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In a randomized trial of PCI in patients with stable angina who were receiving little or no antianginal medication and had documented ischemia, PCI resulted in a better health status with respect to angina than placebo at 12 weeks.

Because of possible adverse outcomes, many of the >6 million annual emergency department (ED) patients with suspected acute coronary syndromes (ACS) undergo extensive evaluations. To minimize medical errors, chest pain evaluations are structured to identify accurately nearly 100% of patients with ACS. This is at a cost of negative evaluation rates that can exceed 90%. Ischemia-modified albumin (IMA), a serum biomarker with a high negative predictive value (NPV) at ED presentation, may exclude ACS. Our objective was to perform a meta-analysis of IMA use for ACS risk stratification. By computer literature search and communication with authors of unpublished information, all IMA data were considered. This analysis included studies if they reported IMA results from an ED presentation for suspected ACS. We defined a negative triple prediction test (TPT) as a nondiagnostic electrocardiogram, negative troponin, and negative IMA. Eight studies of >1800 patients met the entry criteria. The TPT sensitivity and NPV for acute ACS were 94.4% and 97.1% and, for longer-term outcomes, were 89.2% and 94.5%, respectively. A negative TPT of a nondiagnostic electrocardiogram, negative troponin, and negative IMA has a high NPV for excluding ACS in the ED.

BackgroundCalcified coronary lesions often cause suboptimal stent expansion, which is one of the greatest predictors of adverse outcomes such as stent thrombosis and restenosis.Shockwave intravascular lithotripsy (IVL) is a relatively recently NICE approved technique used in the treatment of heavily calcified coronary lesions. This audit presents Salisbury NHS trust experience with the IVL device in 2019just at the initial introduction of the device in the UKMethodsAll patients treated with IVL between beginning of March2019 and end of February 2020 (1 year period) during their percutaneous coronary intervention (PCI) at Salisbury District Hospital.ResultsDuring this period, there were 24 patients who were treated with IVL prior to stent implantation/PCI. 16 of them were males (67%). Mean age of all patients was 71(range 54–86).Indications for PCI were Acute Coronary Syndrome(ACS) in 11 patients(46%), stable angina in 13 patients (54%), PCI was performed in the context of investigating severe LVSD that was incidentally discovered after PEA arrest and IVL was also used to further expand an incompletely expanded stent without restenting in 1 patient . The rest of the cases were treated with IVL in the context of severe calcification seen with adjunctive use of OCT and or IVUS. IVL was most commonly used in the left anterior descending coronary artery and Right Coronary artery in (50%) – (46%) respectively, while it was used in to treat the Circumflex in only one patient (4%). Angiographic and IVUS/OCT imaging guided success (<20% residual stenosis) occurred in all cases except one (96%).Only 1 case had an IVL related complication (4%) with a balloon bursting during the first energy delivery at 6 atmospheres of pressure with no haemodynamic sequelae. Another case was complicated by a limited distal vessel wire dissection managed conservatively.ConclusionFrom our initial experience IVL appears to be a safe and efficacious adjunctive modality in coronary calcium modification to optimise stent delivery and expansion.Conflict of InterestNone

IntroductionMicrovascular angina is a category of ischaemia with non-obstructive coronary arteries (INOCA) which typically occurs as exertional angina but may feature angina at rest if there is coexistent microvascular vasospasm. Coronary vasospasm typically produces anginal symptoms at rest with preserved exercise tolerance, often with a circadian pattern. The CorMicA trial demonstrated that stratified medical therapy guided by invasive guidewire-based measurements of microvascular resistance (IMR), coronary flow reserve (CFR), and fractional flow reserve (FFR), with acetylcholine vasoreactivity testing, improves angina and quality of life. This is a non-comparative summarised retrospective case series of patients undergoing invasive measurement of IMR, CFR, and FFR at a district general hospital in the United Kingdom over a seven-month period.MethodsUsing the electronic records of 16 patients who had undergone invasive assessment of microvascular resistance (with or without vasoreactivity testing), we assessed primary endpoints of whether the procedure changed management and whether there was a subsequent improvement in symptoms. Secondary endpoints included rates of positive tests for microvascular dysfunction (MVD) or vasospasm and significant adverse events.Results5/16 (31%) patients who underwent invasive assessment of microvascular function were found to have clear-cut MVD with an IMR ≥ 25. A further 3 (20%) were felt to have mild, or borderline MVD. 9 of these 16 patients underwent acetylcholine testing, inducing vasospasm in 5/9 (56%).Two patients were found intra-procedurally to have obstructive coronary artery disease and underwent angioplasty. Excluding these, where available notes were sufficient to draw conclusions, 10/11 patients (91%) had a change in either diagnostic approach to or treatment of their symptoms following the procedure. 3/11 (27%; 2 with MVD, 1 with vasospasm) had a documented improvement in symptoms, although not all of these 11 had follow-up documentation.In terms of adverse events 1 patient with known chronic obstructive pulmonary disease developed significant bronchospasm during adenosine infusion. Two patients developed atrial fibrillation after acetylcholine infusion (with no known history of atrial fibrillation).ConclusionThis retrospective observational case series suggests that invasive assessment of microvascular resistance and vasoreactivity in selected patients is feasible even in non-tertiary cardiology services equipped with cardiac catheterisation facilities, and that it is a high-yield investigation that frequently influences future investigative and therapeutic decisions.Conflict of InterestNone

The primary study aim was to determine whether ischemia-modified albumin (IMA) predicts adverse outcome in patients attending the emergency department (ED) with acute chest pain. Ischemia-modified albumin is a sensitive marker of myocardial ischemia. However, little is known about its ability to predict outcome in patients presenting to the ED with acute chest pain. We prospectively studied 207 patients who presented to the ED with acute chest pain suggestive of acute coronary syndrome within 3 h of the onset of symptoms. Blood samples for IMA assessment were obtained on admission. We evaluated a 30-day combined end point (cardiac death, myocardial infarction, recurrent angina) and 1-year all-cause mortality. A total of 31 (15%) patients experienced the 30-day composite end point and 16 patients (7.7%) died during the 1-year follow-up. Short-term combined end point (9.6% vs 20.4%, P = 0.03) and 1-year mortality rate (11.7% vs 3.8%, log rank 3.978, P = 0.046) were significantly higher in patients with IMA levels >93.3 U/ml compared to patients with lower IMA. On multivariate analysis, IMA remained an independent predictor of both 30-day combined end point (odds ratio 1.04, 95% confidence interval [CI] 1.01–1.07, P = 0.01) and 1-year mortality (hazard ratio 1.038, 95% CI 1.006–1.070, P = 0.018). Ischemia-modified albumin is an independent predictor of short-and long-term adverse outcomes in patients presenting to the ED with typical acute chest pain.

IntroductionAnalyse whether Heartflow (HF) has decreased downstream testing in our hospital compared to our previous standard practice based on CADRADS/NICE guidance, along with accuracy of CTFFR compared to invasive pressure wire study( FFR).MethodsRetrospective analysis of 184 patients with new onset stable chest pain undergone CTFFR (CADRADS 3-5) from September 2021- June 2023.CTFFR accuracy results were evaluated by comparing them with invasive FFR (FFR<0.80).ResultsDownstream testsHF positive (n=46): 5 invasive diagnostic angiography (ICA),31 percutaneous coronary intervention( PCI) ,3 awaiting ICA, 2 stress CMRI ,1 stress echo, 2 awaiting stress CMRI and 2/46(4.3%) had no further tests.HF indeterminate(n=30): 4 ICA,9 had PCI, 3 stress echo, 1 exercise tolerance test(ETT), 2 awaiting ICA, 1 awaiting CMRI and 10/30 (33.3%) had no further tests.HF negative(n=108): 7 ICA , 5 had PCI , 3 awaiting ICA, 3 stress CMRI , 1 stress echo, 1 ETT ,1 MPS, 1 awaiting stress CMRI, 3 awaiting echo and 83/108(76%) had no further tests.CTFFR VS FFR: 31/184(16%) patients had subsequent Invasive FFR, 26/31(83%) FFR was equivalent to the CTFFR and 5/31(16%) invasive FFR was different to the CTFFR(3 CTFFR were positive while invasive FFR was negative and 2 CTFFR were negative while invasive FFR was positive).ConclusionHF has significantly reduced our need for downstream testing in the CTCA population. A total of 76% of patients in HF negative group did not have any further tests.In addition, there was high sensitivity of CTFFR when compared to invasive FFR.

IntroductionTo describe ANP role within current CTCA service, including administering beta-blockade, and future progression to ANP-led CTCA listsMethodsOur CTCA service started in 2015 with a Cardiologist/Radiologist, 2 radiographers and 1 ANP per list, and expanded with updated stable chest pain NICE guideline (CG95) 2016. At CTCA the ANP administers rate control up to a total of 50mg IV Metoprolol and GTN. We formally agreed a betablockade protocol and referrals detail drug suitability. The ANP has access to patient notes and collaborative decision-making support within the team. The ANP must have Advanced Life Support Provider qualification to support lists. The ANP role also includes history taking, diagnosis and treatment of patients with potential cardiac disease including patients with chest pain. ANPs request investigations and prescribe pre-procedural rate control medication. ANPs interpret reported findings and commence appropriate treatment. Satisfaction questionnaires were obtained from patients alongside regular audit of CTCA service. Standardisation of the service was met with clear pharmaceutical protocols and referral guidelines.ResultsData from local audit has highlighted positive CTCA outcomes and high level of patient satisfaction. This supported expansion of the service, including team, lists and advancing technologies. The ANP-led service has freed up consultant time for reporting.ConclusionANP-led patient care and drug administration at CTCA improves continuity of care for patients, provides efficient team structure for supporting cardiac imaging and facilitates consultant reporting time. Fully ANP-led lists with our new scanners in 2024 should reduce ongoing service costs and further increase consultant reporting time.

IntroductionNICE Guidance (CG95 and MTG32) recommends FFR-CT for the investigation of stable angina. It acts as a gatekeeper to reduce the number of patients from undergoing potentially unnecessary invasive coronary angiography(ICA) and intervention(PCI) even in the presence of moderate or significant anatomical disease but normal FFRCT value.AimAnalyse whether Heartflow (HF)has decreased downstream testing in our hospital compared to our previous standard practice based on CADRADS/NICE guidance.Additionally, we looked at the ability of CTFFR in the CADRADS 3 group in predicting future events along with accuracy of CTFFR compared to invasive FFR or other functional tests.MethodsRetrospective analysis of 117 consecutive patients with suspected symptomatic coronary artery disease undergoing CT FFR from September 2021- December 2022.Follow up data included down streaming tests in all groups and calculation of major adverse cardiovascular and cerebrovascular events ( stroke, fatal or nonfatal myocardial infarction, cardiovascular death) and revascularization (PCI or CABG) in the CADRADS 3 patient group.Diagnostic accuracy of CTFFR results were evaluated by comparing them with invasive pressure wire study (PWS) (FFR<0.80) or indirectly by functional testingResultsAmong 117 cases sent for Heart flow, 114 patients were in CAD RADS 3-5 and 3 patients in CAD RADS 2.Downstream tests: Invasive FFR/ angiography and non-invasive testingCADRADS 4/5 group:Heart flow positive (n=29): 28/29 (96%) patients either undergone or currently awaiting ICA+/-PCI , 1 patient had negative stress CMRI.Heart flow indeterminate (n=5): 2 patient had ICA only, 2 had stress echo and 1 patient had negative exercise tolerance test.Heart flow negative (n=16): 6/16 (37%) patients either undergone or currently awaiting ICA+/-PCI, 1/16 patient had negative stress CMRI and 9/16(56%) patients did not have any further downstream tests.CADRADS 3 group:Heart flow positive(n=7): 5/7 (71%) patients had ICA +/-PCI procedure, 1/7 (14%) had stress CMRI and 1/7 (14%) did not have any further testing based on symptoms.Indeterminate group(n=8): 4/8 (50%) patients had ICA+/- PCI and 4/8 (50%) patients did not have any further tests after symptom review.Heart flow negative (n=49): 3/49(6.1%) patients either undergone or currently awaiting ICA+/-PCI, 4/49 (8%) patient had functional tests and 42/49 (85%) patients did not have any further testsCTFFR VS FFR13/117(11%) patients had subsequent PWS with adenosine.10/13(78%) patient FFR was similar to CTFFR and 3 /13 (22%)FFR was different reading than CTFFR.36/117 (30%) patients had down stream testing of either CMRI, MPS, ETT, angiogram or direct stenting to corresponding vessel, all 36/36 (100%) was correlated to CTFFR measures reading. Combining accuracy of CTFFR compare to both invasive FFR and functional tests was 46/49 (94%).Major adverse cardiovascular event in CADRADS 3 groupNo MACCE event reported for up to 16 months follow up in this group.ConclusionHeartflow has significantly reduced our need for downstream testing in the CTCA population. Of the CTFFR negative group, 51/117 (43%) of patients did not need any further tests who would have previously needed further testing when CT FFR was previously unavailable.In addition, there was high sensitivity of CTFFR when compared to either pressure wire study or functional ischemia testing. In short term follow up, none of the patients in the CADRADS 3 group had any MACCE.Abstract 187 Figure 1Flow chart of CTFFR negative patients in all CADRADS groups(3-5) with down streaming tests vs no further testsAbstract 187 Table 1Down streaming tests distribution among different CADRADS category, functional tests includes stress CMRI, stress ECHO, MPS and ETT CADRADS group Functional tests Invasive coronary angiogram/PCI No further test CADRADS 4/5 negative (n=16)169Indeterminate (n5)320Positive(n29)1280CADRADS 3 negative (n49)4342Indeterminate (n=8)044Positive (n=7)151Conflict of Interestnone

A 44-year-old woman with known trichorhinophalangeal syndrome presented with an unheralded out of hospital cardiac arrest. Transthoracic echocardiography showed severe left ventricular systolic dysfunction with an ejection fraction <25% and cardiac MRI confirmed a diagnosis of congenital non-ischaemic dilated cardiomyopathy. The case highlights a very rare syndrome, it is previously unknown association with dilated cardiomyopathy and the possible benefit of cardiac screening for patients with known trichorhinophalangeal syndrome.

Background: Ischemia-modified albumin (IMA) is a new marker of myocardial ischemia, there is concern that IMA concentrations may be affected by ischemia occurring in tissues other than the myocardium. Methods: We assessed 23 consecutive patients (15 males; mean age, 67 years) with typical leg claudication and documented peripheral vascular disease (PVD). All patients underwent both treadmill-exercise stress testing to induce leg ischemia and dobutamine stress echocardiography 1 week apart for the assessment of myocardial ischemia. Blood samples for IMA measurements were obtained at baseline, immediately after peak exercise/stress, and 1 h after exercise/stress. Statistical analysis was performed with the ANOVA repeated-measures test. Results: Compared with baseline, mean (SD) IMA was significantly lower after the induction of skeletal muscle ischemia and returned to baseline values at 1 h: baseline, 74.6 (15.6) kilounits/L; peak stress, 69.5 (14.0) kilounits/L (P <0.0001 vs baseline); 1 h after stress, 75.9 (15.7) kilounits/L (P <0.0001 vs peak stress; P = 0.3 vs baseline). Baseline, peak stress, and 1-h poststress IMA concentrations were inversely correlated with the ankle-brachial index after exercise (r = −0.4; P <0.05). None of the patients showed regional wall motion abnormalities during dobutamine stress echocardiography, and IMA concentrations remained unchanged from baseline. There were no differences in baseline [74.6 (15.6) vs 72.7 (11.5) kilounits/L; P = 0.6], peak stress, or poststress IMA concentrations when exercise testing and dobutamine stress echocardiography values were compared. Conclusions: The relationship between disease severity (of a noncardiac origin) and baseline IMA values is an important and novel finding. IMA is significantly lower immediately after exercise-induced leg ischemia in patients with PVD and is related to disease severity. IMA concentrations can therefore be affected by the development of skeletal muscle ischemia, and this may have implications regarding the ability of IMA to detect myocardial ischemia in PVD patients.