N. Van Pelt

Dual source coronary computed tomography angiography for detecting in-stent restenosis

Objective: To evaluate the performance of dual source CT coronary angiography (DSCT-CA) in the detection of in-stent restenosis (⩾50% luminal narrowing) in symptomatic patients referred for conventional angiography (CA). Design/patients: 100 patients (78 males, age 62 (SD 10)) with chest pain were prospectively evaluated after coronary stenting. DSCT-CA was performed before CA. Setting: Many patients undergo coronary artery stenting; availability of a non-invasive modality to detect in-stent restenosis would be desirable. Results: Average heart rate (HR) was 67 (SD 12) (range 46–106) bpm. There were 178 stented lesions. The interval between stenting and inclusion in the study was 35 (SD 41) (range 3–140) months. 39/100 (39%) patients had angiographically proven restenosis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of DSCT-CA, calculated in all stents, were 94%, 92%, 77% and 98%, respectively. Diagnostic performance at HR <70 bpm (nu200a=u200a69; mean 58 bpm) was similar to that at HR ⩾70 bpm (nu200a=u200a31; mean 78 bpm); diagnostic performance in single stents (nu200a=u200a95) was similar to that in overlapping stents and bifurcations (nu200a=u200a83). In stents ⩾3.5 mm (nu200a=u200a78), sensitivity, specificity, PPV, NPV were 100%; in 3 mm stents (nu200a=u200a59), sensitivity and NPV were 100%, specificity 97%, PPV 91%; in stents ⩽2.75 mm (nu200a=u200a41), sensitivity was 84%, specificity 64%, PPV 52%, NPV 90%. Nine stents ⩽2.75 mm were uninterpretable. Specificity of DSCT-CA in stents ⩾3.5 mm was significantly higher than in stents ⩽2.75 mm (OR u200a=u200a6.14; 99%CI: 1.52 to 9.79). Conclusion: DSCT-CA performs well in the detection of in-stent restenosis. Although DSCT-CA leads to frequent false positive findings in smaller stents (⩽2.75 mm), it reliably rules out in-stent restenosis irrespective of stent size.

Residual pulmonary vasoreactivity to inhaled nitric oxide in patients with severe obstructive pulmonary hypertension and Eisenmenger syndrome

OBJECTIVE To determine whether inhaled NO (iNO) can reduce pulmonary vascular resistance in adults with congenital heart disease and obstructive pulmonary hypertension or Eisenmenger syndrome. DESIGN 23 patients received graded doses of iNO. Pulmonary and systemic haemodynamic variables and circulating cyclic guanosine monophosphate (cGMP) concentrations were measured at baseline and after 20 and 80 ppm iNO. Patients were considered responders when total pulmonary resistance was reduced by at least 20%, and rebound was defined as a greater than 10% increase in total pulmonary resistance upon withdrawal from iNO. RESULTS In response to 20 ppm iNO, total pulmonary resistance decreased in four patients (18%, 95% confidence interval (CI), 2% to 34%), while in response to 80 ppm iNO it decreased in six patients (29%, 95% CI 10% to 38%). Systemic blood pressure did not change. Withdrawal resulted in rebound in three patients (16%, 95% CI 0% to 32%) after cessation of 20 ppm iNO, and in six patients (35%, 95% CI 12% to 58%) after cessation of 80 ppm iNO. Patients with predominant right to left shunting did not respond. In all patients cGMP increased from (mean (SD)) 28 (13)u2009μmol/l at baseline to 55 (30) and 78 (44)u2009μmol/l after 20 and 80 ppm iNO (pu2009<u20090.05 v baseline). CONCLUSIONS NO inhalation is safe and is associated with a dose dependent increase in circulating cGMP concentrations. Pulmonary vasodilatation in response to iNO was observed in 29% of patients and was influenced by baseline pulmonary haemodynamics. Responsiveness to acute iNO may identify patients with advanced obstructive pulmonary hypertension and Eisenmenger syndrome who could benefit from sustained vasodilator treatment.

Pattern of investigations in nurse led chest pain clinic

Background: Improving uptake of Cardiac Rehabilitation (CR) is a focus of our service. To facilitate this we have developed a range of programmes for patients to choose from. A previous audit in 2010 identified thatMaori were significantly under accessingCR services compared to other ethnicities and our aim was to evaluate current Maori attendance. Methods: Between 1/1/13 and 1/1/14, we identified all Maori registered in ANZACS QI and using the CR tracking system we analysed contact with CR services. Results: 108 patients were identified with complete data. The majority were male (54%), mean age 57.9 10.7 years, post-ACS (67%) and had received Phase I CR (79%). Admission LDL was 2.60 1.25 (mean SD), 44% had Diabetes and 19% were current smokers. 62%, 36% and 2% opted for the Healthy Hearts group education programme, home programme (HGA) or CR clinic, respectively with 41% completing and 25% partially completing CR, 34% did not attend any programme. There was a low uptake (11%) of the hospital based CR exercise programme. There were no important differences between the demographic and risk characteristics of the patients who completed, partially completed or didn’t attend CR. Conclusion: This audit provides an accurate picture of Maori attendance to CR showing good representation. Despite this, one third of Maori patients do not attend CR and there is still work to be done, particularly around structured exercise, to increase engagement and to provide accessible CR options for high risk populations.