Lisa Lusk

A comparison of cardiac computerized tomography and exercise stress electrocardiogram test for the investigation of stable chest pain: the clinical results of the CAPP randomized prospective trial.

AIMS To determine the symptomatic and prognostic differences resulting from a novel diagnostic pathway based on cardiac computerized tomography (CT) compared with the traditional exercise stress electrocardiography test (EST) in stable chest pain patients. METHODS AND RESULTS A prospective randomized controlled trial compared selected patient outcomes in EST and cardiac CT coronary angiography groups. Five hundred patients with troponin-negative stable chest pain and without known coronary artery disease were recruited. Patients completed the Seattle Angina Questionnaires (SAQ) at baseline, 3, and 12 months to assess angina symptoms. Patients were also followed for management strategies and clinical events. Over the year 12 patients withdrew, resulting in 245 in the EST cohort and 243 in the CT cohort. There was no significant difference in baseline demographics. The CT arm had a statistical difference in angina stability and quality-of-life domains of the SAQ at 3 and12 months, suggesting less angina compared with the EST arm. In the CT arm, there was more significant disease identified and more revascularizations. Significantly, more inconclusive results were seen in the EST arm with a higher number of additional investigations ordered. There was also a longer mean time to management. There were no differences in major adverse cardiac events between the cohorts. At 1 year in the EST arm, there were more Accident and Emergency (A&E) attendances and cardiac admission. CONCLUSION Cardiac CT as an index investigation for stable chest pain improved angina symptoms and resulted in fewer investigations and re-hospitalizations compared with EST. CLINICAL TRIAL REGISTRATION http://www.controlled-trials.com/ISRCTN52480460.

‘I am still a bit unsure how much of a heart attack it really was!’ Patients presenting with non ST elevation myocardial infarction lack understanding about their illness and have less motivation for secondary prevention

Background: There are considerable differences in the type of treatments offered to patients presenting with acute myocardial infarction (AMI), in terms of the speed and urgency with which they are admitted, treated and discharged from hospital. The impact of these different treatment experiences on patients’ illness perception and motivation for behavioural changes is unknown. Aim: The aim of this study was to explore and compare patients’ illness perception and motivation for behavioural change following myocardial infarction (MI) treated by different methods. Methods: Semi-structured, domiciliary interviews (n=15) based on the common sense model of self regulation, were conducted with three groups of MI patients within four weeks of diagnosis: (a) primary percutaneous coronary intervention (PPCI) (n=5); (b) thrombolysis (n=5); (c) non ST elevation MI (NSTEMI) (n=5). Framework analysis was used to identify and compare themes between groups. Results: Patients presenting with a ST-elevation MI (STEMI) receiving either PPCI or thrombolysis had similar perceptions of their illness as a serious, life-threatening event and were determined to make lifestyle changes. In contrast, patients with a NSTEMI experienced uncertainty about symptoms and diagnosis, causing misconceptions about the severity of their condition and less determination for lifestyle changes. Conclusion: Patients with NSTEMI in this study expressed very different perceptions of their illness compared to those experiencing STEMI. Patients’ clinical presentation and treatment experience during an AMI can impact on their illness perception, motivation for behavioural change and uptake of cardiac rehabilitation. Nurses should consider the patients’ illness experience and perception when planning secondary prevention interventions.

The cost-effectiveness of cardiac computed tomography for patients with stable chest pain

Objective To assess the cost-effectiveness of cardiac CT compared with exercise stress testing (EST) in improving the health-related quality of life of patients with stable chest pain. Methods A cost–utility analysis alongside a single-centre randomised controlled trial carried out in Northern Ireland. Patients with stable chest pain were randomised to undergo either cardiac CT assessment or EST (standard care). The main outcome measure was cost per quality adjusted life year (QALY) gained at 1 year. Results Of the 500 patients recruited, 250 were randomised to cardiac CT and 250 were randomised to EST. Cardiac CT was the dominant strategy as it was both less costly (incremental total costs −£50.45; 95% CI −£672.26 to £571.36) and more effective (incremental QALYs 0.02; 95% CI −0.02 to 0.05) than EST. At a willingness-to-pay threshold of £20 000 per QALY the probability of cardiac CT being cost-effective was 83%. Subgroup analyses indicated that cardiac CT appears to be most cost-effective in patients with a likelihood of coronary artery disease (CAD) of <30%, followed by 30%–60% and then >60%. Conclusions Cardiac CT is cost-effective compared with EST and cost-effectiveness was observed to vary with likelihood of CAD. This finding could have major implications for how patients with chest pain in the UK are assessed, however it would need to be validated in other healthcare systems. Trial registration number (ISRCTN52480460); results.

Serum- and HDL3-serum amyloid A and HDL3-LCAT activity are influenced by increased CVD-burden

BACKGROUND High density lipoproteins (HDL) protect against cardiovascular disease (CVD). However, increased serum amyloid-A (SAA) related inflammation may negate this property. This study investigated if SAA was related to CVD-burden. METHODS Subjects referred to the rapid chest pain clinic (n = 240) had atherosclerotic burden assessed by cardiac computerised tomography angiography. Subjects were classified as: no-CVD (n = 106), non-obstructive-CVD, stenosis<50% (n = 58) or moderate/significant-CVD, stenosis ≥50% (n = 76). HDL was subfractionated into HDL2 and HDL3 by rapid-ultracentrifugation. SAA-concentration was measured by ELISA and lecithin cholesterol acyltransferase (LCAT) activity measured by a fluorimetric assay. RESULTS We illustrated that serum-SAA and HDL3-SAA-concentration were higher and HDL3-LCAT-activity lower in the moderate/significant-CVD-group, compared to the no-CVD and non-obstructive-CVD-groups (percent differences: serum-SAA, +33% & +30%: HDL3-SAA, +65% and +39%: HDL3-LCAT, -6% & -3%; p < 0.05 for all comparisons). We also identified a positive correlation between serum-SAA and HDL3-SAA (r = 0.698; p < 0.001) and a negative correlation between HDL3-SAA and HDL3-LCAT-activity (r = -0.295; p = 0.003), while CVD-burden positively correlated with serum-SAA (r = 0.150; p < 0.05) and HDL3-SAA (r = 0.252; p < 0.001) and negatively correlated with HDL3-LCAT-activity (r = -0.182; p = 0.006). Additionally, multivariate regression analysis adjusted for age, gender, CRP and serum-SAA illustrated that HDL3-SAA was significantly associated with modifying CVD-risk of moderate/significant CVD-risk (p < 0.05). CONCLUSION This study has demonstrated increased SAA-related inflammation in subjects with moderate/significant CVD-burden, which appeared to impact on the antiatherogenic potential of HDL. We suggest that SAA may be a useful biomarker to illustrate increased CVD-burden, although this requires further investigation.

096 A comparative study of standard filtered back projection with novel iterative reconstruction techniques in cardiac CT

Background Iterative reconstruction (IR) is a novel but significant development in CT image acquisition. There have been a number of studies that have reported on the potential of IR in cardiac CT. These retrospectively applied IR in the image domain to images acquired with standard filtered back projection (FBP) techniques. This study was part of an ongoing randomised control trial [ISRCTN52480460] evaluating the cost effectiveness of cardiac CT. Methods 250 patients were prospectively enrolled to have a cardiac CT for the investigation of stable chest pain. Written and informed consent was obtained. Data acquisition were performed on a Philips Brilliance 64. The patients were divided into two groups. Cohort A underwent standard FBP imaging, and Cohort B underwent IR with Idose® (Philips, Cleveland, Ohio, USA). Within each cohort the scan parameters (kv, mAs, pitch) and reconstruction protocols (prospective or retrospective) were determined by patient characteristics. Images were assessed for noise and signal quality within regions of interest (ROI) on axial images, and subjectively for image quality by two experienced readers. Noise was defined as the SD of the measured HU, and signal as the HU mean attenuation value. The ROIs were in the ascending aorta, interventricular septum and left ventricular cavity. Subjective image quality was rated blindly using a 5-point Likert scale. Effective radiation dose (ED) of each CTCA was estimated by multiplying the dose-length product by a chest-specific conversion coefficient (κ=0.014 mSv×mGy−1×cm−1). Results Of the 250 patients enrolled 3 withdrew. 146 of the 247 subjects were male with a mean age of 57.93 (SD 9.93). Cohort A consisted of 124 patients, and cohort B 123, with no significant difference in baseline demographics. The mean dose of all FBP was 6.09 mSv, (SD 3.16) compared to an IR mean of 4.23 mSv, (SD 2.01) which was a dose saving of 1.86 mSv (30.54%). This was a significant dose reduction (p value <0.0001.) Mean image quality score obtained from the IR images was 3.67 (SD 1.04) compared to the FBP images of 3.29 (SD 1.17) p value of 0.0067. There was good agreement between the readers—κ coefficient 0.83. Cohort A consisted of 74 retrospective images and 50 prospective. Cohort B had 116 with retrospective and 7 with prospective. The mean ED for a prospective FBP was 3.50 mSv (SD 1.15), with the IR equivalent being 2.00 mSv (0.72), giving a mean dose saving of 1.50 mSv (42.86%). The mean ED for FBP retrospective studies was 7.85 mSv (SD 2.87), with the IR equivalent being 4.36 mSv (SD 1.99), with a mean dose saving of 3.49 mSv (44.46%). There was no statistical difference in noise or mean attenuation between the IR and FBP images in all three areas of interest Abstract 096 table 1.Abstract 096 Table 1 Region of interest Image noise Attenuation FBP IR p Value FBP IR p Value Ascending aorta 29.76±32.00 27.33±10.10 0.42 505.85±95.64 520.72±103.07 0.24 Interventricular septum 28.96±9.63 28.27±7.53 0.53 154.76±35.28 153.63±32.41 0.79 Left ventricle 29.78±9.36 28.55±12.39 0.38 464.27±92.50 484.07±99.38 0.11 Conclusions To our knowledge this is the first study to prospectively compare FBP with IR. It suggests that cardiac IR protocols confer a substantial radiation dose reduction without a compromise in diagnostic quality.

A comparison of Functional and Anatomical Investigations with Angina Symptoms: Results from a Randomised Controlled Trial

The presence of angina is a potential source of reduced quality of life and may be a predictor of adverse cardiovascular outcomes. Recent guidelines suggest that management of angina should revolve around the use of the Diamond Forrester (DF) score to determine which tests should be used for an individual patient. The choice of test can be broadly categorized into anatomical or function. Little is known about how either type of test correlates with the DF score. This study was part of a larger randomized Controlled Trial to compare the use of cardiac Computerized Tomography (CT) and exercise Electrocardiogram Stress Test (EST) in patients with stable angina. This analysis compared the results from EST and CT against the DF scores. Overall all results showed that there is a poor correlation between DF and both tests. R-squared value from the linear model showed correlation between EST and DF scores to be 0.315, with the correlation between CT and DF scores 0.415. This calls into question the useful of symptoms to drive investigations. Received Date: April 13, 2016 Accepted Date: May 20, 2016 Published Date: May 26, 2016 Citation: McKavanagh, P., et al. A Comparison of Functional and Anatomical Investigations with Angina Symptoms: Results from a Randomized Controlled Trial. (2016) J Heart Cardiol 2(2): 17. McKavanagh, P., et al.

“I am still a wee bit iffy how much of a heart attack it was”, patients presenting with non ST elevation myocardial infarction lack understanding about their illness: a qualitative study

Introduction: After a first coronary event there is an increased risk for a recurrent event. Despite that risk, 1/5 of the patients continue to smoke, 1/3 is obese and more than half of the patients have elevated blood pressure and total cholesterol. Secondary preventive self-care activities are needed to improve outcomes and the belief of patients plays a vital role in changing behavior. Aim: To examine patients’ beliefs of self-care 6-12 months after a coronary event. Method: The study design was qualitative. Twenty-five patients, including 10 women, mean age 65 years with stable coronary artery disease participated in four focus group interviews. Data were taped, transcribed and analyzed according to the conventional content analysis. Findings: Patients’ belief of self-care is influenced by their desire of a good life even though life seems fragile. Patients try to live up to the standard of health care prescription and advices. However, these achievements require behavior change and conscious boundaries, which are challenged by various obstacles such as fear of, overstrain and stress. Physical activity is considered as both a source to well-being and a necessity, but patients are uncertain and afraid for overstraining. A healthy diet is seen as important but the advices given are sometimes contradictory and create confusion. Medication is found important but not at the cost of all the side-effects. Patients also report that in order to believe in their ability and to be responsible for self-care, support from health care providers is expected. But at the same time the invaluable support and information is often not provided, creating uncertainty. Discussion: The study highlights the patients’ perspective of self-care and what they view as important in self-care after an event of coronary artery disease. The patients’ expectations on health services comprise information, support and continuous follow-up. This is necessary to facilitate the patient’s responsibility for their own care. Conclusion: Patients’ beliefs about the concept of self-care after an event of coronary artery disease are multifaceted and voluminous compared to the health care definition. The findings of the study challenge health care policies approach to self-care. There is a need to reconsider and assess what and how secondary preventive patient education should be performed after an event of coronary artery disease.