Atypical chest pain in diabetic patients with suspected stable angina: impact on diagnosis and coronary outcomes

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Atypical chest pain in diabetic patients with suspected stable angina: impact on diagnosis and coronary outcomes"

Transcription

1 European Heart Journal Quality of Care and Clinical Outcomes (2015) 1, doi: /ehjqcco/qcv003 CLINICAL RESEARCH Atypical chest pain in diabetic patients with suspected stable angina: impact on diagnosis and coronary outcomes Cornelia Junghans 1, Neha Sekhri 2, M. Justin Zaman 3, Harry Hemingway 1,4, Gene S. Feder 5, and Adam Timmis 6 * 1 Department of Epidemiology and Public Health, University College London, London, UK; 2 Barts Health, London Chest Hospital, London, UK; 3 James Paget University Hospital, Norfolk NR31 6LA, UK; 4 FarrInstitute of Health Informatics Researchat London, London, UK; 5 Centrefor Academic Primary Care,School of Social and Community Medicine, Universityof Bristol, Bristol, UK; and 6 Dept Cardiology, Barts Heart Centre, Queen Mary University London, West Smithfield, London EC1A 7BE, UK Received 30 March 2015; accepted 1 April 2015; online publish-ahead-of-print 12 June 2015 Aims Silent myocardial ischaemia occurs commonly in diabetes. Whether altered perception of ischaemia also predisposes to atypical presentations with under-diagnosis of coronary disease is not known. To determine whether (i) patients with diabetes diagnosed with angina are more likely to report atypical symptoms compared with patients without diabetes, and (ii) atypical symptoms in patients with diabetes cause angina to go unrecognized, increasing the risk of coronary events.... Methods Prospective, multicentre cohort study of 8662 ambulatory patients with suspected angina, of whom 906 had diabetes. and results We recorded detailed chest pain descriptors and fatal and non-fatal coronary events over a median of 3.08 years of follow-up. Proportionately more patients with than without diabetes received a diagnosis of angina (42.7 vs. 25.1%). Among patients with diabetes diagnosed with angina, a greater proportion had atypical chest pain compared with patients without diabetes (21.0 vs. 11.3%), but the hazard of fatal and non-fatal coronary events was similar. However, among patients diagnosed with non-cardiac chest pain, those with diabetes most of whom had atypical symptoms remained at greater risk of coronary events [2.29 (95% CI 1.54, 3.41)] and all-cause mortality [1.67 (95% confidence interval, CI 1.04, 2.69)] compared with non-diabetic patients.... Conclusion Patients with diabetes and atypical symptoms are nearly twice as likely to be diagnosed with angina compared with nondiabetic patients. Those diagnosed with non-cardiac pain are at increased risk of coronary events. Our study emphasizes the need for more intensive investigation of diabetic patients with chest pain, particularly those presenting with atypical symptoms Keywords Diabetes Angina Silent ischaemia Prognosis Introduction The clinical history is the cornerstone of diagnosis in patients presenting with stable chest pain, symptoms that are typical in terms of character, location, and relation to exertion permitting a reliable diagnosis of stable angina in the majority of cases. 1 3 In patients with diabetes, however, there is evidence that ischaemia may be painless, or experienced atypically due to autonomic neuropathy affecting the sensory innervation of the heart. 4 6 The clinical implications of altered pain perception in diabetic coronary disease remain uncertain and while some investigators have reported that atypical or silent presentations are more frequent in diabetic patients with acute myocardial infarction, 7 15 others have found no differences compared with non-diabetic patients Studies in stable coronary disease have been more consistent in showing that patients with diabetes have a higher prevalence of silent ischaemia compared with those without, 10,22,23 but it is not known whether atypical angina presentations are also more common as there have been no large cohort studies comparing chest pain descriptors in patients with and without diabetes. The question is important for two reasons, * Corresponding author. Tel: , Published on behalf of the European Society of Cardiology. All rights reserved. & The Author For permissions please

2 38 C. Junghans et al. first because misinterpretation of atypical chest pain may cause angina to go unrecognized with adverse prognostic consequences and second because recent guidelines on stable chest pain and coronary disease cite no evidence on typicality of symptoms in patients with diabetes and present no guidance for physicians as to whether this should influence investigational or diagnostic strategy. In the present study, we have examined the symptomatic presentation of a large cohort of patients with incident chest pain referred for cardiological assessment to test (i) whether patients with diabetes diagnosed with angina are more likely to report atypical symptoms compared with patients without diabetes, and (ii) whether atypical symptoms in patients with diabetes that cause angina to go unrecognized are associated with an increased risk of non-fatal and fatal coronary events. Methods Population Ten thousand five hundred and eighty six consecutive patients were recruited in six rapid access chest pain clinics from January 1996 to December 2002, mostly within 48 h after referral from primary care with new-onset chest pain. Details of the cohort have been reported previously. 28 We included only appropriate referrals (patients with no previous history of chest pain or documented IHD) (n ¼ ), those with a presentation of stable chest pain with a recorded diagnosis and follow-up data and complete clinical or demographic details (see Figure 1 for selection criteria), leaving 8662 patients for analysis. Baseline characteristics Diabetes was recorded in patients on insulin or oral hypoglycaemic drugs and included both type I and type II diabetes. The clinician assessing the patient in the clinic ascribed ethnicity as Asian, White, Black, or Other during the consultation. Asian included patients of Indian, Pakistani, Sri Lankan, and Bangladeshi origin, usually referred to as South Asian. Data on smoking status, history of hypertension, diabetes, and ECG results were recorded by the treating physician. Classification of chest pain The physician made an overall assessment of symptoms as typical or atypical, and entered a diagnosis of angina or non-cardiac chest pain at the end of the consultation. We used the physician assessment of chest pain typicality in our primary analysis but in a separate analysis, to exclude the possibility of selection bias, we made an objective assessment of chest pain typicality using modified Diamond Forrester criteria 29 where features of typical cardiac chest pain, recorded during the consultation from a dropdown menu (see Table 2), were defined as (i) constricting quality, (ii) central or left-side location, (iii) 15 min duration, and (iv) provocation by exercise. Atypical pain was defined as 2 of these features. Figure 1 Flowchart of patients included in the analysis.

3 Table 1 Baseline characteristics in diabetics and non-diabetics Demographic and clinical Non-diabetic patients Diabetic patients characteristics Atypical Typical P for Total Atypical Typical P for Total (n ) (n ) difference (n ) (n 5 582) (n 5 324) difference (n 5 906)... Median age in years (IQR) 51 (42 51) 59 (50 68) 53 (44 63) 56 (47 56) 61 (63 59) 58 (49 67) Female gender 2780 (48.2%) 918 (46.2%) (47.7%) 272 (46.9%) 154 (47.5%) (47.1%) South Asian ethnicity 1441 (25.0%) 343 (17.2%) 1784 (23.0%) 296 (50.9%) 137 (42.3%) (47.8%) Risk factors Current smoker 1397 (24.2%) 534 (26.9%) (24.9%) 99 (17.0%) 45 (14.9%) (15.9%) Hypertension 1706 (29.9%) 792 (38.8%) 2498 (32.2%) 312 (53.6%) 191 (58.9%) (55.5%) Hypercholesterolaemia 935 (16.2%) 491 (24.7%) 1426 (18.4%) 183 (31.4%) 116 (35.8%) (33.0%)... Clinical characteristics Mean pulse rate (+SD) 76.5 (+0.15) 76.2 (+0.27) (+11.7) 79.5 (+0.52) 77.4 (+0.65) (+12.2) Mean SBP (+SD) 138 (+0.26) 145 (+0.48) 140 (+20.6) 143 (+0.89) 147 (+1.12) (+21.1) Mean DBP (+SD) 85 (+0.15) 87 (+0.26) 85 (+11.5) 86 (+0.48) 85 (+0.65) (+11.6)... Exercise ECG Test done 3014 (52.3%) 1452 (73.0%) 4466 (57.6%) 333 (57.2%) 216 (66.6%) (60.6%) Test +ve for ischaemia 274 (9.1%) 471 (32.4%) 745 (16.8%) 47 (14.1%) 92 (42.6%) 139 (25.3%)... Diagnosis Non-cardiac chest pain 5117 (88.7%) 689 (34.6%) 5806 (74.9%) 460 (79.0%) 59 (18.2%) 519 (57.3%) Angina 650 (11.3%) 1300 (65.4%) 1950 (25.1%) 122 (21.0%) 265 (81.8%) 387 (42.7%) Atypical chest pain in diabetes 39

4 40 C. Junghans et al. Table 2 Chest pain characteristics in diabetics and non-diabetics Non-diabetics (n ) Diabetics (n 5 906) P for difference History of chest pain weeks 3690 (47.6%) 463 (51.1%).1 month and, 6 months 3050 (39.9%) 345 (38.0%).6 months and,12 months 1016 (13.1%) 98 (10.8%) Location of chest pain 0.26 Central 4078 (52.6%) 495 (54.6%) Left sided 2366 (30.5%) 277 (30.6%) Right sided 234 (3.0%) 33 (3.6%) Sub-mammary 556 (7.2%) 49 (5.4%) Epigastric 509 (6.6%) 51 (5.6%) Other 13 (0%) 1 (0%) Radiation of chest pain None 4849 (62.5%) 504 (55.6%) Left arm/shoulder 1856 (23.9%) 244 (26.9%) Right arm/shoulder 161 (2.1%) 25 (2.8%) Throat/jaw 462 (6.0%) 65 (7.2%) Back 405 (5.2%) 62 (6.8%) Other 23 (0.3%) 6 (0.7%) Chest pain trigger Nothing 4417 (57.0%) 433 (47.8%) Exercise 1948 (25.1%) 312 (34.4%) Exercise and rest 898 (11.6%) 127 (14.0%) Stress 283 (3.7%) 14 (1.6%) Eating 196 (2.5%) 20 (2.2%) Other 14 (0.2%) 0 (0%) Quality of chest pain Aching 2906 (37.5%) 293 (32.3%) Stabbing 1801 (23.2%) 166 (18.3%) Constricting 2054 (26.5%) 319 (35.2%) Nondescript 995 (12.8%) 128 (14.1%) CP duration Seconds 504 (6.5%) 47 (5.2%),5 min 1484 (19.1%) 181 (20.0%) 5 15 min 1844 (23.8%) 276 (30.5%) min 787 (10.2%) 104 (11.5%) Hours/variable 3137 (40.5%) 298 (32.9%) Associated symptoms None 5177 (66.8%) 556 (61.4%) SOB 2002 (25.8%) 287 (31.7%) Dizziness 111 (1.4%) 15 (1.7%) Palpitations 287 (3.7%) 26 (2.9%) Other 159 (2.0%) 21 (2.3%).1 Symptom 20 (0.3%) 1 (0.1%) Follow-up and outcomes Patients were flaggedfor mortalitywiththeofficefornational Statistics and for hospital admissions and procedures with the Secondary User Service. Successful matching was achieved in 99.5% of the cohort. The coronary outcome was a composite endpoint of death due to coronary heart disease (International Classification of Diseases-10 codes I20 I25) or nonfatal acute coronary syndrome [non-fatal myocardial infarction (I21 I23), unstable angina (I24)], with mean follow-up of 3.12 years (SD 1.62).

5 Atypical chest pain in diabetes 41 Statistical analysis Forthe comparison of baseline characteristics, continuous variables were presented as a median with inter-quartile range or mean with standard deviation and compared using Student s t-test. Proportions were compared using the c-statistic. To examine the probability of receiving a diagnosis of angina according to physician assessment, odds ratios with 95% confidence intervals by diabetic status were calculated. To examine the prognostic validity of physician assessment on coronary outcome, we used Cox proportional hazards regression, adjusting for age, sex, ethnicity, hypertension, and hypercholesterolemia. We used the computer-generated classification of typicality based on the Diamond Forrester algorithm in sensitivity analyses. Stata 8 (version 8.2, StataCorp, College Station, TX, USA) was used for all analyses in this study. We compared physician-defined and algorithm-defined chest pain classification using the kappa statistic. Results Demographic and clinical characteristics Of the 8662 patients with suspected angina, 906 (10.5%) had diabetes. Patients with diabetes were older and a higher proportion had prior hypertension and hypercholesterolaemia, but fewer were current smokers (Table 1). The frequency of exercise stress testing was comparable in patients with and without diabetes (60.6 vs. 57.6%), but positive test results were more common in patients with diabetes whether chest pain was recorded as typical (42.6 vs. 32.4%) or atypical (14.1 vs. 9.1%). Proportionately more patients with than without diabetes received a diagnosis of angina (42.7 vs. 25.1%). Chest pain characteristics and diabetes Across the whole cohort of 8662 patients, there was 86.4% agreement (kappa 0.64) between chest pain typicality recorded by the clinic physician and chest pain typicality derived by applying the Diamond Forrester criteria. Using the assessment of the clinic physician, chest pain was recorded as typical in a greater proportion of patients with than without diabetes (34.3 vs. 21.5%). This was reflected in the chest pain descriptors recorded at the consultation, patients with diabetes being more likely to report chest pain as constricting and occurring in response to exertion with radiation to arms, neck, throat, or jaw (Table 2). However, among patients with diabetes diagnosed with angina, a greater proportion had atypical symptoms, compared with patients without diabetes (21.0 vs. 11.3%) (Table 1). Prognosis Mean follow-up was years. The cumulative probability of coronary events (Figure 2) was higher in patients with typical symptoms, with little difference in the hazard of coronary events between patients with [hazards ratio, HR 3.89 (95% confidence interval, CI 2.92, 5.18)] and without [HR 2.78 (95% CI 2.31, 3.35)] diabetes (Table 3). Among patients diagnosed with angina, diabetic status and typicality of symptoms had no significant effect on the hazard of coronary events or all-cause mortality (Table 3). However, among patients diagnosed with non-cardiac chest pain, those with diabetes most of whom had atypical symptoms remained at significantly greater risk of coronary events [2.29 (95% CI 1.54, 3.41)] Figure 2 Kaplan Meier survival curves showing the effect of symptom typicality and diabetic status on cumulative probability of non-fatal acute coronary syndromes and coronary death. and all-cause mortality [1.67 (95% CI 1.04, 2.69)] compared with non-diabetic patients. Discussion Main findings This is the first large cohort comparison of the relation between diabetes, chest pain characteristics, and clinical outcomes in patients presenting for cardiological assessment of suspected angina. Atypical presenting symptoms were recorded twice as frequently in diabetic patients diagnosed with angina compared with non-diabetic patients but were associated with a risk of coronary events similar to patients with typical symptoms. Atypical symptoms that caused angina to go unrecognized in patients with diabetes, leading to a diagnosis of noncardiac chest pain, were associated with an increased risk of non-fatal and fatal coronary events. Context Evidence for altered perception of ischaemic cardiac pain in people with diabetes is based largely on reports that symptoms of myocardial ischaemia and infarction are more commonly not experienced or not recognized compared with people without diabetes. 6 14,21,22 In some studies, this has been related to diabetic autonomic neuropathy affecting the sensory innervation of the heart, and there is further evidence that neuropathy might influence pain thresholds. 4 6 However, there is no evidence that autonomic neuropathy affects the quality of chest pain and its relation to exertion in other respects. The belief that atypical presentations are common in patients with diabetes with suspected angina is largely based on collective clinical experience now enshrined in medical textbooks and websites. 30,31 Clinical implications Our study validates the perception that atypical presentations of angina are more common in diabetes and merit more aggressive investigation than in patients with atypical symptoms who do not have diabetes. Patients with diabetes and atypical symptoms had a somewhat higher frequency of exercise electrocardiography and

6 42 C. Junghans et al. Table 3 Hazard ratios (95% CI) for typical versus non-typical symptoms in prediction of coronary events (coronary heart disease death or non-fatal acute coronary syndrome) and all-cause mortality All patients (n ) Patients diagnosed with Patients diagnosed with angina (n ) non-cardiac chest pain (n )... n/n HR a (95% CI) P HR a (95% CI) P HR a (95% CI) P Coronary events (n ¼ 598) Atypical non-diabetics 222/ (reference) 1 (reference) (reference) Typical diabetics 66/ (2.92, 5.18) 1.38 (0.99, 1.92) 2.26 (0.92, 5.60) Typical non-diabetics 256/ (2.31, 3.35) 1.11 (0.88, 1.40) 1.52 (1.02, 2.27) Atypical diabetics 53/ (1.42, 2.63) 0.91 (0.54, 1.53) 2.29 (1.54, 3.41) Death all causes (n ¼ 350) Atypical non-diabetics 180/ (reference) 1 (reference) (reference) Typical diabetics 28/ (1.16, 2.62) 1.22 (0.73, 2.02) 2.35 (0.86, 6.42) Typical non-diabetics 111/ (0.87, 1.41) 0.98 (0.69, 1.39) 0.47 (0.25, 0.90) Atypical diabetics 31/ (1.03, 2.27) 1.19 (0.58, 2.45) 1.67 (1.04, 2.69) a Adjusted for age, sex, ethnicity, hypertension, and hypercholesterolemia. positive tests compared with patients without diabetes, and this may have contributed to their over-representation among patients diagnosed with angina. However, differences in non-invasive testing were small and other factors must also have contributed, notably awareness by physicians of the increased risk of coronary disease in patients with diabetes and an intuitive lowering of diagnostic thresholds to include more with atypical symptoms among those diagnosed with angina. The outcome data provide evidence that the diagnostic decisions made by physicians were appropriate by showing similar hazards of non-fatal and fatal coronary events for diabetic and non-diabetic patients diagnosed with angina, regardless of the typicality of symptoms. However, the outcome data also showed that among patients diagnosed with non-cardiac chest pain, hazards were significantly higher in patients with diabetes, and the opportunity to treat this high-risk group when they present with atypical symptoms should not be missed. There may be a need, therefore, for further lowering of diagnostic thresholds and for more intensive investigation of patients with diabetes presenting with atypical symptoms, recent studies confirming the value of non-invasive testing for identifying high-risk patients who present in this way. 32,33 Implications for guidelines and future research Quantitative analysis of the probability of coronary disease in patients presenting with chest pain is recommended in guidelines for decisions about non-invasive investigation, but some widely used algorithms take no account of diabetes in their probability estimates. Our data illustrate the importance of modifying these estimates to take account of the heightened risk in patients with diabetes and other risk factors. Our data also indicate a need for further research into the extended cardiovascular risks associated with diabetes, recent work using linked primary care and disease registries showing considerable heterogeneity, the heightened risk of coronary disease contrasting with the protection against aneurysmal disease. 34 Strengths and limitations Strengths of this study were the contemporaneous recording of detailed chest pain descriptors in a large cohort of patients with recent onset symptoms and the linked coronary outcomes. The baseline data collection and follow-up for this analysis were completed 7 years ago, but this is unlikely to have affected our main findings relating to typicality of symptoms, diagnosis of angina, and coronary outcomes in patients with diabetes. Angina is a clinical diagnosis and in our study was validated by the coronary outcome data, not always by anatomical or functional testing. Diabetes was defined only by treatment being received at the time of the consultation without additional tests. Although south Asian ethnicity was more common among patients with diabetes, we have previously reported that angina does not present atypically in this group, and in the present study, there is no interaction of ethnicity with diabetes status in its relation with atypical presentations. 35 Conclusions In a large cohort of patients with undifferentiated chest pain, atypical symptoms were more likely to be a manifestation of angina in patients with diabetes. Clinicians lowered diagnostic thresholds in these patients, but this was not sufficient to capture all those at risk, as reflected by the adverse outcomes in diabetic patients diagnosed with non-cardiac chest pain. Our study emphasizes the need for more intensive investigation of diabetic patients with chest pain, particularly those presenting with atypical symptoms. Funding A.T. acknowledges support of Barts Cardiovascular Biomedical Research Unit, funded by the National Institute for Health Research. The study was funded by the National Health Service s Service Delivery and Organisation research and development programme. Conflict of interest: none declared.

7 Atypical chest pain in diabetes 43 References 1. Diamond GA. A clinically relevant classification of chest discomfort. J Am Coll Cardiol 1983;1(2 Pt 1): Pryor DB, Shaw L, McCants CB, Lee KL, Mark DB, Harrell FE Jr, Muhlbaier LH, Califf RM. Value of the history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med 1993;118: Constant J. The clinical diagnosis of nonanginal chest pain: the differentiation of angina from nonanginal chest pain by history. Clin Cardiol 1983;6: Umachandran V, Ranjadayalan K, Ambepityia G, Marchant B, Kopelman PG, Timmis AD. The perception of angina in diabetes: relation to somatic pain threshold and autonomic function. Am Heart J 1991;121: Marchant B, Umachandran V, Stevenson R, Kopelman PG, Timmis AD. Silent myocardial ischemia: roleof subclinical neuropathyin patients with and without diabetes. J Am Coll Cardiol 1993;22: Ambepityia G, Kopelman PG, Ingram D, Swash M, Mills PG, Timmis AD. Exertional myocardial ischemia in diabetes: a quantitative analysis of anginal perceptual threshold and the influence of autonomic function. J Am Coll Cardiol 1990;15: Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, Frederick PD, Lambrew CT et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. J Am Med Assoc 2000;283: Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. Am Heart J 2002;144: Davis TM, Fortun P, Mulder J, Davis WA, Bruce DG. Silent myocardial infarction and itsprognosis inacommunity-based cohort of Type2diabetic patients: the Fremantle Diabetes Study. Diabetologia 2004;47: DeLuca AJ, Kaplan S, Aronow WS, Sandhu R, Butt A, Akoybyan A, Weiss MB. Comparison of prevalence of unrecognized myocardialinfarction andof silentmyocardial ischemia detected by atreadmill exercise sestamibi stress test in patients with versus without diabetes mellitus. Am J Cardiol 2006;98: Kwong RY, Sattar H, Wu H, Vorobiof G, Gandla V, Steel K, Siu S, Brown KA. Incidence and prognostic implication of unrecognized myocardial scar characterized by cardiac magnetic resonance in diabetic patients without clinical evidence of myocardial infarction. Circulation 2008;118: Omerovic E, Brohall G, Muller M, Ramunddal T, Matejka G, Waagstein F et al. Silent myocardial infarction in women with type II diabetes mellitus and microalbuminuria. Ther Clin Risk Manag 2008;4: Meijs MF, Bots ML, Cramer MJ, Vonken EJ, Velthuis BK, van der Graaf Y, Visseren FL, Mali WP, Doevendans PA; SMART Study group. Unrecognised myocardial infarction insubjectsat highvascular risk:prevalence anddeterminants. Heart2009;95: Hasin T, Hochadel M, Gitt AK, Behar S, Bueno H, Hasin Y. Comparison of treatment and outcome of acute coronary syndrome in patients with versus patients without diabetes mellitus. Am J Cardiol 2009;103: Kirchberger I, Heier M, Kuch B, Wende R, Meisinger C. Sex differences in patientreported symptoms associated with myocardial infarction (from the populationbased MONICA? KORA Myocardial Infarction Registry). Am J Cardiol 2011;107: Richman PB, Brogan GX Jr, Nashed AN, Thode HC Jr. Clinical characteristics of diabetic vs nondiabetic patients who rule-in for acute myocardial infarction. Acad Emerg Med 1999;6: FunkM, NaumJB, MilnerKA, Chyun D. Presentation andsymptompredictorsofcoronary heart disease in patients with and without diabetes. Am J Emerg Med 2001;19: Kentsch M, Rodemerk U, Gitt AK, Schiele R, Wienbergen H, Schubert J et al. Angina intensity is not different in diabetic and non-diabetic patients with acute myocardial infarction. Z Kardiol 2003;92: Falcone C, Nespoli L, Geroldi D, Gazzaruso C, Buzzi MP, Auguadro C et al. Silent myocardial ischemia in diabetic and nondiabetic patients with coronary artery disease. Int J Cardiol 2003;90: Thuresson M, Jarlov MB, Lindahl B, Svensson L, Zedigh C, Herlitz J. Symptoms and type of symptom onset in acute coronary syndrome in relation to ST elevation, sex, age, and a history of diabetes. Am Heart J 2005;150: Angerud KH, Brulin C, Näslund U, Eliasson M. Patients with diabetes are not more likely to have atypical symptoms when seeking care of a first myocardial infarction. An analysis of 4028 patients in the Northern Sweden MONICA Study. Diabet Med 2012;29:e82 e Chiariello M, Indolfi C, Cotecchia MR, Sifola C, Romano M, Condorelli M. Asymptomatic transient changes during ambulatory ECG monitoring in diabetic patients. Am Heart J 1985;110: Nesto RW, Phillips RT, Kett KG, Hill T, Perper E, Young E, Leland OS Jr. Angina and exertional myocardial ischemia in diabetic and nondiabetic patients: assessment by exercise thallium scintigraphy. AnnInternMed1988; 108: Gibbons RJ, Abrams J, Chatterjee K, Daley J, DeedwaniaPC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O Rourke RA, Pasternak RC, Williams SV; American College of Cardiology; American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). ACC/AHA 2002 guideline update for the management of patients with chronic stable angina-summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). J Am Coll Cardiol 2003;41: Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F, Daly C, De Backer G, Hjemdahl P, Lopez-Sendon J, Marco J, Morais J, Pepper J, Sechtem U, Simoons M, Thygesen K, Priori SG, Blanc JJ, Budaj A, Camm J, Dean V, Deckers J, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo J, Zamorano JL; Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology; ESC Committee for Practice Guidelines (CPG). Guidelines on the management of stable angina pectoris: executive summary. Eur Heart J 2006;27: NICE. Chest pan of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. NICE guidelines [CG95]. (March 2010). 27. NICE. Management of stable angina. NICE guidelines [CG126]. org.uk/guidance/cg126 (July 2011). 28. Sekhri N, Feder GS, Junghans C, Hemingway H, Timmis AD. How effective are rapid access chest pain clinics? Prognosis of incident angina and non-cardiac chest pain in 8762 consecutive patients. Heart 2007;93: Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300: Wikipedia. Coronary ischemia. (19 March 2014). 31. Clark LT, McFarlane SI. Cardiovascular Disease and Diabetes. New York: McGraw-Hill Professional; ISBN , Fujimoto S, Kondo T, Kodama T, Orihara T, Sugiyama J, Kondo M, Endo A, Fukazawa H, Nagaoka H, Oida A, Ikeda T, Yamazaki J, Takase S, Narula J. Coronary computed tomography angiography-based coronary risk stratification in subjects presenting with no or atypical symptoms. Circ J 2012;76: Gheydari ME, Jamali M, Hajsheikholeslami F, Yazdani S, Jamali M. Value of exercise tolerance testing in evaluation of diabetic patients presenting with atypical chest discomfort. Int J Endocrinol Metab 2013;11: Shah AD, Langenberg C, Rapsomaniki E, Denaxas S, Pujades-Rodriguez M, Gale CP, Deanfield J, Smeeth L, Timmis A, Hemingway H. Type 2 diabetes and incidence of cardiovascular diseases: a cohort study in 1.9 million people. Lancet Diab Endocrinol 2015;3: Zaman MJ, Junghans C, Sekhri N, Chen R, Feder GS, Timmis AD et al. Presentation of stable angina pectoris among women and South Asian people. CMAJ 2008;179:

Myocardial ischaemia and angina in the early post-infarction period: a comparison with patients

Myocardial ischaemia and angina in the early post-infarction period: a comparison with patients 438 Department of Cardiology, London Chest Hospital B Marchant R Stevenson S Vaishnav A D Timmis Department of Cardiology, Newham General Hospital, London K Ranjadayalan Correspondence to: Dr Bradley Marchant,

More information

Diagnosis of CAD S Richard Underwood

Diagnosis of CAD S Richard Underwood Diagnosis of CAD S Richard Underwood Professor of Cardiac Imaging Royal Brompton Hospital & Imperial College Faculty of Medicine London, UK The history and diagnosis 89% Non-cardiac chest pain 50% Atypical

More information

Articles. Funding Medical Research Council, National Institute for Health Research, and Wellcome Trust.

Articles. Funding Medical Research Council, National Institute for Health Research, and Wellcome Trust. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1 5 million people Eleni Rapsomaniki, Adam Timmis, Julie George,

More information

Diagnostic Algorithms

Diagnostic Algorithms Diagnostic Algorithms Udo Sechtem Robert-Bosch-Krankenhaus Stuttgart Germany Montalescot G et al. ESC Guideline on the Management of Stable Coronary Artery Disease Eur Heart J. 2013;34:2949-3003. European

More information

exercise and the heart Clinical Utility of the Exercise ECG in Patients With Diabetes and Chest Pain*

exercise and the heart Clinical Utility of the Exercise ECG in Patients With Diabetes and Chest Pain* exercise and the heart Clinical Utility of the Exercise ECG in Patients With Diabetes and Chest Pain* David P. Lee, MD; William F. Fearon, MD; and Victor F. Froelicher, MD Objective: The purpose of this

More information

FFR-CT Not Ready for Primetime

FFR-CT Not Ready for Primetime FFR-CT Not Ready for Primetime Leslee J. Shaw, PhD, MASNC, FACC, FAHA, FSCCT R. Bruce Logue Professor of Medicine Co-Director, Emory Clinical CV Research Institute Emory University School of Medicine Atlanta,

More information

Imaging ischemic heart disease: role of SPECT and PET. Focus on Patients with Known CAD

Imaging ischemic heart disease: role of SPECT and PET. Focus on Patients with Known CAD Imaging ischemic heart disease: role of SPECT and PET. Focus on Patients with Known CAD Hein J. Verberne Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands International Conference

More information

Risk Stratification for CAD for the Primary Care Provider

Risk Stratification for CAD for the Primary Care Provider Risk Stratification for CAD for the Primary Care Provider Shimoli Shah MD Assistant Professor of Medicine Directory, Ambulatory Cardiology Clinic Knight Cardiovascular Institute Oregon Health & Sciences

More information

The ESC Registry on Chronic Ischemic Coronary Disease

The ESC Registry on Chronic Ischemic Coronary Disease EURObservational Research Programme The ESC Registry on Chronic Ischemic Coronary Disease Prof. Fausto J. Pinto, FESC, FACC, FASE, FSCAI Immediate Past-President, ESC University Hospital Sta Maria University

More information

Καηεσθσνηήριες οδηγίες για ηην εκηίμηζη και ηη διάγνωζη ηης ζηαθερής ζηηθάγτης

Καηεσθσνηήριες οδηγίες για ηην εκηίμηζη και ηη διάγνωζη ηης ζηαθερής ζηηθάγτης Καηεσθσνηήριες οδηγίες για ηην εκηίμηζη και ηη διάγνωζη ηης ζηαθερής ζηηθάγτης Francisco de Goya, 1820 Δημήηριος Ρίτηερ, MD, FESC, FAHA Διεσθσνηής Καρδιολογικής Κλινικής Εσρωκλινικής Αθηνών Angina: A diagnosis

More information

Management of ST-elevation myocardial infarction Update 2009 Late comers: which options?

Management of ST-elevation myocardial infarction Update 2009 Late comers: which options? European Society of Cardiology Annual Session 2009 Management of ST-elevation myocardial infarction Update 2009 Late comers: which options? Antonio Abbate, MD Assistant Professor of Medicine Virginia Commonwealth

More information

Παύλος Στουγιάννος. Καρδιολόγος ΓΝΑ «Η ΕΛΠΙΣ»

Παύλος Στουγιάννος. Καρδιολόγος ΓΝΑ «Η ΕΛΠΙΣ» Επεμβατική Καρδιολογία. STEMI. Σύγχρονη θεώρηση Παύλος Στουγιάννος Καρδιολόγος ΓΝΑ «Η ΕΛΠΙΣ» Criteria for acute myocardial infarction Thygesen K, et al. Third universal definition of myocardial infarction.

More information

Value of Exercise Treadmill Testing in Women

Value of Exercise Treadmill Testing in Women JACC Vol. 32, No. 6 November 15, 1998:1657 64 1657 MYOCARDIAL ISCHEMIA Value of Exercise Treadmill Testing in Women KAREN P. ALEXANDER, MD,* LESLEE J. SHAW, PHD, ELIZABETH R. DELONG, PHD, DANIEL B. MARK,

More information

PAINLESS MYOCARDIAL INFARCTION; Its frequency in patients of acute coronary syndrome.

PAINLESS MYOCARDIAL INFARCTION; Its frequency in patients of acute coronary syndrome. ; Its frequency in patients of acute coronary syndrome. Dr. Ijaz-Ul-Haque Taseer, Dr. Shahzad Alam Khan, Dr. Muhammad Imran Nazir, Mr. Sohail Safdar ORIGINAL PROF-2264 ABSTRACT... Objective: To determine

More information

They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see:

They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see: Assessment and immediate management of suspected acute coronary syndrome bring together everything NICE says on a topic in an interactive flowchart. are interactive and designed to be used online. They

More information

SUPPLEMENTAL MATERIAL. Supplemental Methods. Duke CAD Index

SUPPLEMENTAL MATERIAL. Supplemental Methods. Duke CAD Index SUPPLEMENTAL MATERIAL Supplemental Methods Duke CAD Index The Duke CAD index, originally developed by David F. Kong, is an angiographic score that hierarchically assigns prognostic weights (0-100) based

More information

Case Study 50 YEAR OLD MALE WITH UNSTABLE ANGINA

Case Study 50 YEAR OLD MALE WITH UNSTABLE ANGINA Case Study 50 YEAR OLD MALE WITH UNSTABLE ANGINA Case History A 50-year-old man with type 1 diabetes mellitus and hypertension presents after experiencing 1 hour of midsternal chest pain that began after

More information

Screening for Asymptomatic Coronary Artery Disease: When, How, and Why?

Screening for Asymptomatic Coronary Artery Disease: When, How, and Why? Screening for Asymptomatic Coronary Artery Disease: When, How, and Why? Joseph S. Terlato, MD FACC Clinical Assistant Professor, Brown Medical School Coastal Medical Definition The presence of objective

More information

Effect of upstream clopidogrel treatment in patients with ST-segment elevation myocardial infarction undergoing primary PCI

Effect of upstream clopidogrel treatment in patients with ST-segment elevation myocardial infarction undergoing primary PCI Effect of upstream clopidogrel treatment in patients with ST-segment elevation myocardial infarction undergoing primary PCI Dr Sasha Koul, MD Dept of Cardiology, Lund University Hospital, Lund, Sweden

More information

Proper risk stratification is critical for the management of

Proper risk stratification is critical for the management of Prediction of Death and Nonfatal Myocardial Infarction in High-Risk Patients: A Comparison Between the Duke Treadmill Score, Peak Exercise Radionuclide Angiography, and SPECT Perfusion Imaging Lawrence

More information

Topic. Updates on Definition of Myocardial Infarction

Topic. Updates on Definition of Myocardial Infarction Topic Updates on Definition of Myocardial Infarction In the past, general consensus for MI? Definition of MI by WHO - Combination of 2 of 3 characteristics - 1. Typical Symptoms 2. Enzyme Rise 3. Typical

More information

OP Chest Pain General Data Element List. All Records All Records. All Records All Records All Records. All Records. All Records.

OP Chest Pain General Data Element List. All Records All Records. All Records All Records All Records. All Records. All Records. Material inside brackets ([and]) is new to this Specifications Manual version. Hospital Outpatient Quality Measures Chest Pain (CP) Set Measure ID # OP-4 * OP-5 * Measure Short Name Aspirin at Arrival

More information

Reducing the Population Health Burden of Cardiovascular Disease

Reducing the Population Health Burden of Cardiovascular Disease Reducing the Population Health Burden of Cardiovascular Disease Joseph A. Ladapo, MD, PhD Assistant Professor of Medicine Department of Population Health NYU School of Medicine Disclosures: K23 HL116787

More information

This clinical study synopsis is provided in line with Boehringer Ingelheim s Policy on Transparency and Publication of Clinical Study Data.

This clinical study synopsis is provided in line with Boehringer Ingelheim s Policy on Transparency and Publication of Clinical Study Data. abcd Clinical Study Synopsis for Public Disclosure This clinical study synopsis is provided in line with s Policy on Transparency and Publication of Clinical Study Data. The synopsis which is part of the

More information

03/30/2016 DISCLOSURES TO OPERATE OR NOT THAT IS THE QUESTION CAROTID INTERVENTION IS INDICATED FOR ASYMPTOMATIC CAROTID OCCLUSIVE DISEASE

03/30/2016 DISCLOSURES TO OPERATE OR NOT THAT IS THE QUESTION CAROTID INTERVENTION IS INDICATED FOR ASYMPTOMATIC CAROTID OCCLUSIVE DISEASE CAROTID INTERVENTION IS INDICATED FOR ASYMPTOMATIC CAROTID OCCLUSIVE DISEASE Elizabeth L. Detschelt, M.D. Allegheny Health Network Vascular and Endovascular Symposium April 2, 2016 DISCLOSURES I have no

More information

Overview. Health and economic burden of coronary artery disease (CAD) Pitfalls in care of patients suspected of having CAD

Overview. Health and economic burden of coronary artery disease (CAD) Pitfalls in care of patients suspected of having CAD Quality Challenges and Pitfalls in the Evaluation of Patients with Suspected Heart Disease Joseph A. Ladapo, MD, PhD Assistant Professor of Medicine Department of Population Health NYU School of Medicine

More information

PRIORITIZING PATIENTS FOR CORONARY ANGIOGRAPHY USING SIMPLIFIED TREADMILL SCORE IN HIGH RISK ASIAN SUBJECTS IN SAUDI ARABIA

PRIORITIZING PATIENTS FOR CORONARY ANGIOGRAPHY USING SIMPLIFIED TREADMILL SCORE IN HIGH RISK ASIAN SUBJECTS IN SAUDI ARABIA PRIORITIZING PATIENTS FOR CORONARY ANGIOGRAPHY USING SIMPLIFIED TREADMILL SCORE IN HIGH RISK ASIAN SUBJECTS IN SAUDI ARABIA Syed Iftikhar Ali 1 ABSTRACT Objective: Our aim was to prioritize & identify

More information

Role of Myocardial Perfusion Imaging in the Cardiac Evaluation of Aviators

Role of Myocardial Perfusion Imaging in the Cardiac Evaluation of Aviators Original Research Role of Myocardial Perfusion Imaging in the Cardiac Evaluation of Aviators Anil Kumar AVS *, Kumar PG +, Prakash MS # ABSTRACT In an attempt to provide more accurate and inclusive information

More information

The use of Cardiac CT and MRI in Clinical Practice

The use of Cardiac CT and MRI in Clinical Practice The use of Cardiac CT and MRI in Clinical Practice Matthew W. Martinez, MD Assistant Professor of Medicine LVPG - Lehigh Valley Heart Specialists Lehigh Valley Health Network Oct. 3, 2009 DISCLOSURE Relevant

More information

The value of routine non-invasive tests to predict clinical outcome in stable angina

The value of routine non-invasive tests to predict clinical outcome in stable angina European Heart Journal (2003) 24, 532 540 The value of routine non-invasive tests to predict clinical outcome in stable angina C. Daly a*, J. Norrie b1, D.L. Murdoch c, I. Ford b1, H.J. Dargie d2, K. Fox

More information

High Sensitivity Troponin Improves Management. But Not Yet

High Sensitivity Troponin Improves Management. But Not Yet High Sensitivity Troponin Improves Management But Not Yet Allan S. Jaffe, MD.* Consultant - Cardiology & Laboratory Medicine Professor of Medicine Chair, CCLS Division, Department of Laboratory Medicine

More information

Hospital and 1-year outcome after acute myocardial infarction in patients with diabetes mellitus and hypertension

Hospital and 1-year outcome after acute myocardial infarction in patients with diabetes mellitus and hypertension (2003) 17, 665 670 & 2003 Nature Publishing Group All rights reserved 0950-9240/03 $25.00 www.nature.com/jhh ORIGINAL ARTICLE Hospital and 1-year outcome after acute myocardial infarction in patients with

More information

Optimal antiplatelet and anticoagulant therapy for patients treated in STEMI network

Optimal antiplatelet and anticoagulant therapy for patients treated in STEMI network Torino 6 Joint meeting with Mayo Clinic Great Innovation in Cardiology 14-15 Ottobre 2010 Optimal antiplatelet and anticoagulant therapy for patients treated in STEMI network Diego Ardissino Ischemic vs

More information

Exercise Test: Practice and Interpretation. Jidong Sung Division of Cardiology Samsung Medical Center Sungkyunkwan University School of Medicine

Exercise Test: Practice and Interpretation. Jidong Sung Division of Cardiology Samsung Medical Center Sungkyunkwan University School of Medicine Exercise Test: Practice and Interpretation Jidong Sung Division of Cardiology Samsung Medical Center Sungkyunkwan University School of Medicine 2 Aerobic capacity and survival Circulation 117:614, 2008

More information

A Randomized Comparison of Anatomic versus Functional Diagnostic Testing Strategies in Symptomatic Patients with Suspected Coronary Artery Disease

A Randomized Comparison of Anatomic versus Functional Diagnostic Testing Strategies in Symptomatic Patients with Suspected Coronary Artery Disease A Randomized Comparison of Anatomic versus Functional Diagnostic Testing Strategies in Symptomatic Patients with Suspected Coronary Artery Disease Pamela S. Douglas, Udo Hoffmann, Manesh R. Patel, Daniel

More information

The Final 10-Year Follow-up Results from the Bari Randomized Trial J Am Coll Cardiol (2007) 49;1600-6

The Final 10-Year Follow-up Results from the Bari Randomized Trial J Am Coll Cardiol (2007) 49;1600-6 The Final 10-Year Follow-up Results from the Bari Randomized Trial J Am Coll Cardiol (2007) 49;1600-6 n&list_uids=17433949 64-Multislice Detector Computed Tomography Coronary Angiography as Potential Alternative

More information

CLINICAL RESEARCH STUDY

CLINICAL RESEARCH STUDY CLINICAL RESEARCH STUDY Prevalence, Extent, and Independent Predictors of Silent Myocardial Infarction Nisha Arenja, MD, Christian Mueller, MD, Niklas F. Ehl, MD, Miriam Brinkert, MD, Katharina Roost,

More information

Journal of the American College of Cardiology Vol. 35, No. 5, by the American College of Cardiology ISSN /00/$20.

Journal of the American College of Cardiology Vol. 35, No. 5, by the American College of Cardiology ISSN /00/$20. Journal of the American College of Cardiology Vol. 35, No. 5, 2000 2000 by the American College of Cardiology ISSN 0735-1097/00/$20.00 Published by Elsevier Science Inc. PII S0735-1097(00)00546-5 CLINICAL

More information

Local Coverage Determination (LCD) for Cardiac Catheterization (L29090)

Local Coverage Determination (LCD) for Cardiac Catheterization (L29090) Local Coverage Determination (LCD) for Cardiac Catheterization (L29090) Contractor Information Contractor Name First Coast Service Options, Inc. Contractor Number 09102 Contractor Type MAC - Part B LCD

More information

DECLARATION OF CONFLICT OF INTEREST

DECLARATION OF CONFLICT OF INTEREST DECLARATION OF CONFLICT OF INTEREST F. Baborski 1, I. Scuric 1, D. Cerovec 1, M. Novoselec 1, V. Slivnjak 1, K. Fuckar 1, N. Lakusic 1, Z. Vajdic 2, R. Bernat 3, K. Kapov-Svilicic 3 (1) Special Hospital

More information

Preoperative tests (update)

Preoperative tests (update) National Institute for Health and Care Excellence. Preoperative tests (update) Routine preoperative tests for elective surgery NICE guideline NG45 Appendix C: April 2016 Developed by the National Guideline

More information

Does quality of life predict morbidity or mortality in patients with atrial fibrillation (AF)?

Does quality of life predict morbidity or mortality in patients with atrial fibrillation (AF)? Does quality of life predict morbidity or mortality in patients with atrial fibrillation (AF)? Erika Friedmann a, Eleanor Schron, b Sue A. Thomas a a University of Maryland School of Nursing; b NEI, National

More information

Diagnostic and Prognostic Value of Coronary Ca Score

Diagnostic and Prognostic Value of Coronary Ca Score Diagnostic and Prognostic Value of Coronary Ca Score Dr. Ghormallah Alzahrani Cardiac imaging division, Adult Cardiology department Prince Sultan Cardiac Center ( PSCC) Madina, June 2 Coronary Calcium

More information

Three-Year Clinical Outcomes with Everolimus-Eluting Bioresorbable Scaffolds: Results from the Randomized ABSORB III Trial Stephen G.

Three-Year Clinical Outcomes with Everolimus-Eluting Bioresorbable Scaffolds: Results from the Randomized ABSORB III Trial Stephen G. Three-Year Clinical Outcomes with Everolimus-Eluting Bioresorbable Scaffolds: Results from the Randomized ABSORB III Trial Stephen G. Ellis MD Dean J. Kereiakes MD and Gregg W. Stone MD for the ABSORB

More information

Chapter 1. Introduction

Chapter 1. Introduction Chapter 1 Introduction Introduction 9 Even though the first reports on venous thromboembolism date back to the 13 th century and the mechanism of acute pulmonary embolism (PE) was unraveled almost 150

More information

Ischemic Heart Disease

Ischemic Heart Disease Ischemic Heart Disease Dr Rodney Itaki Lecturer Division of Pathology University of Papua New Guinea School of Medicine & Health Sciences Division of Pathology General Consideration Results from partial

More information

Reperfusion Strategy in Europe: Temporal Trends in Performance Measures for Reperfusion Therapy in ST Elevation Myocardial Infarction

Reperfusion Strategy in Europe: Temporal Trends in Performance Measures for Reperfusion Therapy in ST Elevation Myocardial Infarction Reperfusion Strategy in Europe: Temporal Trends in Performance Measures for Reperfusion Therapy in ST Elevation Myocardial Infarction F. Schiele 1, M. Hochadel 2, M. Tubaro 3, N. Meneveau 1, W. Wojakowski

More information

Chest pain management. Ruvin Gabriel and Niels van Pelt August 2011

Chest pain management. Ruvin Gabriel and Niels van Pelt August 2011 Chest pain management Ruvin Gabriel and Niels van Pelt August 2011 Introduction Initial assessment Case 1 Case 2 and 3 Comparison of various diagnostic techniques Summary 1-2 % of GP consultations are

More information

What have We Learned in Dyslipidemia Management Since the Publication of the 2013 ACC/AHA Guideline?

What have We Learned in Dyslipidemia Management Since the Publication of the 2013 ACC/AHA Guideline? What have We Learned in Dyslipidemia Management Since the Publication of the 2013 ACC/AHA Guideline? Salim S. Virani, MD, PhD, FACC, FAHA Associate Professor, Section of Cardiovascular Research Baylor

More information

Mode of admission and its effect on quality indicators in Belgian STEMI patients

Mode of admission and its effect on quality indicators in Belgian STEMI patients 2015 Mode of admission and its effect on quality indicators in Belgian STEMI patients Prof dr M Claeys National Coordinator STEMI registry 29-6-2015 Background The current guidelines for the management

More information

Isolated Post-challenge Hyperglycemia: Concept and Clinical Significance

Isolated Post-challenge Hyperglycemia: Concept and Clinical Significance CLINICAL PRACTICE Isolated Post-challenge Hyperglycemia: Concept and Clinical Significance John MF. Adam*, Daniel Josten** ABSTRACT The American Diabetes Association has strongly recommended that fasting

More information

The PAIN Pathway for the Management of Acute Coronary Syndrome

The PAIN Pathway for the Management of Acute Coronary Syndrome 2 The PAIN Pathway for the Management of Acute Coronary Syndrome Eyal Herzog, Emad Aziz, and Mun K. Hong Acute coronary syndrome (ACS) subsumes a spectrum of clinical entities, ranging from unstable angina

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA) Page 1 of 27 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Contrast-Enhanced Coronary Computed

More information

COMPARISON OF 2014 ACCAHA VS. ESC GUIDELINES EDITORIAL

COMPARISON OF 2014 ACCAHA VS. ESC GUIDELINES EDITORIAL COMPARISON OF 2014 ACCAHA VS. ESC GUIDELINES EDITORIAL Guidelines in review: Comparison of the 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac

More information

Θα πρέπει να αναζηηείηαι η παροσζία ζιωπηλής κολπικής μαρμαρσγή ζε αζθενείς με κρσπηογενές εγκεθαλικό επειζόδιο; Ποιά είναι η καλύηερη μέθοδος;

Θα πρέπει να αναζηηείηαι η παροσζία ζιωπηλής κολπικής μαρμαρσγή ζε αζθενείς με κρσπηογενές εγκεθαλικό επειζόδιο; Ποιά είναι η καλύηερη μέθοδος; Θα πρέπει να αναζηηείηαι η παροσζία ζιωπηλής κολπικής μαρμαρσγή ζε αζθενείς με κρσπηογενές εγκεθαλικό επειζόδιο; Ποιά είναι η καλύηερη μέθοδος; Νικόλαος Φραγκάκης Λέκηορας Καρδιολογίας, FESC Ιπποκράηειο

More information

Guidelines on cardiovascular risk assessment and management

Guidelines on cardiovascular risk assessment and management European Heart Journal Supplements (2005) 7 (Supplement L), L5 L10 doi:10.1093/eurheartj/sui079 Guidelines on cardiovascular risk assessment and management David A. Wood 1,2 * 1 Cardiovascular Medicine

More information

Richard Grocott Mason

Richard Grocott Mason Richard Grocott Mason What to do with a 50 year old man with chest pain? Does the pain sound cardiac? Is this a possible acute coronary syndrome? Does patient have a previous cardiac history? Natural history

More information

Acetylcholine coronary spasm provocation testing: Revaluation in the real clinical practice

Acetylcholine coronary spasm provocation testing: Revaluation in the real clinical practice Research article Interventional Cardiology Acetylcholine coronary spasm provocation testing: Revaluation in the real clinical practice Background: Japanese Circulation Society guidelines for coronary spastic

More information

Clinical guideline Published: 23 July 2011 nice.org.uk/guidance/cg126

Clinical guideline Published: 23 July 2011 nice.org.uk/guidance/cg126 Stable angina: management Clinical guideline Published: 23 July 2011 nice.org.uk/guidance/cg126 NICE 2017. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).

More information

Statin pretreatment and presentation patterns in patients with acute coronary syndromes

Statin pretreatment and presentation patterns in patients with acute coronary syndromes Brief Report Page 1 of 5 Statin pretreatment and presentation patterns in patients with acute coronary syndromes Marcelo Trivi, Ruth Henquin, Juan Costabel, Diego Conde Cardiovascular Institute of Buenos

More information

Fractional Flow Reserve Guided PCI versus Medical Therapy in Stable Coronary Disease. FAME 2 Trial

Fractional Flow Reserve Guided PCI versus Medical Therapy in Stable Coronary Disease. FAME 2 Trial Fractional Flow Reserve Guided PCI versus Medical Therapy in Stable Coronary Disease FAME 2 Trial Clinicaltrials.gov NCT01132495 Bernard De Bruyne, Nico H.J. Pijls, William F Fearon, Peter Juni, Emanuele

More information

Clinical Appropriateness Guidelines: Diagnostic Coronary Angiography

Clinical Appropriateness Guidelines: Diagnostic Coronary Angiography Clinical Appropriateness Guidelines: Diagnostic Coronary Angiography Appropriate Use Criteria Effective Date: January 2, 2018 Proprietary Date of Origin: 08/27/2015 Last revised: 02/23/2017 Last reviewed:

More information

Imaging. Prof Geneviève DERUMEAUX Hôpital Henri Mondor Créteil, FRANCE

Imaging. Prof Geneviève DERUMEAUX Hôpital Henri Mondor Créteil, FRANCE Imaging Prof Geneviève DERUMEAUX Hôpital Henri Mondor Créteil, FRANCE Conflicts of Interest Speaker/advisor/research grant for Actelion, Sanofi, Servier, Toshiba # esccongress www.escardio.org/esc2014

More information

Significance of QRS duration in non-st elevation myocardial infarction.

Significance of QRS duration in non-st elevation myocardial infarction. Thomas Jefferson University Jefferson Digital Commons Cardiology Faculty Papers Department of Cardiology 5-6-2015 Significance of QRS duration in non-st elevation myocardial infarction. Chinualumogu Nwakile

More information

O ver the past decade, advances in the invasive management

O ver the past decade, advances in the invasive management 1031 CARDIOVASCULAR MEDICINE Prognostic value of dobutamine stress echocardiography in patients with previous coronary revascularisation M Bountioukos, A Elhendy, R T van Domburg, A F L Schinkel, J J Bax,

More information

Chapter # 4 Angina. Know what to do if you feel angina

Chapter # 4 Angina. Know what to do if you feel angina Chapter # 4 Angina Know what to do if you feel angina You will learn: 1) What angina is 2) How angina affects you 3) How to prevent and manage angina during exercise Chapter 4 Angina pg. 23 What is Angina?

More information

The Influence of Race on Health Status Outcomes One Year After an Acute Coronary Syndrome

The Influence of Race on Health Status Outcomes One Year After an Acute Coronary Syndrome Journal of the American College of Cardiology Vol. 46, No. 10, 2005 2005 by the American College of Cardiology Foundation ISSN 0735-1097/05/$30.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2005.05.092

More information

Takotsubo Cardiomyopathy

Takotsubo Cardiomyopathy Advances in Heart Disease 2008 Takotsubo Cardiomyopathy Mary O. Gray, MD, FAHA, FACC Associate Professor of Medicine University of California, San Francisco Staff Cardiologist and Training Faculty Divisions

More information

10-Year Mortality of Older Acute Myocardial Infarction Patients Treated in U.S. Community Practice

10-Year Mortality of Older Acute Myocardial Infarction Patients Treated in U.S. Community Practice 10-Year Mortality of Older Acute Myocardial Infarction Patients Treated in U.S. Community Practice Ajar Kochar, MD on behalf of: Anita Y. Chen, Puza P. Sharma, Neha J. Pagidipati, Gregg C. Fonarow, Patricia

More information

Lack of Effect of Beta-blocker Therapy in Patients with ST-elevation Acute Myocardial Infarction in PCI Era

Lack of Effect of Beta-blocker Therapy in Patients with ST-elevation Acute Myocardial Infarction in PCI Era Lack of Effect of Beta-blocker Therapy in Patients with ST-elevation Acute Myocardial Infarction in PCI Era B. Bao 1, N. Ozasa 1, T. Morimoto 2, Y. Furukawa 3, M. Shirotani 4, H. Ogawa 5, C. Tei 6, H.

More information

Prior research has revealed that event rates associated

Prior research has revealed that event rates associated Prognostic Value of Normal Exercise and Adenosine Tc-Tetrofosmin SPECT Imaging: Results from the Multicenter Registry of 4,728 Patients Leslee J. Shaw, PhD 1 ; Robert Hendel, MD 2 ; Salvador Borges-Neto,

More information

Quality ID #257 (NQF 1519): Statin Therapy at Discharge after Lower Extremity Bypass (LEB) National Quality Strategy Domain: Effective Clinical Care

Quality ID #257 (NQF 1519): Statin Therapy at Discharge after Lower Extremity Bypass (LEB) National Quality Strategy Domain: Effective Clinical Care Quality ID #257 (NQF 1519): Statin Therapy at Discharge after Lower Extremity Bypass (LEB) National Quality Strategy Domain: Effective Clinical Care 2018 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY

More information

Chapter 2: Identification and Care of Patients With Chronic Kidney Disease

Chapter 2: Identification and Care of Patients With Chronic Kidney Disease Chapter 2: Identification and Care of Patients With Chronic Kidney Disease Introduction The examination of care in patients with chronic kidney disease (CKD) is a significant challenge, as most large datasets

More information

Soo LIM, MD, PHD Internal Medicine Seoul National University Bundang Hospital

Soo LIM, MD, PHD Internal Medicine Seoul National University Bundang Hospital Soo LIM, MD, PHD Internal Medicine Seoul National University Bundang Hospital Agenda Association between Cardiovascular Disease and Type 2 Diabetes Importance of HbA1c Management esp. High risk patients

More information

The Diagnostic Value of Troponin T and Myoglobin Levels in Acute Myocardial Infarction: a Study in Turkish Patients

The Diagnostic Value of Troponin T and Myoglobin Levels in Acute Myocardial Infarction: a Study in Turkish Patients The Journal of International Medical Research 2003; 31: 76 83 The Diagnostic Value of Troponin T and Myoglobin Levels in Acute Myocardial Infarction: a Study in Turkish Patients S VATANSEVER 1, V AKKAYA

More information

Contra-indications, Risks, and Safety Precautions for Stress Testing. ACSM guidelines, pg 20 7 ACSM RISK FACTORS. Risk Classifications pg 27

Contra-indications, Risks, and Safety Precautions for Stress Testing. ACSM guidelines, pg 20 7 ACSM RISK FACTORS. Risk Classifications pg 27 Contra-indications, Risks, and Safety Precautions for Stress Testing Data to Support Stress Testing How safe is stress testing? Contra-indications Termination Criteria Ellstad Chapt 5 ACSM Chapts 3-6 Seattle

More information

Efficacy of beta-blockers in heart failure patients with atrial fibrillation: An individual patient data meta-analysis

Efficacy of beta-blockers in heart failure patients with atrial fibrillation: An individual patient data meta-analysis Efficacy of beta-blockers in heart failure patients with atrial fibrillation: An individual patient data meta-analysis Dipak Kotecha, MD PhD on behalf of the Selection of slides presented at the European

More information

zum Erwerb des Doktorgrades der Medizin an der Medizinischen Fakultät der Ludwig-Maximilians-Universität zu München vorgelegt von Ulla Kandler

zum Erwerb des Doktorgrades der Medizin an der Medizinischen Fakultät der Ludwig-Maximilians-Universität zu München vorgelegt von Ulla Kandler Aus dem Institut für Medizinische Informatik, Biometrie und Epidemiologie der Ludwig-Maximilians-Universität München Lehrstuhl für Epidemiologie: Prof. Dr. Dr. H.-E. Wichmann Long-term mortality after

More information

Coronary Artery Calcification

Coronary Artery Calcification Coronary Artery Calcification Julianna M. Czum, MD OBJECTIVES CORONARY ARTERY CALCIFICATION Julianna M. Czum, MD Dartmouth-Hitchcock Medical Center 1. To review the clinical significance of coronary heart

More information

Difference in Clinical Symptoms of Myocardial Infarction between Men and Women

Difference in Clinical Symptoms of Myocardial Infarction between Men and Women Iranian Journal of Critical Care Nursing Spring 2011, Volume 4, Issue 1; 33-38 Difference in Clinical Symptoms of Myocardial Infarction between Men and Women Seyyed Hamid Sharif Nia 1 MSc, Ali Akbar Haghdost

More information

Prevenzione secondaria dell ischemia cerebrale di origine arteriosa. Marco Cattaneo. Ospedale San Paolo Università degli Studi di Milano

Prevenzione secondaria dell ischemia cerebrale di origine arteriosa. Marco Cattaneo. Ospedale San Paolo Università degli Studi di Milano Prevenzione secondaria dell ischemia cerebrale di origine arteriosa Marco Cattaneo Ospedale San Paolo Università degli Studi di Milano Cerebral Ischemia of Arterial Origin (CIAO) Cumulative meta-analysis

More information

The use of myocardial perfusion imaging (MPI) for estimating cardiac risk

The use of myocardial perfusion imaging (MPI) for estimating cardiac risk Clinical Investigation Shalabh Chandra, MD Daniel J. Lenihan, MD, FACC Wei Wei, MS Syed Wamique Yusuf, MBBS, MRCPI Ann T. Tong, MD, FACC Key words: Aspirin/therapeutic use; comorbidity; coronary disease/epidemiology/radionuclide

More information

Typical chest pain with normal ECG

Typical chest pain with normal ECG Typical chest pain with normal ECG F. Mut, C. Bentancourt, M. Beretta Nuclear Medicine Service, Asociacion Española Montevideo, Uruguay Clinical history Male 41 y.o. Overweight, hypertension, high cholesterol,

More information

Supplementary Appendix

Supplementary Appendix Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Weintraub WS, Grau-Sepulveda MV, Weiss JM, et al. Comparative

More information

Incidence and Prevalence of Atherosclerotic Renal Artery Stenosis (RAS) in Patients with Coronary Artery Disease (CAD)

Incidence and Prevalence of Atherosclerotic Renal Artery Stenosis (RAS) in Patients with Coronary Artery Disease (CAD) Incidence and Prevalence of Atherosclerotic Renal Artery Stenosis (RAS) in Patients with Coronary Artery Disease (CAD) AHMW Islam, S Munwar, S Talukder, AQM Reza Dept. of Invasive & Interventional Cardiology,

More information

HEART CONDITIONS IN SPORT

HEART CONDITIONS IN SPORT HEART CONDITIONS IN SPORT Dr. Anita Green CHD Risk Factors Smoking Hyperlipidaemia Hypertension Obesity Physical Inactivity Diabetes Risks are cumulative (multiplicative) Lifestyles predispose to RF One

More information

SPECT-CT: Τι πρέπει να γνωρίζει ο Καρδιολόγος

SPECT-CT: Τι πρέπει να γνωρίζει ο Καρδιολόγος SPECT-CT: Τι πρέπει να γνωρίζει ο Καρδιολόγος Δρ Αναστασία Κίτσιου Διευθύντρια, Καρδιολογική Κλινική, Σισμανόγλειο ΓΝΑ Chair, Education Committee, Section on Nuclear Cardiology & Cardiac CT, EACVI, ESC

More information

FFR in Multivessel Disease

FFR in Multivessel Disease FFR in Multivessel Disease April, 26 2013 Coronary Physiology in the Catheterization Laboratory Location: European Heart House, Nice, France Pim A.L. Tonino, MD, PhD Hartcentrum, Eindhoven, the Netherlands

More information

REFERRAL HOSPITAL. The Importance of Door In Door Out Time DIDO

REFERRAL HOSPITAL. The Importance of Door In Door Out Time DIDO REFERRAL HOSPITAL The Importance of Door In Door Out Time DIDO Jean Skonhovd,RN,BSN,MSAS Emergency Department Director Avera Heart Hospital of South Dakota Time to Treatment is critical for STEMI patients

More information

Nazlı Pınar Karahan Şen, Recep Bekiş 1, Ali Ceylan 2, Erkan Derebek 1

Nazlı Pınar Karahan Şen, Recep Bekiş 1, Ali Ceylan 2, Erkan Derebek 1 ARTICLE IN PRESS Original Investigation The use of pre-test and post-test probability values as criteria before selecting patients to undergo coronary angiography in patients who have ischemic findings

More information

Platelet glycoprotein IIb/IIIa inhibition in acute coronary syndromes

Platelet glycoprotein IIb/IIIa inhibition in acute coronary syndromes European Heart Journal (00) 3, 1441 1448 doi:10.1053/euhj.00.3160, available online at http://www.idealibrary.com on Platelet glycoprotein IIb/IIIa inhibition in acute coronary syndromes Gradient of benefit

More information

Impact of diabetes mellitus on long-term outcome after unstable. angina and non-st-segment elevation myocardial infarction.

Impact of diabetes mellitus on long-term outcome after unstable. angina and non-st-segment elevation myocardial infarction. Diabetologia (2004) 47:1188 1195 DOI 10.1007/s00125-004-1450-3 Impact of diabetes mellitus on long-term outcome after unstable angina and non-st-segment elevation myocardial infarction treated with a very

More information

The 2016 NASCI Keynote: Trends in Utilization of Cardiac Imaging: The Coronary CTA Conundrum. David C. Levin, M.D.

The 2016 NASCI Keynote: Trends in Utilization of Cardiac Imaging: The Coronary CTA Conundrum. David C. Levin, M.D. The 2016 NASCI Keynote: Trends in Utilization of Cardiac Imaging: The Coronary CTA Conundrum David C. Levin, M.D. October 16, 2016 MPI Utilization Rates/1000[includes PET] total radiologists 2014 total

More information

Treatment Options for Angina

Treatment Options for Angina Treatment Options for Angina Interventional Cardiology Perspective Michael A. Robertson, M.D. 10/30/10 Prevalence of CAD in USA 15 million Americans with CAD 2 million diagnostic catheterizations 1 million

More information

Central pressures and prediction of cardiovascular events in erectile dysfunction patients

Central pressures and prediction of cardiovascular events in erectile dysfunction patients Central pressures and prediction of cardiovascular events in erectile dysfunction patients N. Ioakeimidis, K. Rokkas, A. Angelis, Z. Kratiras, M. Abdelrasoul, C. Georgakopoulos, D. Terentes-Printzios,

More information

OUTCOME OF THROMBOLYTIC AND NON- THROMBOLYTIC THERAPY IN ACUTE MYOCARDIAL INFARCTION

OUTCOME OF THROMBOLYTIC AND NON- THROMBOLYTIC THERAPY IN ACUTE MYOCARDIAL INFARCTION OUTCOME OF THROMBOLYTIC AND NON- THROMBOLYTIC THERAPY IN ACUTE MYOCARDIAL INFARCTION FEROZ MEMON*, LIAQUAT CHEEMA**, NAND LAL RATHI***, RAJ KUMAR***, NAZIR AHMED MEMON**** OBJECTIVE: To compare morbidity,

More information

Case Report Left Main Stenosis. Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Graft Surgery (CABG)?

Case Report Left Main Stenosis. Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Graft Surgery (CABG)? Cronicon OPEN ACCESS CARDIOLOGY Case Report Left Main Stenosis. Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Graft Surgery (CABG)? Valentin Hristov* Department of Cardiology, Specialized

More information

Landmesser U et al. Eur Heart J 2017; https://doi.org/ /eurheartj/ehx549

Landmesser U et al. Eur Heart J 2017; https://doi.org/ /eurheartj/ehx549 2017 Update of ESC/EAS Task Force on Practical Clinical Guidance for PCSK9 inhibition in Patients with Atherosclerotic Cardiovascular Disease or in Familial Hypercholesterolaemia Cardiovascular Outcomes

More information