seldom promote or facilitate SDM. It is currently unknown whether these findings extend to contemporary cardiovascular guidelines. Objective To identify and characterize integration of SDM in contemporary cardiovascular guideline recommendations using a systematic classification system. Design, Setting, and Participants This cross-sectional study assessed the latest guidelines or subsequent updates that included pharmacotherapy recommendations and were published between January 2012 and December 2022 by the American College of Cardiology (ACC), Canadian Cardiovascular Society (CCS), and European Society of Cardiology (ESC). Data were analyzed from February 21 to July 21, 2023. Main Outcomes and Measures All pharmacotherapy recommendations were identified within each guideline. Recommendations that incorporated SDM were rated according to a systematic rating framework to evaluate the quality of SDM incorporation based on directness (range, 1-3; assessing whether SDM was incorporated directly and impartially into the recommendation's text, with 1 indicating direct and impartial incorporation of SDM into the recommendation's text) and facilitation (range, A-D; assessing whether decision aids or quantified benefits and harms were provided, with A indicating that a decision aid quantifying benefits and harms was provided). The proportion of recommendations incorporating SDM was also analyzed according to guideline society and category (eg, general cardiology, heart failure). Results Analyses included 65 guideline documents, and 33 documents (51%) incorporated SDM either in a general statement or within specific recommendations. Of 7499 recommendations, 2655 (35%) recommendations addressed pharmacotherapy, and of these, 170 (6%) incorporated SDM. By category, general cardiology guidelines contained the highest proportion of pharmacotherapy recommendations incorporating SDM (86 of 865 recommendations [10%]), whereas heart failure and myocardial disease contained the least (9 of 315 recommendations [3%]). The proportion of pharmacotherapy recommendations incorporating SDM was comparable across societies (ACC: 75 of 978 recommendations [8%]; CCS: 29 of 333 recommendations [9%]; ESC: 67 of 1344 recommendations [5%]), with no trend for change over time. Only 5 of 170 SDM recommendations (3%) were classified as grade 1A (impartial recommendations for SDM supported by a decision aid), whereas 114 of 170 recommendations (67%) were grade 3D (SDM mentioned only in supporting text and without any tools or information to facilitate SDM). Conclusions and Relevance In this cross-sectional study across guidelines published by 3 major cardiovascular societies over the last decade, 51% of guidelines mentioned the importance of SDM, yet only 6% of recommendations incorporated SDM in any form, and fewer adequately facilitated SDM.
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Affiliation(s)
- Blair J. MacDonald
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ricky D. Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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9
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Pandey A, D'Souza MM, Pandey AS, Mir H. A Web-Based Application for Risk Stratification and Optimization in Patients With Cardiovascular Disease: Pilot Study. JMIR Cardio 2023; 7:e46533. [PMID: 37535400 PMCID: PMC10436122 DOI: 10.2196/46533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/05/2023] [Accepted: 06/19/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND In addition to aspirin, angiotensin-converting enzyme inhibitors, statins, and lifestyle modification interventions, novel pharmacological agents have been shown to reduce morbidity and mortality in atherosclerotic cardiovascular disease patients, including new antithrombotics, antihyperglycemics, and lipid-modulating therapies. Despite their benefits, the uptake of these guideline-directed therapies remains a challenge. There is a need to develop strategies to support knowledge translation for the uptake of secondary prevention therapies. OBJECTIVE The goal of this study was to test the feasibility and usability of Stratification and Optimization in Patients With Cardiovascular Disease (STOP-CVD), a point-of-care application that was designed to facilitate knowledge translation by providing individualized risk stratification and optimization guidance. METHODS Using the REACH (Reduction of Atherothrombosis for Continued Health) Registry trial and predictive modeling (which included 67,888 patients), we designed a free web-based secondary risk calculator. Based on demographic and comorbidity profiles, the application was used to predict an individual's 20-month risk of cardiovascular events and cardiovascular mortality and provides a comparison to an age-matched control with an optimized cardiovascular risk profile to illustrate the modifiable residual risk. Additionally, the application used the patient's risk profile to provide specific guidance for possible therapeutic interventions based on a novel algorithm. During an initial 3-month adoption phase, 1-time invitations were sent through email and telephone to 240 physicians that refer to a regional cardiovascular clinic. After 3 months, a survey of user experience was sent to all users. Following this, no further marketing of the application was performed. Google Analytics was collected postimplementation from January 2021 to December 2021. These were used to tabulate the total number of distinct users and the total number of monthly uses of the application. RESULTS During the 1-year pilot, 47 of the 240 invited clinicians used the application 1573 times, an average of 131 times per month, with sustained usage over time. All 24 postimplementation survey respondents confirmed that the application was functional, easy to use, and useful. CONCLUSIONS This pilot suggests that the STOP-CVD application is feasible and usable, with high clinician satisfaction. This tool can be easily scaled to support the uptake of guideline-directed medical therapy, which could improve clinical outcomes. Future research will be focused on evaluating the impact of this tool on clinician management and patient outcomes.
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Affiliation(s)
- Avinash Pandey
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Cambridge Cardiac Care, Cambridge, ON, Canada
| | | | - Amritanshu Shekhar Pandey
- Cambridge Cardiac Care, Cambridge, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Hassan Mir
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Cardiology and Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada
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10
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Taylor RS, Fredericks S, Jones I, Neubeck L, Sanders J, De Stoutz N, Thompson DR, Wadhwa DN, Grace SL. Global perspectives on heart disease rehabilitation and secondary prevention: a scientific statement from the Association of Cardiovascular Nursing and Allied Professions, European Association of Preventive Cardiology, and International Council of Cardiovascular Prevention and Rehabilitation. Eur Heart J 2023; 44:2515-2525. [PMID: 37477626 PMCID: PMC10361025 DOI: 10.1093/eurheartj/ehad225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 01/26/2023] [Accepted: 03/30/2023] [Indexed: 07/22/2023] Open
Abstract
Cardiovascular disease is a leading cause of death, morbidity, disability, and reduced health-related quality of life, as well as economic burden worldwide, with some 80% of disease burden occurring in the low- and middle-income country (LMIC) settings. With increasing numbers of people living longer with symptomatic disease, the effectiveness and accessibility of secondary preventative and rehabilitative health services have never been more important. Whilst LMICs experience the highest prevalence and mortality rates, the global approach to secondary prevention and cardiac rehabilitation, which mitigates this burden, has traditionally been driven from clinical guidelines emanating from high-income settings. This state-of-the art review provides a contemporary global perspective on cardiac rehabilitation and secondary prevention, contrasting the challenges of and opportunities for high vs. lower income settings. Actionable solutions to overcome system, clinician, programme, and patient level barriers to cardiac rehabilitation access in LMICs are provided.
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Affiliation(s)
- Rod S Taylor
- Former ACNAP Science committee member, Professor of Population Health, School of Health and Well Being, University of Glasgow, Glasgow G12 8QQ, UK
| | - Suzanne Fredericks
- ACNAP Science committee member, Professor, Daphne Cockwell School of Nursing, Toronto Metropolitan University, Toronto, Canada
| | - Ian Jones
- ACNAP Science committee member, Professor of Cardiovascular Nursing, Liverpool Centre for Cardiovascular Science, Liverpool John Moores University, Liverpool, UK
| | - Lis Neubeck
- ACNAP President, Professor and Head of Cardiovascular Health, Centre for Cardiovascular Health, Edinburgh Napier University, Edinburgh, UK
| | - Julie Sanders
- ACNAP Science committee chair, Director of Clinical Research, St Bartholomew’s Hospital, Barts Health NHS Trust, West Smithfield, UK
- Clinical Professor of Cardiovascular Nursing, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Noemi De Stoutz
- ESC Patient forum representative, Member of ‘Cuore Matto’ and Global ARCH, Zumikon, Switzerland
| | - David R Thompson
- EAPC representative, Professor of Nursing, School of Nursing and Midwifery, Queen’s University Belfast, Belfast, UK
| | - Deepti N Wadhwa
- ACNAP Young community member, Associate Professor, MVPS College of Physiotherapy, Nashik, India
| | - Sherry L Grace
- ICCPR Immediate past-Chair, Professor, Faculty of Health, York University, Toronto, Canada
- KITE-Toronto Rehabilitation Institute & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
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11
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Godoy LC, Farkouh ME, Austin PC, Shah BR, Qiu F, Jackevicius CA, Wijeysundera HC, Krumholz HM, Ko DT. Association of Beta-Blocker Therapy With Cardiovascular Outcomes in Patients With Stable Ischemic Heart Disease. J Am Coll Cardiol 2023; 81:2299-2311. [PMID: 37316110 DOI: 10.1016/j.jacc.2023.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Previous studies have failed to show a cardioprotective benefit of beta-blockers in patients with stable coronary artery disease (CAD). OBJECTIVES This study sought to determine the association between beta-blockers and cardiovascular events in patients with stable CAD using a new user design. METHODS All patients aged >66 years undergoing elective coronary angiography in Ontario, Canada, from 2009 to 2019 with diagnosed obstructive CAD were included. Exclusion criteria included heart failure or a recent myocardial infarction, as well as having a beta-blocker prescription claim in the previous year. Beta-blocker use was defined as having at least 1 beta-blocker prescription claim in the 90 days preceding or after the index coronary angiography. The main outcome was a composite of all-cause mortality and hospitalization for heart failure or myocardial infarction. Inverse probability of treatment weighting using the propensity score was used to account for confounding. RESULTS This study included 28,039 patients (mean age: 73.0 ± 5.6 years; 66.2% male), and 12,695 of those (45.3%) were newly prescribed beta-blockers. The 5-year risks of the primary outcome were 14.3% in the beta-blocker group and 16.1% in the no beta-blocker group (absolute risk reduction: -1.8%; 95% CI: -2.8 to -0.8; HR: 0.92; 95% CI: 0.86-0.98; P = 0.006). This result was driven by reductions in myocardial infarction hospitalization (cause-specific HR: 0.87; 95% CI: 0.77-0.99; P = 0.031), whereas no differences were observed in all-cause death or heart failure hospitalization. CONCLUSIONS In patients with angiographically documented stable CAD without heart failure or a recent myocardial infarction, beta-blockers were associated with a small but significant reduction in cardiovascular events at 5 years.
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Affiliation(s)
- Lucas C Godoy
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Ontario, Canada; Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada; Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Ontario, Canada
| | - Baiju R Shah
- ICES, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Cynthia A Jackevicius
- ICES, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Ontario, Canada; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA; Western University of Health Services, Pomona, California, USA
| | - Harindra C Wijeysundera
- ICES, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
| | - Dennis T Ko
- ICES, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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12
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Peix A. Cardiac Imaging in Women with Ischemic Heart Disease. Life (Basel) 2023; 13:1389. [PMID: 37374171 DOI: 10.3390/life13061389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Cardiac diseases are the main cause of death for both sexes worldwide. Treatment varies widely according to the sex of a patient, as there are differences in physiopathology, epidemiology, clinical presentation and management. However, women have been largely excluded from research studies in this field. At present, differences are starting to be recognized and more attention is being paid to the identification of female-specific (or emergent) atherosclerotic risk factors. Diagnostic testing also merits attention because cardiac imaging offers important information to help diagnosis and guide cardiac disease management. In this sense, multimodal imaging should be used with the most cost-effective approach, integrating this information into the clinical sphere according to the pretest probability of the disease. In this review, we address sex-specific features of ischemic heart disease that should be considered in the clinical assessment of women, as well as the value of different imaging techniques (including technical and clinical aspects) for management of women with ischemic heart disease, and identify future areas of action concerning ischemic heart disease in women.
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Affiliation(s)
- Amalia Peix
- Institute of Cardiology and Cardiovascular Surgery, 17 No. 702, Vedado, Havana CP 10 400, Cuba
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13
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Al Samarraie A, Pichette M, Rousseau G. Role of the Gut Microbiome in the Development of Atherosclerotic Cardiovascular Disease. Int J Mol Sci 2023; 24:ijms24065420. [PMID: 36982492 PMCID: PMC10051145 DOI: 10.3390/ijms24065420] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is the primary cause of death globally, with nine million deaths directly attributable to ischemic heart diseases in 2020. Since the last few decades, great effort has been put toward primary and secondary prevention strategies through identification and treatment of major cardiovascular risk factors, including hypertension, diabetes, dyslipidemia, smoking, and a sedentary lifestyle. Once labelled “the forgotten organ”, the gut microbiota has recently been rediscovered and has been found to play key functions in the incidence of ASCVD both directly by contributing to the development of atherosclerosis and indirectly by playing a part in the occurrence of fundamental cardiovascular risk factors. Essential gut metabolites, such as trimethylamine N-oxide (TMAO), secondary bile acids, lipopolysaccharides (LPS), and short-chain fatty acids (SCFAs), have been associated with the extent of ischemic heart diseases. This paper reviews the latest data on the impact of the gut microbiome in the incidence of ASCVD.
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Affiliation(s)
- Ahmad Al Samarraie
- Internal Medicine Department, Faculty of Medicine, University of Montreal, Montréal, QC H3T 1J4, Canada
| | - Maxime Pichette
- Cardiology Department, Faculty of Medicine, University of Montreal, Montréal, QC H3T 1J4, Canada
| | - Guy Rousseau
- Centre de Biomédecine, CIUSSS-NÎM/Hôpital du Sacré-Cœur, Montréal, QC H4J 1C5, Canada
- Correspondence:
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14
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Schwalm JD, Bouck Z, Natarajan MK, Pinilla N, Walker D, Syed N, Landry D, Sabri A, Tandon V, Nkurunziza J, Taljaard M, Sheth T. Centralized Triage of Suspected Coronary Artery Disease Using Coronary Computed Tomographic Angiography to Optimize the Diagnostic Yield of Invasive Angiography. CJC Open 2023; 5:148-157. [PMID: 36880068 PMCID: PMC9984898 DOI: 10.1016/j.cjco.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/26/2022] [Indexed: 11/21/2022] Open
Abstract
Background Coronary computed tomographic angiography (CCTA) is preferable to invasive coronary angiography (ICA) for coronary artery disease (CAD) diagnosis in elective patients without known CAD. Methods We conducted a nonrandomized interventional study involving 2 tertiary care centres in Ontario. From July 2018 to February 2020, outpatients referred for elective ICA were identified through a centralized triage process and were recommended to undergo CCTA first instead of ICA. Patients with borderline or obstructive CAD on CCTA were recommended to undergo subsequent ICA. Intervention acceptability, fidelity, and effectiveness were assessed. Results A total of 226 patients were screened, with 186 confirmed to be eligible, of whom 166 had patient and physician approval to proceed with CCTA (89% acceptability). Among consenting patients, 156 (94%) underwent CCTA first; 43 (28%) had borderline/obstructive CAD on CCTA, and only 1 with normal/nonobstructive CAD on CCTA was referred for subsequent ICA against protocol (99% fidelity). Overall, 119 of 156 CCTA-first patients did not have ICA within the following 90 days (i.e., 76% potentially avoided ICA, due to the intervention). Among the 36 who underwent ICA post-CCTA per protocol, 24 had obstructive CAD (66.7% diagnostic yield). If all patients who were referred for and underwent ICA at either centre between July 2016 and February 2020 (n = 694 pre-implementation; n = 333 post-implementation) had had CCTA first, an additional 42 patients per 100 would have had an obstructive CAD finding on their ICA (95% confidence interval = 26-59). Conclusion A centralized triage process, in which elective outpatients referred for ICA are instead referred for CCTA first, appears to be acceptable and effective in diagnosing obstructive CAD and improving efficiencies in our healthcare system.
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Affiliation(s)
- J-D Schwalm
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada.,Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Medicine, Niagara Health Services, St. Catharine's, Ontario, Canada
| | - Zachary Bouck
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Madhu K Natarajan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada.,Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Medicine, Niagara Health Services, St. Catharine's, Ontario, Canada
| | - Natalia Pinilla
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada.,Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Medicine, Niagara Health Services, St. Catharine's, Ontario, Canada
| | - Danielle Walker
- Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Nida Syed
- Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - David Landry
- Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Ali Sabri
- Department of Radiology, Niagara Health Services, St. Catharine's, Ontario, Canada
| | - Vikas Tandon
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada.,Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - James Nkurunziza
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada.,Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Tej Sheth
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada.,Hamilton Health Sciences, Hamilton, Ontario, Canada.,Department of Medicine, Niagara Health Services, St. Catharine's, Ontario, Canada
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15
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It's not all about ISCHEMIA: the case for coronary artery bypass grafting in stable coronary artery disease. Curr Opin Cardiol 2022; 37:459-467. [PMID: 36094460 DOI: 10.1097/hco.0000000000000994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The recent American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions Guidelines for Coronary Artery Revascularization have raised concerns on the survival benefits of coronary artery bypass grafting (CABG) over guideline-directed medical therapy (GDMT) in stable coronary artery disease (CAD) and appropriate conduit selection for CABG. This review summarizes the evidence supporting CABG for stable CAD and use of the radial artery as a conduit for CABG. RECENT FINDINGS CABG has consistently demonstrated a survival benefit over GDMT for patients with stable multivessel CAD. These benefits were more pronounced in patients with diabetes and/or anatomically complex coronary artery disease. The recently published International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial was not designed to and did not include an appropriate patient population to compare revascularization with CABG to GDMT. These results should thus be viewed in the context of previously published studies. Furthermore, increasing evidence suggests that use of a radial artery in CABG is associated with reduced myocardial infarction and repeat revascularization. This should be considered when selecting the appropriate conduits based on underlying patient factors. SUMMARY Readers should be cautious when applying these guidelines broadly. Appropriate consideration of patient and anatomic factors, and in consultation with a multidisciplinary heart team, is important to achieve the best outcomes for patients.
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16
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Boivin-Proulx LA, Potter BJ, Dorais M, Perreault S. Evolution of and Evidence-Practice Gaps in Antithrombotic Management of Atrial Fibrillation Patients After Percutaneous Coronary Intervention. CJC Open 2022; 5:15-23. [PMID: 36700177 PMCID: PMC9869359 DOI: 10.1016/j.cjco.2022.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022] Open
Abstract
Background The management of atrial fibrillation and flutter (AF) patients undergoing percutaneous coronary intervention (PCI) has evolved rapidly in the past decade. We determine whether the publication of the 2016 Canadian Cardiovascular Society AF guidelines were associated with a shift in practice patterns. Methods Using Quebec provincial administrative database information for the period from 2010-2017, a retrospective cohort of patients with inpatient or outpatient coding for AF, who subsequently underwent PCI with placement of a coronary stent, was created and analyzed for the antithrombotic regimen received in the following year. Prescribing behavior was compared among 3 time periods (2010-2011, 2012-2015, 2016-2017), and use of antithrombotics was compared to guideline-predicted therapy using the χ2 test. Predictors of oral anticoagulation (OAC) prescription were identified using adjusted logistic regression. Results A total of 3740 AF patients undergoing PCI were included. The proportion of OAC prescription increased over time (2010-2011 = 51.4%; 2012-2015 = 54.3%; 2016-2017 = 56.6%; P = 0.13), with a significant increase in direct OAC prescription (P < 0.01). A substantial treatment gap in OAC prescription persisted after publication of the 2016 guidelines (56.6% observed vs 89.7% predicted; P < 0.01). Previous stroke, CHADS2 score, Charlson Comorbidity Index ≥ 4, and prior use of direct OAC or warfarin were predictors of being exposed to OAC claims; previous major bleeding, and low-dose acetylsalicylic acid or P2Y12 inhibitor use were predictors of not being exposed to OACs. Conclusion Expert guidance contributed to an increase in OAC prescription following PCI, but up to 2017, substantial further changes in practice patterns would have been required to achieve the recommended rates of OAC prescription.
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Affiliation(s)
- Laurie-Anne Boivin-Proulx
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada,Centre Cardiovasculaire du Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Brian J. Potter
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada,Centre Cardiovasculaire du Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l'Île-Perrot, Quebec, Canada
| | - Sylvie Perreault
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada,Chaire Sanofi sur l'utilisation des médicaments, Université de Montréal, Montreal, Quebec, Canada,Centre de recherche en santé publique (CReSP), partenaire CIUSSS du Centre-Sud-de-l’Île-de-Montréal et l’Université de Montréal, Montreal, Quebec, Canada,Corresponding author: Dr Sylvie Perreault, Chaire Sanofi sur l'utilisation des médicaments, Faculté de Pharmacie, Université de Montréal, Case Postale 6128, Succursale Centre-Ville, Montréal, Québec H3C 3J7, Canada. Tel.: +1-514-343-6111 x3149; fax: +1-514-343-6120.
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17
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El Hussein MT, Fibich E. Noninvasive diagnostic modalities for the diagnosis of coronary artery disease: A guide for acute care NPs. Nurse Pract 2022; 47:27-36. [PMID: 36165970 DOI: 10.1097/01.npr.0000873524.89648.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Selecting noninvasive diagnostic tests for coronary artery disease can be a daunting task to acute care NPs. This article provides an overview of the pathophysiology of coronary artery disease, relevant noninvasive diagnostic imaging modalities, and an evidence-based approach to guide subsequent diagnostic and therapeutic interventions.
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18
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Eurlings CGMJ, Bektas S, Sanders-van Wijk S, Tsirkin A, Vasilchenko V, Meex SJR, Failer M, Oehri C, Ruff P, Zellweger MJ, Brunner-La Rocca HP. Use of artificial intelligence to assess the risk of coronary artery disease without additional (non-invasive) testing: validation in a low-risk to intermediate-risk outpatient clinic cohort. BMJ Open 2022; 12:e055170. [PMID: 36167368 PMCID: PMC9516207 DOI: 10.1136/bmjopen-2021-055170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Predicting the presence or absence of coronary artery disease (CAD) is clinically important. Pretest probability (PTP) and CAD consortium clinical (CAD2) model and risk scores used in the guidelines are not sufficiently accurate as the only guidance for applying invasive testing or discharging a patient. Artificial intelligence without the need of additional non-invasive testing is not yet used in this context, as previous results of the model are promising, but available in high-risk population only. Still, validation in low-risk patients, which is clinically most relevant, is lacking. DESIGN Retrospective cohort study. SETTING Secondary outpatient clinic care in one Dutch academic hospital. PARTICIPANTS We included 696 patients referred from primary care for further testing regarding the presence or absence of CAD. The results were compared with PTP and CAD2 using receiver operating characteristic (ROC) curves (area under the curve (AUC)). CAD was defined by a coronary stenosis >50% in at least one coronary vessel in invasive coronary or CT angiography, or having a coronary event within 6 months. OUTCOME MEASURES The first cohort validating the memetic pattern-based algorithm (MPA) model developed in two high-risk populations in a low-risk to intermediate-risk cohort to improve risk stratification for non-invasive diagnosis of the presence or absence of CAD. RESULTS The population contained 49% male, average age was 65.6±12.6 years. 16.2% had CAD. The AUCs of the MPA model, the PTP and the CAD2 were 0.87, 0.80, and 0.82, respectively. Applying the MPA model resulted in possible discharge of 67.7% of the patients with an acceptable CAD rate of 4.2%. CONCLUSIONS In this low-risk to intermediate-risk population, the MPA model provides a good risk stratification of presence or absence of CAD with a better ROC compared with traditional risk scores. The results are promising but need prospective confirmation.
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Affiliation(s)
- Casper G M J Eurlings
- Cardiology Department, Laurentius Hospital, Roermond, The Netherlands
- Cardiology Department, Maastricht UMC+, Maastricht, The Netherlands
| | - Sema Bektas
- Cardiology Department, Maastricht UMC+, Maastricht, The Netherlands
| | | | - Andrew Tsirkin
- Software and Modeling, Exploris Health, Wallisellen/Zürich, Switzerland
| | | | - Steven J R Meex
- Central Diagnostic Laboratory, Clinical Chemistry, Maastricht UMC+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Michael Failer
- Software and Modeling, Exploris Health, Wallisellen/Zürich, Switzerland
| | - Caroline Oehri
- Software and Modeling, Exploris Health, Wallisellen/Zürich, Switzerland
| | - Peter Ruff
- Software and Modeling, Exploris Health, Wallisellen/Zürich, Switzerland
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19
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Nikhanj A, Bautista J, Siddiqi ZA, Phan CL, Oudit GY. Low Prevalence of Cardiomyopathy in Patients with Mitochondrial Disease and Neurological Manifestations. J Cardiovasc Dev Dis 2022; 9:jcdd9070221. [PMID: 35877583 PMCID: PMC9320353 DOI: 10.3390/jcdd9070221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 02/01/2023] Open
Abstract
Patients with mitochondrial diseases can develop cardiomyopathy but with variable expressivity and penetrance. Our prospective study enrolled and evaluated a cohort of 53 patients diagnosed with chronic progressive ophthalmoplegia (CPEO, n = 34), Kearns-Sayre syndrome (KSS, n = 3), neuropathy ataxia and retinitis pigmentosa (NARP, n = 1), myoclonic epilepsy with ragged red fibers (MERRF, n = 1), Harel-Yoon Syndrome (HYS, n = 1) and 13 patients with undefined mitochondrial diseases, presenting primarily with neurological symptoms. Over a 4-year period, six patients in our study cohort were diagnosed with heart disease (11.3%), with only three patients having defined cardiomyopathy (5.7%). Cardiomyopathy was present in a 21-year-old patient with HYS and two CPEO patients having mild cardiomyopathy at an older age. Two CPEO patients had congenital heart disease, and a third CPEO had LV hypertrophy secondary to hypertension. In three patients, traditional risk factors for heart disease, including dyslipidemia, hypertension, and respiratory disease, were present. The majority of our adult cohort of patients have normal cardiac investigations with a median left ventricular (LV) ejection fraction of 59.0%, indexed LV mass of 67.0 g/m2, and normal diastolic and valvular function at baseline. A 12-lead electrocardiogram showed normal cardiac conduction across the study cohort. Importantly, follow-up assessments showed consistent cardiac structure and function. Our study shows a low prevalence of cardiomyopathy and highlights the breadth of phenotypic variability in patients with mitochondrial disorders. The presence of cardiovascular risk factors and aging are important comorbidities in our cohort.
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Affiliation(s)
- Anish Nikhanj
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada;
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Jesi Bautista
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada; (J.B.); (Z.A.S.); (C.L.P.)
| | - Zaeem A. Siddiqi
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada; (J.B.); (Z.A.S.); (C.L.P.)
| | - Cecile L. Phan
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada; (J.B.); (Z.A.S.); (C.L.P.)
| | - Gavin Y. Oudit
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada;
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB T6G 2R3, Canada
- Correspondence: ; Tel.: +780-407-8569; Fax: +780-407-6452
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Parry M, Van Spall HG, Mullen KA, Mulvagh SL, Pacheco C, Colella TJ, Clavel MA, Jaffer S, Foulds HJ, Grewal J, Hardy M, Price JA, Levinsson AL, Gonsalves CA, Norris CM. The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 6: Sex- and Gender-Specific Diagnosis and Treatment. CJC Open 2022; 4:589-608. [PMID: 35865023 PMCID: PMC9294990 DOI: 10.1016/j.cjco.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/12/2022] [Indexed: 10/26/2022] Open
Abstract
This chapter summarizes the sex- and gender-specific diagnosis and treatment of acute/unstable presentations and nacute/stable presentations of cardiovascular disease in women. Guidelines, scientific statements, systematic reviews/meta-analyses, and primary research studies related to diagnosis and treatment of coronary artery disease, cerebrovascular disease (stroke), valvular heart disease, and heart failure in women were reviewed. The evidence is summarized as a narrative, and when available, sex- and gender-specific practice and research recommendations are provided. Acute coronary syndrome presentations and emergency department delays are different in women than they are in men. Coronary angiography remains the gold-standard test for diagnosis of obstructive coronary artery disease. Other diagnostic imaging modalities for ischemic heart disease detection (eg, positron emission tomography, echocardiography, single-photon emission computed tomography, cardiovascular magnetic resonance, coronary computed tomography angiography) have been shown to be useful in women, with their selection dependent upon both the goal of the individualized assessment and the testing resources available. Noncontrast computed tomography and computed tomography angiography are used to diagnose stroke in women. Although sex-specific differences appear to exist in the efficacy of standard treatments for diverse presentations of acute coronary syndrome, many cardiovascular drugs and interventions tested in clinical trials were not powered to detect sex-specific differences, and knowledge gaps remain. Similarly, although knowledge is evolving about sex-specific difference in the management of valvular heart disease, and heart failure with both reduced and preserved ejection fraction, current guidelines are lacking in sex-specific recommendations, and more research is needed.
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Affiliation(s)
- Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Harriette G.C. Van Spall
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, Research Institute of St. Joe’s, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Kerri-Anne Mullen
- Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sharon L. Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christine Pacheco
- Hôpital Pierre-Boucher, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Tracey J.F. Colella
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- KITE, Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de pneumologie de Québec— Université Laval, Quebec City, Quebec, Canada
| | - Shahin Jaffer
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Heather J.A. Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jasmine Grewal
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marsha Hardy
- Canadian Women's Heart Health Alliance, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | | | - Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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21
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Roifman I, Han L, Fang J, Chu A, Austin P, Ko DT, Douglas P, Wijeysundera H. Patient, physician and geographic predictors of cardiac stress testing strategy in Ontario, Canada: a population-based study. BMJ Open 2022; 12:e059199. [PMID: 35273065 PMCID: PMC8915339 DOI: 10.1136/bmjopen-2021-059199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To identify patient, physician and geographic level factors that are associated with variation in initial stress testing strategy in patients evaluated for chest pain. DESIGN Retrospective cohort study. SETTING Population-based study of patients undergoing evaluation for chest pain in Ontario, Canada between 1 January 2011 and 31 March 2018. PARTICIPANTS 103 368 patients who underwent stress testing (graded exercise stress testing (GXT), stress echocardiography (stress echo) or myocardial perfusion imaging (MPI)) following evaluation for chest pain. PRIMARY AND SECONDARY OUTCOME MEASURES To identify the patient, physician and geographic level factors associated with variation in initial test selection, we fit two separate 2-level hierarchical multinomial logistic regression models for which the outcome was initial stress testing strategy (GXT, MPI or stress echo). RESULTS There was significant variability in the initial type of stress test performed, with approximately 50% receiving a GXT compared with approximately 36% who received MPI and 14% who received a stress echo. Physician-level factors were key drivers of this variation, accounting for up to 59.0% of the variation in initial testing. Physicians who graduated medical school >30 years ago were approximately 45% more likely to order an initial stress echo (OR 1.45, 95% CI 1.17 to 1.80) than a GXT. Cardiovascular disease specialists were approximately sevenfold more likely to order an initial MPI (OR 7.35, 95% CI 5.38 to 10.03) than a GXT. Patients aged >70 years were approximately fivefold more likely to receive an MPI (OR 4.74, 95% CI 4.42 to 5.08) and approximately 26% more likely to receive a stress echo (OR 1.26, 95% CI 1.15 to 1.38) than a GXT. CONCLUSIONS We report significant variability in initial stress testing strategy in Ontario. Much of that variability was driven by physician-level factors that could potentially be addressed through educational campaigns geared at reducing this variability and improving guideline adherence.
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Affiliation(s)
- Idan Roifman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Lu Han
- ICES, Toronto, Ontario, Canada
| | | | | | - Peter Austin
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Dennis T Ko
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Pamela Douglas
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Harindra Wijeysundera
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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22
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Bertrand T, Bartlett-Esquilant G, Fischer K, Friedrich MG. Patient and physician preferences for non-invasive diagnostic cardiovascular imaging technologies: a discrete choice experiment. J Patient Rep Outcomes 2022; 6:15. [PMID: 35182263 PMCID: PMC8858356 DOI: 10.1186/s41687-022-00419-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 01/28/2022] [Indexed: 11/10/2022] Open
Abstract
Purpose Diagnostic imaging techniques have to be selected for their accuracy, efficiency, cost-efficiency, and impact on outcome. But beyond that, the choice of non-invasive cardiovascular imaging tests for diagnosing coronary artery disease also has to respect patient safety and comfort. In this study, we investigated patient and physician preference in relation to the choice of cardiovascular imaging tests. Results A total of 211 subjects (148 cardiac patients and 63 physicians) were enrolled and completed a discrete choice experiment. Tests and modalities were deconstructed into 6 attributes (risks and side effects, diagnostic accuracy, patient out-of-pocket cost, type of procedure, type of scanner and test duration). A Sawtooth software choice-based conjoint analysis with hierarchical Bayes estimation was performed and showed the risks and side effects attribute was assigned the most relative importance (30%) when considering patients’ preference. Patients gave notably high value to tests with milder side effects, while preferring to avoid exposure to ionizing radiation and risks associated the use of pharmacological agents inducing direct coronary arteriolar vasodilation. Physicians allocated more importance to the patient out-of-pocket cost attribute (29%). Both patients and physicians valued tests’ risks and side effects, diagnostic accuracy, patient out-of-pocket cost as the three most important attributes, but in diverging order. A market simulation comparing current cardiovascular imaging tests revealed breathing maneuver-enhanced cardiac magnetic resonance had the highest shares of preference in both patients (59.6%) and physicians (32.7%). Conclusion A patients’ preference for a particular cardiovascular imaging test was most determined by the risks and side effects, while physicians prioritized less costly tests for their patients. In shared decision-making with patients, physicians should therefore focus on a balanced discussion of risks and side effects associated with cardiovascular imaging tests. Both, patients and physicians would prefer a cardiovascular MR imaging test using a vasoactive breathing maneuver instead of currently used alternatives that require intravenous contrast agents, pharmacological stress, or radiation.
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Affiliation(s)
- Thomas Bertrand
- Department of Family Medicine, McGill University, 5858 Côte-des-Neiges Road, Montreal, QC, H3S 1Z1, Canada.,Departments of Medicine and Diagnostic Radiology, Research Institute of the McGill University Health Center, 1001 Decarie Boulevard, Montreal, QC, H4A 3J1, Canada
| | - Gillian Bartlett-Esquilant
- Department of Family Medicine, McGill University, 5858 Côte-des-Neiges Road, Montreal, QC, H3S 1Z1, Canada
| | - Kady Fischer
- Departments of Medicine and Diagnostic Radiology, Research Institute of the McGill University Health Center, 1001 Decarie Boulevard, Montreal, QC, H4A 3J1, Canada
| | - Matthias G Friedrich
- Department of Family Medicine, McGill University, 5858 Côte-des-Neiges Road, Montreal, QC, H3S 1Z1, Canada. .,Departments of Medicine and Diagnostic Radiology, Research Institute of the McGill University Health Center, 1001 Decarie Boulevard, Montreal, QC, H4A 3J1, Canada.
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23
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Li T, Tan Y, Ouyang S, He J, Liu L. Resveratrol protects against myocardial ischemia-reperfusion injury via attenuating ferroptosis. Gene 2022; 808:145968. [PMID: 34530090 DOI: 10.1016/j.gene.2021.145968] [Citation(s) in RCA: 95] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/09/2021] [Accepted: 09/09/2021] [Indexed: 01/18/2023]
Abstract
Resveratrol (Res) is a polyphenol with a variety of biological activities. However, whether Res can prevent myocardial ischemia-reperfusion (I/R) injury is not yet known. This study aimed to investigate the protective effect of Res on myocardial I/R injury and to explore its potential mechanism. H9c2 cells were used for the in vitro experiments and oxygen-glucose deprivation/reoxygenation (OGD/R) model was established. Rats were ligated and perfused by the left anterior descending branch with or without Res (50 mg/kg·bw) for 14 days.The higher level of oxidative stress and Fe2+ content was observed in OGD/R-induced H9c2 cells than that of normal cells. OGD/R-induced H9c2 cells showed increased ferroptosis, mainly by reducing the expression of glutathione peroxidase 4 (GPX4) and ferritin heavy chain 1 (FTH1), but enhancing the expression of transferrin receptor 1 (TfR1). Both in vivo and in vitro experiments indicated that Res reduced the level of oxidative stress and Fe2 + content. In addition, Res inhibited ferroptosis, decreased TfR1 expression, and increased the expressions of FTH1 and GPX4 in OGD/R-induced H9c2 cells and I/R rats. Moreover, we found that Res inhibited ferroptosis by the regulation of ubiquity specific peptidase 19 (USP19)-Beclin1 autophagy. Res protects against myocardial I/R injury via reducing oxidative stress and attenuating ferroptosis. Res could be a potential agent to the prevention of myocardial I/R injury.
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Affiliation(s)
- Ting Li
- Departments of Cardiovascular Medicine, The First Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, PR China.
| | - Ying Tan
- Departments of Cardiovascular Medicine, The First Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, PR China
| | - Shao Ouyang
- Departments of Cardiovascular Medicine, The Second Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, PR China
| | - Jin He
- Departments of Cardiovascular Medicine, The First Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, PR China
| | - Lingling Liu
- Departments of Cardiovascular Medicine, The First Affiliated Hospital, University of South China, Hengyang, Hunan, 421001, PR China
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24
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Roy M, Trudeau F, Diaz A, Houle J. 7500 pas quotidiens ou 15 minutes d’activité physique d’intensité moyenne à intense : est-ce suffisant pour la prévention secondaire des cardiopathies ischémiques ? Sci Sports 2021. [DOI: 10.1016/j.scispo.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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25
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Cormier P, Poree J, Bourquin C, Provost J. Dynamic Myocardial Ultrasound Localization Angiography. IEEE TRANSACTIONS ON MEDICAL IMAGING 2021; 40:3379-3388. [PMID: 34086566 DOI: 10.1109/tmi.2021.3086115] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Dynamic Myocardial Ultrasound Localization Angiography (MULA) is an ultrasound-based imaging modality destined to enhance the diagnosis and treatment monitoring of coronary pathologies. Current diagnosis methods of coronary artery disease focus on the observation of vessel narrowing in the coronary vasculature to assess the organ's condition. However, we would strongly benefit from mapping and measuring flow from intramyocardial arterioles and capillaries as they are the direct vehicle of the myocardium blood income. With the advent of ultrafast ultrasound scanners, imaging modalities based on the localization and tracking of injected microbubbles allow for the subwavelength resolution imaging of an organ's vasculature. Yet, the application of these vascular imaging modalities relies on an accumulation of cine loops of a region of interest undergoing no or minimal tissue motion. This work introduces the MULA framework that combines 1) the mapping of the dynamics of the microvascular flow using an ultrasound sequence triggered by the electrocardiogram with a 2) novel Lagrangian beamformer based on non-rigid motion registration algorithm to form images directly in the myocardium's material coordinates and thus correcting for the large myocardial motion and deformation. Specifically, we show that this framework enables the non-invasive imaging of the angioarchitecture and dynamics of intramyocardial flow in vessels as small as a few tens of microns in the rat's beating heart in vivo.
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26
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Beaulieu MC, Boivin-Proulx LA, Matteau A, Mansour S, Gobeil JF, Potter BJ. Evolution of Antithrombotic Management of Atrial Fibrillation After Percutaneous Coronary Intervention Over 10 Years and Guidelines Uptake. CJC Open 2021; 3:1025-1032. [PMID: 34505042 PMCID: PMC8413257 DOI: 10.1016/j.cjco.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/05/2021] [Indexed: 02/07/2023] Open
Abstract
Background The management of atrial fibrillation and/or flutter (AF) patients requiring percutaneous coronary intervention (PCI) has evolved significantly. The Canadian Cardiovascular Society AF guidelines, last updated in 2020, seek to aid physicians in balancing both bleeding and thrombotic risks. Methods A tertiary academic centre registry of patients with AF who had PCI was examined for the antithrombotic therapy at discharge in 4 time periods (cohort 2010–2011; cohort 2014–2015; cohort 2017; cohort 2019). Discharge prescription patterns were compared among the cohorts, using the χ2 test. In addition, antithrombotic management in cohorts 2017 and 2019 were compared to guideline-expected therapy, using the χ2 test. Results A total of 576 AF patients undergoing PCI were included. Clinical and procedural characteristics were similar among cohorts, except for an increase in drug-eluting stent use in the most recent cohort (94% vs 99%; P = 0.04). The rate of oral anticoagulation increased over time (75% vs 89%; P < 0.01), driven primarily by an increase in direct oral anticoagulants prescription (63% vs 84%; P < 0.01). In contrast to previous cohorts, there was no significant difference between the observed and the guideline-expected anticoagulation rate in cohort 2019 (89% vs 94%; P = 0.23). Conclusions A combination of expert guidance and educational initiatives in the past decade contributed to dramatic changes in the management of patients with AF undergoing PCI.
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Affiliation(s)
| | | | | | | | | | - Brian J. Potter
- Corresponding author: Dr Brian J. Potter, Health Innovation and Evaluation Hub, Research Centre of CHUM, Cardiology & Interventional Cardiology, CHUM, Pavillon S, S03-334, 850, Rue St-Denis, Montréal, Quebec H2 × 0A9, Canada. Tel.: +1-514-890-8000 ext.15473; fax: +1-514-412-7212.
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27
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Sud M, Ko DT, Chong A, Koh M, Azizi PM, Austin PC, Stukel TA, Jackevicius CA. Renin-angiotensin-aldosterone system inhibitors and major cardiovascular events and acute kidney injury in patients with coronary artery disease. Pharmacotherapy 2021; 41:988-997. [PMID: 34496067 DOI: 10.1002/phar.2624] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/11/2021] [Accepted: 07/14/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Renin-angiotensin-aldosterone system inhibitors (RAASIs) are recommended for most patients with coronary artery disease (CAD). However, there is debate across guidelines as to which patients with CAD benefit the most from these agents. This study investigated the association between RAASIs and cardiovascular outcomes and acute kidney injury in a contemporary cohort of patients with CAD. METHODS Patients ≥65 years of age with CAD alive on April 1, 2012 in Ontario, Canada were included. Outcomes included major adverse cardiovascular events (MACE: cardiovascular death, myocardial infarction (MI), unstable angina, stroke, or coronary revascularization), and acute kidney injury (AKI) hospitalizations at 4 years. Inverse probability of treatment-weighted Cox proportional hazards regression models was used to compare the rates of each outcome in patients treated with and without RAASIs (angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers). RESULTS There were 165,058 patients with CAD identified (mean age 75 years, 65.5% male, 64.7% prescribed RAASIs). After inverse-probability weighting, treatment with RAASIs was associated with a lower rate of MACE compared with treatment without RAASIs (17.6% vs 18.2%, hazard ratio [HR]: 0.96, 95% CI: 0.93-0.99, respectively). However, treatment with RAASIs was associated with a higher rate of AKI compared with treatment without RAASIs (1.7% vs 1.5%, HR: 1.14, 95% CI: 1.02-1.29, respectively). The reduction in MACE was greater in patients with prior MI (HR: 0.87, 95% CI: 0.82-0.92) compared with patients without prior MI (HR: 1.00, 95% CI: 0.97-1.04, interaction p < 0.01). The increase in AKI was lower in patients with prior MI (HR: 0.82, 95% CI: 0.66-1.00) compared with patients without prior MI (HR: 1.37, 95% CI: 1.19-1.57, interaction p < 0.01). CONCLUSIONS This study supports the continued use of RAASIs in patients with CAD, although the benefit appears smaller in magnitude than observed in prior trials. High-risk patients, particularly those with prior MI, appear to benefit the most from RAASIs.
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Affiliation(s)
- Maneesh Sud
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dennis T Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Paymon M Azizi
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter C Austin
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Thérèse A Stukel
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Cynthia A Jackevicius
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Western University of Health Services, Pomona, California, USA.,VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
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28
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Abstract
PURPOSE OF REVIEW After coronary artery bypass grafting (CABG), patients remain at increased risk of cardiovascular events and death. Cardiac surgeons have the opportunity to reduce this risk by optimizing post-CABG patients' medical therapy. RECENT FINDINGS Recent developments in lipid-lowering, diabetes management, antithrombotic therapy, and anti-inflammatory therapy can significantly improve prognosis in patients with chronic coronary artery disease. PCSK-9 inhibitors should be used in patients with elevated LDL cholesterol despite maximally tolerated statin therapy. Icosapent ethyl should be considered in patients with elevated triglycerides despite maximally tolerated statin therapy. Long-acting GLP-1 receptor agonists or SLGT-2 inhibitors should be used in all post-CABG patients with type 2 diabetes. Intensified antithrombotic therapy with DAPT or DPI reduces MACE (and DPI reduces mortality) in patients with high atherosclerotic burden. Colchicine has not yet been incorporated into guidelines on OMT for stable CAD but it is reasonable to consider using it in high-risk patients. SUMMARY We review the foundations of optimal medical therapy after CABG, and summarize recent advances with a focus on practical application for the busy cardiac surgeon.
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29
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Xu J, Cai F, Geng C, Wang Z, Tang X. Diagnostic Performance of CMR, SPECT, and PET Imaging for the Identification of Coronary Artery Disease: A Meta-Analysis. Front Cardiovasc Med 2021; 8:621389. [PMID: 34026862 PMCID: PMC8138058 DOI: 10.3389/fcvm.2021.621389] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/23/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Myocardial perfusion imaging modalities, such as cardiac magnetic resonance (CMR), single-photon emission computed tomography (SPECT), and positron emission tomography (PET), are well-established non-invasive diagnostic methods to detect hemodynamically significant coronary artery disease (CAD). The aim of this meta-analysis is to compare CMR, SPECT, and PET in the diagnosis of CAD and to provide evidence for further research and clinical decision-making. Methods: PubMed, Web of Science, EMBASE, and Cochrane Library were searched. Studies that used CMR, SPECT, and/or PET for the diagnosis of CAD were included. Pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio with their respective 95% confidence interval, and the area under the summary receiver operating characteristic (SROC) curve were calculated. Results: A total of 203 articles were identified for inclusion in this meta-analysis. The pooled sensitivity values of CMR, SPECT, and PET were 0.86, 0.83, and 0.85, respectively. Their respective overall specificity values were 0.83, 0.77, and 0.86. Results in subgroup analysis of the performance of SPECT with 201Tl showed the highest pooled sensitivity [0.85 (0.82, 0.88)] and specificity [0.80 (0.75, 0.83)]. 99mTc-tetrofosmin had the lowest sensitivity [0.76 (0.67, 0.82)]. In the subgroup analysis of PET tracers, results indicated that 13N had the lowest pooled sensitivity [0.83 (0.74, 0.89)], and the specificity was the highest [0.91 (0.81, 0.96)]. Conclusion: Our meta-analysis indicates that CMR and PET present better diagnostic performance for the detection of CAD as compared with SPECT.
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Affiliation(s)
- Jianfeng Xu
- Department of Nuclear Sciences and Engineering, Nanjing University of Aeronautics and Astronautics, Nanjing, China.,JYAMS PET Research and Development Limited, Nanjing, China
| | - Fei Cai
- Department of Nuclear Sciences and Engineering, Nanjing University of Aeronautics and Astronautics, Nanjing, China.,JYAMS PET Research and Development Limited, Nanjing, China
| | - Changran Geng
- Department of Nuclear Sciences and Engineering, Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Zheng Wang
- JYAMS PET Research and Development Limited, Nanjing, China
| | - Xiaobin Tang
- Department of Nuclear Sciences and Engineering, Nanjing University of Aeronautics and Astronautics, Nanjing, China
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30
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Intensity of Guideline-Directed Medical Therapy for Coronary Heart Disease and Ischemic Heart Failure Outcomes. Am J Med 2021; 134:672-681.e4. [PMID: 33181105 DOI: 10.1016/j.amjmed.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE The impact of guideline-directed medical therapy for coronary heart disease in those hospitalized with acute heart failure is unknown. METHODS We studied guideline-directed medical therapies for coronary disease: angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta-adrenoreceptor antagonists, antiplatelet agents or anticoagulants, and statins. Using inverse probability of treatment weighting the propensity score, we examined associations of guideline-directed medical therapy intensity (categorized as low [0-1], high [2-3], or very high [4] number of drugs) with mortality in 1873 patients with angina, troponin elevation, or prior myocardial infarction. RESULTS At discharge, 0-1, 2-3, and 4 medications were prescribed in 467 (25%), 705 (38%), and 701 (37%) patients, respectively. Relative to those prescribed 0-1 drugs (reference), all-cause mortality was lower with 2-3 (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.28-0.84, P = 0.009) or all 4 drug classes (HR 0.56, 95% CI 0.33-0.96, P = 0.034) over 181-365 days, with similar reductions present from 0-180 days. In those with heart failure with preserved ejection fraction, mortality trended lower with 2-3 drug classes (HR 0.43, 95% CI 0.18-1.02, P = 0.054) and was significantly reduced with 4 drugs (HR 0.32, 95%CI 0.12-0.84, P = 0.021) during 0-180 day follow-up. In heart failure with reduced ejection fraction, all-cause mortality was reduced during both 0-180 and 181-365 days when discharged on 2-3 (HR 0.30 for 181-365 days, 95%CI 0.14-0.64, P = 0.002) or all 4 drug classes (HR 0.43, 95%CI 0.19-0.95, P = 0.038). CONCLUSIONS Increasing guideline-directed medical therapy intensity for coronary heart disease resulted in lower mortality in patients with acute ischemic heart failure with both preserved and reduced ejection fractions.
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31
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Lee CT, Eastman SE, Arcinas LA, Asselin CY, Cheung D, Mayba A, Zhu A, Strzelczyk J, Maycher B, Memauri B, Kirkpatrick ID, Jassal DS. Prevalence and Functional Implication of Silent Coronary Artery Disease in Marathon Runners Over 40 Years of Age: The MATCH-40 Study. CJC Open 2021; 3:595-602. [PMID: 34027364 PMCID: PMC8134914 DOI: 10.1016/j.cjco.2020.12.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/23/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Marathon participation is becoming increasingly popular among individuals ≥40 years of age. Little is known about the prevalence of subclinical coronary artery disease (CAD) and corresponding ischemia in this patient population. The study objectives are: (1) to characterize the prevalence of silent CAD in marathoners ≥ 40 years old using cardiac computed tomography angiography (CCT); and (2) if subclinical CAD was detected, to determine the functional significance of occult lesions by stress echocardiography (SE). METHODS Marathoners aged ≥ 40 years who completed a full marathon between 2018 and 2019 were recruited to undergo a prospective CCT. Coronary artery stenosis was graded as zero, mild (1%-49%), moderate (50%-69%), or severe (> 70%). All study participants diagnosed with mild-to-severe atherosclerotic CAD on CCT further underwent functional imaging with exercise treadmill SE. RESULTS A total of 65 individuals (53 ± 7 years, 65% males, 24 ± 3 kg/m2) underwent a prospective CCT within 12 months of marathon completion. Of the total study population, 13 participants (20%) were diagnosed with CAD, of whom 10 (77%) had mild disease, 1 (8%) had moderate disease, and 2 (15%) had severe disease by CCT. Despite the identification of subclinical CAD on CCT, none of the 13 patients had any evidence of inducible ischemia on SE. CONCLUSIONS This is the first study to incorporate both CCT and SE in the evaluation of subclinical CAD in marathoners ≥40 years old. Although the overall prevalence of anatomic CAD was 20%, there was no evidence of functional ischemia in this highly competitive cohort.
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Affiliation(s)
- Christopher T. Lee
- Institute of Cardiovascular Sciences, St. Boniface Albrechtsen Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Skyler E. Eastman
- Institute of Cardiovascular Sciences, St. Boniface Albrechtsen Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Liane A. Arcinas
- Institute of Cardiovascular Sciences, St. Boniface Albrechtsen Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Chantal Y. Asselin
- Institute of Cardiovascular Sciences, St. Boniface Albrechtsen Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Cheung
- Institute of Cardiovascular Sciences, St. Boniface Albrechtsen Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrew Mayba
- Institute of Cardiovascular Sciences, St. Boniface Albrechtsen Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Antonia Zhu
- Institute of Cardiovascular Sciences, St. Boniface Albrechtsen Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jacek Strzelczyk
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bruce Maycher
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brett Memauri
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Iain D.C. Kirkpatrick
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Davinder S. Jassal
- Institute of Cardiovascular Sciences, St. Boniface Albrechtsen Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Blanch-Ruiz MA, Ortega-Luna R, Martínez-Cuesta MÁ, Álvarez Á. The Neutrophil Secretome as a Crucial Link between Inflammation and Thrombosis. Int J Mol Sci 2021; 22:4170. [PMID: 33920656 PMCID: PMC8073391 DOI: 10.3390/ijms22084170] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/09/2021] [Accepted: 04/14/2021] [Indexed: 12/24/2022] Open
Abstract
Cardiovascular diseases are a leading cause of death. Blood-cell interactions and endothelial dysfunction are fundamental in thrombus formation, and so further knowledge of the pathways involved in such cellular crosstalk could lead to new therapeutical approaches. Neutrophils are secretory cells that release well-known soluble inflammatory signaling mediators and other complex cellular structures whose role is not fully understood. Studies have reported that neutrophil extracellular vesicles (EVs) and neutrophil extracellular traps (NETs) contribute to thrombosis. The objective of this review is to study the role of EVs and NETs as key factors in the transition from inflammation to thrombosis. The neutrophil secretome can promote thrombosis due to the presence of different factors in the EVs bilayer that can trigger blood clotting, and to the release of soluble mediators that induce platelet activation or aggregation. On the other hand, one of the main pathways by which NETs induce thrombosis is through the creation of a scaffold to which platelets and other blood cells adhere. In this context, platelet activation has been associated with the induction of NETs release. Hence, the structure and composition of EVs and NETs, as well as the feedback mechanism between the two processes that causes pathological thrombus formation, require exhaustive analysis to clarify their role in thrombosis.
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Affiliation(s)
- María Amparo Blanch-Ruiz
- Departamento de Farmacología, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain; (M.A.B.-R.); (R.O.-L.)
| | - Raquel Ortega-Luna
- Departamento de Farmacología, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain; (M.A.B.-R.); (R.O.-L.)
| | - María Ángeles Martínez-Cuesta
- Departamento de Farmacología, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain; (M.A.B.-R.); (R.O.-L.)
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), 46010 Valencia, Spain
| | - Ángeles Álvarez
- Departamento de Farmacología, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain; (M.A.B.-R.); (R.O.-L.)
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), 46010 Valencia, Spain
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Sedighi SM, Fulop T, Mohammadpour A, Nguyen M, Prud’Homme P, Khalil A. Elevated Cardiac Troponin Levels in Geriatric Patients Without ACS: Role of Comorbidities. CJC Open 2021; 3:248-255. [PMID: 33778441 PMCID: PMC7984983 DOI: 10.1016/j.cjco.2020.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/22/2020] [Indexed: 12/12/2022] Open
Abstract
Background Elevated levels of cardiac troponin T as measured by a high-sensitivity test (hscTnT) are common in geriatric patients with a large spectrum of comorbidities but without acute coronary syndrome (ACS). However, the relative contribution of individual comorbidities has never been clearly addressed. This study aimed to determine the relationship between hscTnT elevation as a response variable and individual comorbidities, and to estimate the impact of individual comorbidities on hscTnT elevation in geriatric patients free of ACS. Methods A nonexperimental, retrospective, matched, longitudinal cohort study was designed to evaluate the files of 7062 geriatric patients (aged ≥ 65 years) without ACS. The hscTnT levels of the patients have already been measured in all evaluated medical records. The dataset was split into 2 groups (0 and 1) based on the individual comorbidity (0 and 1) and hscTnT levels (≤ 14 ng/L = 0 and > 14 ng/L = 1). Results Our results show that although age was positively and significantly correlated with hscTnT (r = 0.17, P < 0.0001), the likelihood of experiencing elevated hscTnT levels in older individuals after having excluded ACS was related to the presence of comorbidities independently of their number (P < 0.0001). The regression coefficients (β) associated with renal insufficiency (0.71), cardiomyopathy (0.63), chronic obstructive pulmonary disease (0.30), diabetes (0.25), and anemia (0.22) indicated that there exists a significant association between these comorbidities and the elevated hscTnT levels (P < 0.001). The receiver operating characteristic curve for predictive modeling was estimated at 71% (P < 0.0001). Conclusions Elevated hscTnT levels were mostly associated with renal insufficiency, cardiac myopathies, chronic obstructive pulmonary disease, diabetes, and anemia in geriatric patients without ACS. Developing guidelines to accurately evaluate hscTnT elevation in geriatric patients with comorbidities, without ACS, is clinically essential.
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Affiliation(s)
- Seyed Mahdi Sedighi
- Geriatric Unit, Faculty of Medicine, Sherbrooke University, Sherbrooke, Quebec, Canada
| | - Tamas Fulop
- Geriatric Unit, Faculty of Medicine, Sherbrooke University, Sherbrooke, Quebec, Canada
| | - Adel Mohammadpour
- Department of Mathematics and Statistics, Faculty of Science, McGill University, Montreal, Quebec, Canada
| | - Michel Nguyen
- Cardiology Unit, Faculty of Medicine, Sherbrooke University, Sherbrooke, Quebec, Canada
| | - Patrick Prud’Homme
- Cardiology Unit, Faculty of Medicine, Sherbrooke University, Sherbrooke, Quebec, Canada
| | - Abdelouahed Khalil
- Geriatric Unit, Faculty of Medicine, Sherbrooke University, Sherbrooke, Quebec, Canada
- Corresponding author: Dr Abdelouahed Khalil, CDRV-Health Campus, 12ième Avenue Nord, Sherbrooke, Quebec J1H 1N1, Canada. Tel.: +1-819-821-8000, x70148; fax: +1-819-829-7141.
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Koracevic G, Micic S, Stojanovic M. By discontinuing beta-blockers before an exercise test we may precipitate a rebound phenomenon. Curr Vasc Pharmacol 2021; 19:624-633. [PMID: 33653252 DOI: 10.2174/1570161119666210302152322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/25/2021] [Accepted: 01/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is a need to analyse the current approach to beta-blocker (BB) use in relation to exercise-based stress tests. OBJECTIVE We compared various guidelines regarding recommending abrupt vs gradual discontinuation of BB prior to exercise tests. We also analyse the shortcomings of the currently recommended approach and suggest a new approach to avoid BB rebound. METHODS A narrative review is used to analyse this topic due to lack of valid randomized clinical trials. RESULTS Omitting the BB therapy prior to exercise-based test has been recommended in guidelines for many years. Although reasonable, this approach has potential disadvantages since sudden BB withdrawal may induce a rebound phenomenon, which is, also, acknowledged in several guidelines. CONCLUSIONS We observed inconsistency among relevant guidelines; there is no homogenous approach regarding BB use before exercise tests. Most guidelines recommend BB withdrawal for a couple of days before the test; they do not advise BB dose tapering. This approach is not standardised and raises the risk of BB rebound phenomenon both before and during the test. Therefore, we suggest using the half the prescribed BB dose at the usual time of administration (in the morning, prior to the exercise test).
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Affiliation(s)
- Goran Koracevic
- Department for Cardiovascular Diseases, Clinical Center Nis. Serbia
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Turgeon RD, Sedlak T. Use of Preventive Medications in Patients With Nonobstructive Coronary Artery Disease: Analysis of the PROMISE Trial. CJC Open 2021; 3:159-166. [PMID: 33644729 PMCID: PMC7893195 DOI: 10.1016/j.cjco.2020.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 09/28/2020] [Indexed: 01/18/2023] Open
Abstract
Background Nonobstructive coronary artery disease (NOCAD) is commonly found on coronary computed tomography angiography (CCTA) during evaluation for coronary artery disease (CAD). There are no guidelines for the medical management of NOCAD, and practice is variable. We aimed to compare patterns of preventive medication use and continuation after identifying NOCAD vs normal coronaries or obstructive CAD on CCTA. Methods We analyzed data from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial dataset, restricted to patients with ≥2 follow-up visits after CCTA. We categorized patients as having either obstructive CAD, NOCAD, or normal coronaries. The primary outcome was the proportion of patients reporting continued use of combination preventive medications, defined as a statin, an antithrombotic, and a renin–angiotensin system blocker throughout follow-up after CCTA. Secondary outcomes included the proportion of visits reporting combination therapy and individual medications. Results We included 4388 patients, with a mean follow-up of 2.3 years. Most patients had NOCAD (48.6%), with normal coronaries in 38.9%, and obstructive CAD in 10.1%. Among NOCAD patients, the mean age was 61 years, and 47.2% were women. A total of 9.1% of NOCAD patients continued combination therapy, vs 12.4% with obstructive CAD, and 3.3% with normal coronaries (P < 0.001), primarily due to lower use of statins and antithrombotic agents. Similarly, patients with obstructive CAD, NOCAD, and normal coronaries reported using combination therapy during a mean of 35%, 24%, and 9% of visits, respectively (P < 0.001). Conclusions Few patients with NOCAD identified by CCTA used or continued combination preventive cardiovascular medications. Patients with NOCAD represent an at-risk population with potential for optimization of preventive medications.
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Affiliation(s)
- Ricky D Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tara Sedlak
- Faculty of Medicine (Division of Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
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Wang M, Chen Z, Wong M, Thabane L, Mbuagbaw L, Siegal D, Le Gal G, Holbrook A. Are the correct outcomes being measured in studies of oral anticoagulants? A systematic survey. Thromb Res 2021; 201:30-49. [PMID: 33631520 DOI: 10.1016/j.thromres.2021.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/26/2021] [Accepted: 02/08/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Oral anticoagulant (OAC) intervention trials have typically included clinical event outcomes. However, there is no standard list of outcomes to be used in OAC research. This study aimed to describe and classify the outcomes used in recent prospective clinical studies involving OACs. MATERIALS AND METHODS We searched MEDLINE, EMBASE, and CINAHL databases from January 2009 to July 2019 for prospective studies with an intervention or control group that included one or more oral anticoagulants. We abstracted details about each included study and the outcomes used from the study report and its accompanying protocol. Using the Core Outcome Measures in Effectiveness Trials (COMET) Initiative recommendations, we categorised each outcome into one of five domains (mortality/survival, physiological/clinical, life impact, resource use, and adverse events). Our primary outcome was the prevalence of use of an outcome domain across studies. RESULTS We included 70 prospective studies, including 52 randomized controlled trials and 18 prospective cohort studies. A total of 121 different outcomes were reported. The COMET domains were represented in the 70 studies as follows: mortality (63/70, 90.0%); physiological/clinical domain (70/70, 100%), life impact domain (43/70, 61.4%), resource use domain (26/70, 37.1%), and adverse events domain (55/70, 78.6%). CONCLUSION Outcome reporting in prospective studies of OACs more frequently concentrates on mortality, physiological/clinical domains, and adverse events compared to life impact and resource utilization domains, the latter uncommonly used. A priority for future research includes developing a core outcome set (COS) for OAC research that represents all domains.
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Affiliation(s)
- Mei Wang
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada; Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton L8N 4A6, ON, Canada.
| | - Zhiyuan Chen
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada
| | - Michael Wong
- Bachelor Life Sciences Program, Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada; Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton L8N 4A6, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada; Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton L8N 4A6, ON, Canada
| | - Deborah Siegal
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada
| | - Gregoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth, Ottawa K1H 8L6, ON, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada; Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton L8N 4A6, ON, Canada; Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton L8S 4K1, ON, Canada
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Review of the use of simulators in learning revascularization techniques. Gen Thorac Cardiovasc Surg 2021; 69:415-424. [PMID: 33428083 DOI: 10.1007/s11748-020-01577-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW The apprentice model has been traditionally used to train cardiac surgery and cardiology learners the techniques for revascularization with the use of simulators recently becoming more prevalent in these training programs. This review aims to summarize research conducted on the use of simulation-based teaching (SBT) for trainees learning percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and off-pump CABG (OPCAB). RECENT FINDINGS Prior literature evaluating the utility of SBT has demonstrated remarkable results including reduced procedural times, use of fluoroscopy, incidence of mistakes, improved stent placement, and confidence with PCI simulators. Similarly, the use of CABG and OPCAB simulators demonstrated improvement in forceps use, needle angles, Objective Structured Assessment of Technical Skill, and reduced completion times. The apprentice model has undoubtedly been successful as the most successful cardiac surgeons and cardiologists have been produced through this training model. Even so, many shortcomings have been identified including insufficient time to teach all relevant technical skills, inadequate exposure to rare adverse events, high-cost, and often unstructured format while being time-consuming and resource-intensive with little objective assessment of proficiency. SBT has been pursued as a potential adjunct to fill the gaps left by the traditional apprentice model. While simulations have been demonstrated to be successful in teaching both experienced and inexperienced learners complex techniques, it is unlikely that training will ever solely rely on simulations. The most efficient method of training learners for revascularization in the future will likely involve a combination of hands-on learning and SBT.
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Laukkanen JA, Kunutsor SK. Revascularization versus medical therapy for the treatment of stable coronary artery disease: A meta-analysis of contemporary randomized controlled trials. Int J Cardiol 2020; 324:13-21. [PMID: 33068645 DOI: 10.1016/j.ijcard.2020.10.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/12/2020] [Accepted: 10/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND We conducted a systematic review and meta-analysis of contemporary randomized controlled trials (RCTs) to compare clinical outcomes among stable coronary artery disease (CAD) patients treated with revascularization [percutaneous coronary intervention (PCI), coronary-artery bypass grafting (CABG) or both] plus medical therapy (MT) versus MT alone. METHODS Prospective RCTs were sought from MEDLINE, Embase, The Cochrane Library, and Web of Science up to April 2020. Data was extracted on study characteristics, methods, and outcomes. Relative risks (RRs) with 95% confidence intervals (CIs) were pooled for the composite of all-cause mortality, myocardial infarction (MI), revascularizations, rehospitalizations, or stroke; its individual components and other cardiovascular endpoints. RESULTS Twelve unique RCTs comprising of 15,774 patients were included. There was no significant difference in all-cause mortality risk (0.95, 95% CI: 0.86-1.06); however, revascularization plus MT reduced the risk of the composite outcome of all-cause mortality, MI, revascularizations, rehospitalizations, or stroke (0.69, 95% CI: 0.55-0.87); unplanned revascularization (0.53, 95% CI: 0.40-0.71); and fatal MI (0.65, 95% CI: 0.49-0.84). Revascularization plus MT reduced the risk of stroke at 1 year (0.44, 95% CI: 0.30-0.65) and unplanned revascularization and the composite outcome of all-cause mortality, MI, revascularizations, rehospitalizations, or stroke at 2-5 years. CONCLUSIONS Revascularization plus MT does not confer survival advantage beyond that of MT among patients with stable CAD. However, revascularization plus MT may reduce the overall risk of the combined outcome of mortality, MI, revascularizations, rehospitalizations, or stroke, which could be driven by a decrease in the risk of unplanned revascularizations or fatal MI.
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Affiliation(s)
- Jari A Laukkanen
- Institute of Clinical Medicine, Department of Medicine, University of Eastern Finland, Kuopio, Finland; Central Finland Health Care District, Department of Medicine, Jyväskylä, Finland; Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland.
| | - Setor K Kunutsor
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK; Translational Health Sciences, Bristol Medical School, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, UK
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Feasibility of coronary CT angiography for guidance of CABG. J Cardiovasc Comput Tomogr 2020; 15:281-284. [PMID: 32981883 DOI: 10.1016/j.jcct.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 09/07/2020] [Accepted: 09/15/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the clinical safety and effectiveness of coronary revascularization in patients who underwent coronary artery bypass grafting (CABG) based exclusively on coronary computed tomography angiography (CCTA) results. METHODS 53 patients (62.3 ± 7.1 years) underwent CCTA before a CABG surgery without prior invasive coronary angiography (ICA). Primary endpoints were all-cause mortality and major adverse cardiovascular events (MACE). The secondary endpoint was quality of life (QoL) assessed with the Minnesota Living with Heart Failure Questionnaire (MLHFQ). All were collected one year after the surgery. RESULTS CCTA revealed multivessel coronary artery disease (CAD) in 52 patients. Indication for bypass surgery was made exclusively based on CCTA results. 136 distal anastomoses were performed. Assessment at 1 year (13.3 ± 1.4 months) was completed in 98.1% of the patients. MACE and mortality rates were 0%. The MLHFQ total score was 21.8 ± 8.7, and active lifestyle was maintained in all patients. CONCLUSIONS In this proof of concept prospective pilot study, we observed that non-invasive coronary angiography may provide adequate anatomic detail to guide CABG surgery. Further study of this concept is warranted.
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Noninvasive Testing for Diagnosis of Stable Coronary Artery Disease in the Elderly. Int J Mol Sci 2020; 21:ijms21176263. [PMID: 32872444 PMCID: PMC7503866 DOI: 10.3390/ijms21176263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/20/2020] [Accepted: 08/25/2020] [Indexed: 11/17/2022] Open
Abstract
Efficient diagnostic approaches to detect coronary artery disease (CAD) in elderly patients are necessary to ensure optimal and timely treatment. The population of suspected CAD patients older than 70 years is especially vulnerable and constantly growing. Finding the optimal diagnostic approach is challenging due to certain features of this population, such as high prevalence of comorbidities, existing contraindications to exercise tests or cognitive decline, which hinders correct assessment of the patient's situation. Moreover, some symptoms of CAD can have variable significance in the elderly compared to younger adult groups. In this review, we present current recommendations of the United States (US) and European cardiologists' associations and discuss their applicability for diagnostics in the elderly population. Exercise electrocardiogram (ECG) and exercise stress echocardiography (SE) tests are not feasible for a substantial proportion of elderly patients. Coronary computed tomography angiography (CTA) appears to be an attractive alternative for such patients, but is not universally applicable; for instance, it is problematic in patients with significant calcification of the vessels. Moreover, more studies are needed to compare the results delivered by CTA to those of other diagnostic methods. Future efforts should be focused on comparative studies to better understand the limits and advantages of different diagnostic methods and their combinations. It is possible that some of the currently used diagnostic criteria could be improved to better accommodate the needs of the elderly population.
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He S, Qu L, He X, Zhang D, Xie N. Comparative evaluation of 15-minute rapid diagnosis of ischemic heart disease by high-sensitivity quantification of cardiac biomarkers. Exp Ther Med 2020; 20:1702-1708. [PMID: 32742399 PMCID: PMC7388240 DOI: 10.3892/etm.2020.8853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 04/17/2020] [Indexed: 12/05/2022] Open
Abstract
A rapid clinical diagnosis may efficiently improve the survival rate and prognosis of patients with ischemic heart disease (IHD). Therefore, a one-step, rapid and inexpensive analysis for the quick diagnosis of IHD was investigated in the present study. Consecutive patients who were subjected to myoglobin, cardiac troponin I and creatine kinase-MB isoenzyme assessment at the Emergency Department of Shenzhen Second People's Hospital (Shenzhen, China) between December 2017 and March 2018 prior to treatment were screened. Clinically applicable disposable strips were employed for quantification of the cardiac biomarkers. The analytical performance of the strips was evaluated by receiver operating characteristic (ROC) curves and compared with the traditional chemiluminescence immunoassay (CLIA) method. The data of 391 participants were collected. At the baseline, 57 patients were diagnosed with IHD and 334 patients were diagnosed with other diseases. The area under the ROC curve (AUC) of the CLIA model was 0.787 (95% CI, 0.709-0.865) with a specificity of 76.7% and a sensitivity of 71.9%. At the optimal cutoff value of -1.867, the negative and the positive predictive value were 94.1 and 34.5%, respectively. The AUC of the disposable strip model was 0.792 (95% CI, 0.729-0.855). At the cutoff value of -1.820 or below, the negative predictive value was 94.9%, the positive predictive value was 28.9%, the specificity was 66.8% and the sensitivity was 79.0%. The P-value of the ROCs was 0.858, indicating no statistically significant difference between the two assay methods. The cost of the disposable strip was 50% of that of the CLIA method and it took only 25% of the time that was required for the quantification of the three cardiac markers by CLIA. In conclusion, the disposable strip provides a platform for point-of-care testing and may be an easy, rapid, reliable and cost-saving method for the diagnosis of IHD.
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Affiliation(s)
- Shengnan He
- Institute of Translational Medicine, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong 518035, P.R. China
| | - Long Qu
- Institute of Translational Medicine, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong 518035, P.R. China
| | - Xi He
- Institute of Translational Medicine, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong 518035, P.R. China
| | - Dan Zhang
- Institute of Translational Medicine, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong 518035, P.R. China
| | - Ni Xie
- Institute of Translational Medicine, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong 518035, P.R. China
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Marquis-Gravel G, Moliterno DJ, Francis DP, Jüni P, Rosenberg YD, Claessen BE, Mentz RJ, Mehran R, Cutlip DE, Chauhan C, Quella S, Zannad F, Goodman SG. Improving the Design of Future PCI Trials for Stable Coronary Artery Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 76:435-450. [PMID: 32703515 PMCID: PMC10018282 DOI: 10.1016/j.jacc.2020.05.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/07/2020] [Accepted: 05/15/2020] [Indexed: 01/09/2023]
Abstract
The role of percutaneous coronary interventions in addition to medical therapy for patients with stable coronary artery disease continues to be debated in routine clinical practice, despite more than 2 decades of randomized controlled trials. The residual uncertainty arises from particular challenges facing revascularization trials. Which endpoint do doctors care about, and which do patients care about? Which participants should be enrolled? What background medical therapy should we use? When is placebo control relevant? In this paper, we discuss how these questions can be approached and examine the merits and disadvantages of possible options. Engaging multiple stakeholders, including patients, researchers, regulators, and funders, to ensure the design elements are methodologically valid and clinically meaningful should be an aspirational goal in the development of future trials.
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Affiliation(s)
| | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Darrel P Francis
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Peter Jüni
- Department of Medicine and Institute of Health Policy, Management and Evaluation, Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yves D Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Bimmer E Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | | | | | | | - Faiez Zannad
- Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Regional et Universitaire de Nancy, Vandoeuvre les Nancy, France
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto and Canadian Heart Research Centre, Toronto, Ontario, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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Bartling B, Schwarzmann L, Pliquett RU, Simm A, Hofmann B. Simultaneous influence of sex and age on blood pressure difference between supine and sitting body positions. Z Gerontol Geriatr 2020; 54:597-604. [PMID: 32647989 DOI: 10.1007/s00391-020-01756-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/22/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Doctors' offices and outpatient departments typically measure blood pressure (BP) with the patient in a sitting position, whereas inpatient departments also use the supine position. As sex and age influence the autonomic function associated with BP regulation our study compared BP measurements in supine and sitting positions for men and women of different ages. METHODS We included 91 men and 118 women (≥18 years) without severe diseases. Hypertension was not an exclusion criterion because it is common in older persons. Mean left brachial BP and heart rate were determined by a digital sphygmomanometer in supine position as well as in sitting position before and after hand force measurement. RESULTS In a supine position women had slightly lower diastolic BP values than men. After sitting up, the diastolic BP increased in nearly all subjects. This increase was greater in women older than 50 years than for aged-matched men. In contrast to diastolic BP the systolic BP increased after sitting up in only two thirds of the subjects. Especially in women younger than 50 years the systolic BP often did not increase but decreased in response to postural change. The pulse pressure was mostly reduced after sitting up. This reduction was more pronounced in women than men independent of age and physical effort (i.e. hand force measurement). The sitting position also caused an increased heart rate, which was independent of sex and age. CONCLUSION Postural changes in the systolic and diastolic BP simultaneously depend on sex and age that needs to be considered for BP measurements in supine and sitting body positions.
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Affiliation(s)
- Babett Bartling
- Department of Cardiac Surgery, Mid-German Heart Centre, University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.
| | - Luisa Schwarzmann
- Department of Cardiac Surgery, Mid-German Heart Centre, University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Rainer Ullrich Pliquett
- Department for Internal Medicine II, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Department for Nephrology and Diabetology, Carl Thiem Hospital, Cottbus, Germany
| | - Andreas Simm
- Department of Cardiac Surgery, Mid-German Heart Centre, University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Britt Hofmann
- Department of Cardiac Surgery, Mid-German Heart Centre, University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
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Soini E, Virtanen O, Väätäinen S, Briere JB, Bowrin K, Millier A. Cost-Effectiveness of Coronary and Peripheral Artery Disease Antithrombotic Treatments in Finland. Adv Ther 2020; 37:3348-3369. [PMID: 32519113 PMCID: PMC7467417 DOI: 10.1007/s12325-020-01398-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Indexed: 12/17/2022]
Abstract
Introduction Currently, 15–20% of individuals with coronary artery disease (chronic coronary syndrome [CCS]) or peripheral artery disease (PAD) receiving routine treatment experience cardiovascular events (CVEs) within 3–4 years. Using PICOSTEPS (Patients-Intervention-Comparators-Outcomes-Setting-Time-Effects-Perspective-Sensitivity analysis) reporting, we evaluated the cost-effectiveness of recently approved rivaroxaban 2.5 mg twice daily in combination with acetylsalicylic acid 100 mg daily (RIV + ASA) for the prevention of CVEs among Finns with CCS or symptomatic PAD. Methods Myocardial infarction, ischemic stroke, intracranial hemorrhage, acute limb ischemia, amputations, major extracranial bleeding, venous thromboembolism, and cardiovascular deaths were modeled in a Markov model examining a cohort of patients with CCS or symptomatic PAD. Relative effects of the intervention (RIV + ASA) and comparator (ASA) were based on the COMPASS trial. The primary outcome was 3%/year discounted incremental cost-effectiveness ratio (ICER), defined as cost (2019 euros) per quality-adjusted life year (QALY) gained in the Finnish setting over a lifetime horizon. In addition to nonfatal and fatal CVEs, the effects factored Finnish non-CVE mortality, quality of life, and direct costs from a public payer perspective. Disaggregated costs and QALYs, costs per life year gained (LYG), and ischemic strokes avoided, net monetary benefit (NMB), expected value of perfect information (EVPI), economic value-added (EVA), cost-effectiveness table, and acceptability frontier were examined. Probabilistic and deterministic sensitivity analyses were conducted. Results In the deterministic comparison with ASA over a lifetime horizon, RIV + ASA resulted in a benefit of 0.404 QALYs and 0.474 LYGs for an additional cost of €3241, resulting in an ICER of €8031/QALY. The probabilistic ICER was €4313/QALY (EVPI €1829/patient). RIV + ASA had positive NMB (€8791/patient), low EVPI (€88/patient), high EVA (€8703/patient), and 91% probability of cost-effectiveness using the willingness-to-pay of €25,254/QALY. The primary result was conservative and robust for RIV + ASA. Conclusion RIV + ASA was a cost-effective treatment alternative compared with ASA in patients with CCS or symptomatic PAD in Finland. Electronic supplementary material The online version of this article (10.1007/s12325-020-01398-8) contains supplementary material, which is available to authorized users. Finland lacks published evidence on the cost-effectiveness of approved interventions for the prevention of cardiovascular events among individuals with chronic coronary syndrome (stable coronary artery disease) or symptomatic peripheral artery disease at risk of cardiovascular complications. Rivaroxaban 2.5 mg twice daily plus acetylsalicylic acid 100 mg once daily is indicated and reimbursed in Finland for the prevention of cardiovascular events for patients with stable coronary artery disease or symptomatic peripheral artery disease. We assessed the effectiveness and costs of treatment with rivaroxaban plus acetylsalicylic acid in comparison with treatment with acetylsalicylic acid. That is, we examined whether rivaroxaban is cost-effective when prescribed in combination with acetylsalicylic acid. Cardiovascular events with their associated costs and impact on quality of life were modeled over the lifetime of patients. The main effectiveness outcome was quality-adjusted life years (modeled survival multiplied by the expected quality of life), and costs included those relevant to the Finnish public payer in 2019. Extensive sensitivity analyses were carried out to evaluate the impacts of different model inputs and rationale. Rivaroxaban plus acetylsalicylic acid had high probability of being cost-effective, compared with acetylsalicylic acid. By valuing quality-of-life benefit with a plausible willingness-to-pay, net cost savings of €8791 per patient could be gained or economic value added by €8703 per patient if rivaroxaban was used.
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Roifman I, Sivaswamy A, Chu A, Austin PC, Ko DT, Douglas PS, Wijeysundera HC. Clinical Effectiveness of Cardiac Noninvasive Diagnostic Testing in Outpatients Evaluated for Stable Coronary Artery Disease. J Am Heart Assoc 2020; 9:e015724. [PMID: 32605412 PMCID: PMC7670545 DOI: 10.1161/jaha.119.015724] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Despite more than 4 million cardiac noninvasive diagnostic tests (NIT) being performed annually for stable coronary artery disease in the United States, it is unclear whether they are associated with downstream improvements in outcomes when compared with no testing. We sought to determine whether NIT was associated with reduced downstream major adverse cardiovascular events when compared with not testing. Methods and Results We conducted a population‐based study of ≈1.5 million patients undergoing chest pain evaluation in Ontario, Canada. Patients were categorized into NIT and no‐testing groups. Cause‐specific proportional hazards models were used to compare the rate of major adverse cardiovascular events (composite outcome of unstable angina, acute myocardial infarction or cardiovascular mortality and each constituent) between the 2 groups after adjusting for clinically relevant covariates. The rate of the composite outcome was ≈25% lower for patients undergoing noninvasive testing (hazard ratio [HR], 0.77; 95% CI, 0.75–0.79). The benefits of testing were consistent for all 3 constituents of the composite; unstable angina (HR, 0.87; 95% CI, 0.82–0.93 for the NIT versus the no‐testing group), myocardial infarction (HR, 0.83; 95% CI, 0.79–0.86 for the NIT versus the no‐testing group) and cardiovascular mortality (HR, 0.68; 95% CI, 0.65–0.72 for the NIT versus the no‐testing group). Conclusions Our large population‐based study reports an ≈25% reduction in major adverse cardiovascular events that was independently associated with NIT in outpatients being evaluated for stable angina. This study demonstrates the prognostic importance of NIT versus no testing on the health of contemporary populations.
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Affiliation(s)
- Idan Roifman
- Schulich Heart ProgramSunnybrook Health Sciences CentreUniversity of TorontoCanada
- Institute of Health Policy Management, and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
| | | | | | - Peter C. Austin
- Institute of Health Policy Management, and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
| | - Dennis T. Ko
- Schulich Heart ProgramSunnybrook Health Sciences CentreUniversity of TorontoCanada
- Institute of Health Policy Management, and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
| | | | - Harindra C. Wijeysundera
- Schulich Heart ProgramSunnybrook Health Sciences CentreUniversity of TorontoCanada
- Institute of Health Policy Management, and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
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Affiliation(s)
- Neel M Butala
- Division of Cardiology Massachusetts General Hospital Boston MA USA.,Harvard Medical School Boston MA USA
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Antithrombotic Treatments in Patients with Chronic Coronary Artery Disease or Peripheral Artery Disease: A Systematic Review of Randomised Controlled Trials. Cardiovasc Ther 2020; 2020:3057168. [PMID: 32695228 PMCID: PMC7345917 DOI: 10.1155/2020/3057168] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/23/2019] [Accepted: 05/06/2020] [Indexed: 12/24/2022] Open
Abstract
Aims Acetylsalicylic acid (ASA) is widely used for the prevention of atherothrombotic events in patients with chronic coronary artery disease (CAD) and peripheral artery disease (PAD), but the risk of vascular events remains high. We aimed at identifying randomised controlled trials (RCTs) on antithrombotic treatments in patients with chronic CAD or PAD. Methods Searches were conducted on MEDLINE, EMBASE, and CENTRAL on March 1st, 2018. This systematic review (SR) uses a narrative synthesis to summarize the evidence for the efficacy and safety of antiplatelet and anticoagulant therapies in the population of both chronic CAD or PAD patients. Results Four RCTs from 27 publications were included. Study groups included 15,603 to 27,395 patients. ASA alone was the most extensively studied (n = 3); other studies included rivaroxaban with or without ASA (n = 1), vorapaxar alone (n = 1), and clopidogrel with (n = 1) or without ASA (n = 1). Clopidogrel alone and clopidogrel plus ASA compared to ASA presented similar efficacy with comparable safety profile. Rivaroxaban plus ASA significantly reduced the risk of the composite of cardiovascular death, myocardial infarction, and stroke compared to ASA alone, although major bleeding with rivaroxaban plus ASA increased. Conclusion There is limited and heterogeneous evidence on the prevention of atherothrombotic events in patients with chronic CAD or PAD. Clopidogrel alone and clopidogrel plus ASA did not demonstrate superiority over ASA alone. A combination of rivaroxaban plus ASA may offer significant additional benefit in reducing cardiovascular outcomes, yet it may increase the risk of bleeding, compared to ASA alone.
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Ivers NM, Schwalm JD, Bouck Z, McCready T, Taljaard M, Grace SL, Cunningham J, Bosiak B, Presseau J, Witteman HO, Suskin N, Wijeysundera HC, Atzema C, Bhatia RS, Natarajan M, Grimshaw JM. Interventions supporting long term adherence and decreasing cardiovascular events after myocardial infarction (ISLAND): pragmatic randomised controlled trial. BMJ 2020; 369:m1731. [PMID: 32522811 PMCID: PMC7284284 DOI: 10.1136/bmj.m1731] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To test a scalable health system intervention to improve long term adherence to secondary prevention treatments among patients who have had a recent myocardial infarction. DESIGN Three arm, pragmatic randomised controlled trial with blinded outcome assessment. SETTING Nine cardiac centres in Ontario, Canada. PARTICIPANTS 2632 patients with obstructive coronary artery disease after a myocardial infarction, identified from a centralised cardiac registry. INTERVENTIONS Participants were randomised 1:1:1 to receive usual care, five mail-outs developed through a user centred design process, or mail-outs plus phone calls. The phone calls were delivered first by an interactive automated system to screen for non-adherence to treatment. Trained lay health workers followed up as necessary. Interventions were coordinated centrally but delivered from each patient's hospital site. MAIN OUTCOME MEASURES Co-primary outcomes were completion of cardiac rehabilitation and adherence to recommended medication. Data were collected by blinded assessors through patient report and from administrative health databases at 12 months. RESULTS 2632 patients (mean age 66, 71% male) were randomised: 878 to the full intervention (mail plus phone calls), 878 to mail only, and 876 to usual care. Of the respondents, 174 (27%) of 643 in the usual care group, 200 (32%) of 628 in the mail only group, and 196 (37%) of 531 allocated to the full intervention completed cardiac rehabilitation (adjusted odds ratio 1.55, 95% confidence interval 1.18 to 2.03). In the mail plus phone group, 11.7%, 6.0%, 14.4%, 32.9%, and 35.0% reported adherence to 0, 1, 2, 3, and 4 drug classes after one year, respectively, in comparison with 12.5%, 6.8%, 13.6%, 30.2%, and 36.8% in the mail only group, and 12.2%, 8.4%, 13.1%, 30.3%, and 36.1% in the usual care group, respectively (mail only v usual care, odds ratio 0.98, 95% confidence interval 0.81 to 1.19; full intervention v usual care, 0.99, 0.82 to 1.20). CONCLUSIONS Scalable interventions delivered by mail plus phone can increase completion of cardiac rehabilitation after myocardial infarction but not adherence to medication. More intensive interventions should be tested to improve adherence to medication and to evaluate the association between attendance at cardiac rehabilitation and adherence to medication. TRIAL REGISTRATION ClinicalTrials.gov NCT02382731, registered 9 March 2015 before any patient enrolment.
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Affiliation(s)
- Noah M Ivers
- Department of Family and Community Medicine, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S1B2, Canada
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto ON, Canada
| | - Jon-David Schwalm
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Cardiology, Hamilton Health Sciences, and McMaster University, Hamilton, ON, Canada
| | - Zachary Bouck
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Tara McCready
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Population and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Sherry L Grace
- Faculty of Health, York University, Toronto, ON, Canada
- KITE Research Institute, University Health Network, Toronto, ON, Canada
| | - Jennifer Cunningham
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Beth Bosiak
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Justin Presseau
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Population and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Holly O Witteman
- Department of Family and Emergency Medicine, Université Laval, Quebec City, QC, Canada
| | - Neville Suskin
- Cardiac Rehabilitation and Secondary Prevention Programme of St Joseph's Health Care London, ON, Canada
- Lawson Health Research Institute, Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Harindra C Wijeysundera
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Clare Atzema
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - R Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Madhu Natarajan
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Cardiology, Hamilton Health Sciences, and McMaster University, Hamilton, ON, Canada
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Population and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Morgott M, Heinmüller S, Hueber S, Schedlbauer A, Kühlein T. Do guidelines help us to deviate from their recommendations when appropriate for the individual patient? A systematic survey of clinical practice guidelines. J Eval Clin Pract 2020; 26:709-717. [PMID: 31206241 DOI: 10.1111/jep.13187] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 05/03/2019] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Clinical practice guidelines (CPG) were introduced to summarize the best scientific evidence available. Thereby, CPG were meant to support evidence-based medicine (EBM). However, besides evidence, EBM also asks for patients' preferences and physicians' experiences to be considered when coming to therapeutic decisions. Thus, deviations from CPG recommendations are sometimes necessary when practicing EBM. We wanted to examine whether CPG support deviations from their recommendations when appropriate. For operationalization, we asked whether absolute effect sizes (AES) for benefit and/or harm of suggested therapies were provided along with the respective CPG recommendation. METHODS This systematic survey comprised the most common CPG on chronic coronary heart disease (CCHD) and type 2 diabetes mellitus (T2DM) from English- and German-speaking countries. Only CPG recommendations on pharmacotherapy were evaluated. If AES of a recommended therapy were reported, we rated how easily findable they were within the CPG. Moreover, we assessed whether the CPG provided patient information material and whether this material supplied AES allowing patients to determine the effects to be expected. RESULTS In the 13 CPG surveyed, 144 recommendations on pharmacotherapy were identified. For 108 recommendations (75%), no AES for benefit and/or harm were reported. Thirty-one recommendations (22%) were accompanied by one or more AES for either benefit or harm. Along with five recommendations (3%), one or more AES for both benefit and harm were given. AES were considered easy to find for three of these 36 recommendations (8%). Patient information material was provided in three of the 13 CPG (23%) accounting for AES in one occasion only. CONCLUSION Current CPG on T2DM and CCHD do not sufficiently offer AES for benefits and harms of recommended therapies. Thus, they lack satisfactory information to support deviations from CPG recommendations. Consequently, CPG in their present form do not adequately facilitate EBM.
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Affiliation(s)
- Marc Morgott
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Institute of General Practice, Erlangen, Germany
| | - Stefan Heinmüller
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Institute of General Practice, Erlangen, Germany
| | - Susann Hueber
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Institute of General Practice, Erlangen, Germany
| | - Angela Schedlbauer
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Institute of General Practice, Erlangen, Germany
| | - Thomas Kühlein
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Institute of General Practice, Erlangen, Germany
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Eghtesadi M, Marquis-Gravel G. Rethinking Our Cardiovascular Risk Assessment in the Younger Female Migraine Population. Headache 2020; 60:994-997. [PMID: 32337722 DOI: 10.1111/head.13809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Marzieh Eghtesadi
- Department of Clinical Neurosciences, Headache Center, Université de Montréal, Montréal, QC, Canada
| | - Guillaume Marquis-Gravel
- Department of Medicine, Duke Clinical Research Institute, Durham, NC, USA.,Montreal Heart Institute, Montréal, QC, Canada
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