Rupa Mehta Sanghani

Sexual activity and counseling in the first month after acute myocardial infarction among younger adults in the United States and Spain: a prospective, observational study.

Background— United States and European cardiovascular society guidelines recommend physicians counsel patients about resuming sexual activity after acute myocardial infarction (AMI), but little is known about patients’ experience with counseling about sexual activity after AMI. Methods and Results— The prospective, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, conducted at 127 hospitals in the United States and Spain, was designed, in part, to evaluate gender differences in baseline sexual activity, function, and patient experience with physician counseling about sexual activity after an AMI. This study used baseline and 1-month data collected from the 2:1 sample of women (N=2349) and men (N=1152) ages 18 to 55 years with AMI. Median age was 48 years. Among those who reported discussing sexual activity with a physician in the month after AMI (12% of women, 19% of men), 68% were given restrictions: limit sex (35%), take a more passive role (26%), and/or keep the heart rate down (23%). In risk-adjusted analyses, factors associated with not discussing sexual activity with a physician included female gender (relative risk, 1.07; 95% confidence interval, 1.03–1.11), age (relative risk, 1.05 per 10 years; 95% confidence interval, 1.02–1.08), and sexual inactivity at baseline (relative risk, 1.11; 95% confidence interval, 1.08–1.15). Among patients who received counseling, women in Spain were significantly more likely to be given restrictions than U.S. women (relative risk; 1.36, 95% confidence interval, 1.11–1.66). Conclusions— Very few patients reported counseling for sexual activity after AMI. Those who did were commonly given restrictions not supported by evidence or guidelines. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597922.

ASNC imaging guidelines for nuclear cardiology procedures

The American Society of Nuclear Cardiology (ASNC) published a guideline for the reporting of myocardial perfusion imaging (MPI) in 2009. Over the last eight years there has been significant change in the breadth and depth of nuclear cardiology practice along with significant changes in the landscape of structured reporting. In consideration of this degree of change, it is appropriate that the guideline be updated and expanded to include a broader perspective of nuclear cardiology practice. At the same time, many things have not changed. This includes the fact that the report should provide a basic ‘‘bottom line’’ result to the referring physician and that this result must be clear and concise. This premise was expanded on by the American College of Radiology (ACR) with its development of a reporting and communication guideline with continued recent updates. All these documents emphasized the need for a defined structure containing standardized data elements to facilitate utilization of the complex data contained in an imaging report into the integrated healthcare of the patient through the electronic health record. The structured report is also an integral part to define quality in nuclear cardiology practices. There continues to be interest in the implementation of structured reporting as a mechanism to improve quality and outcomes and to reduce cost in fulfillment of the triple aim.

Sexual Activity and Function in the Year After an Acute Myocardial Infarction Among Younger Women and Men in the United States and Spain.

Importance Most younger adults who experience an acute myocardial infarction (AMI) are sexually active before the AMI, but little is known about sexual activity or sexual function after the event. Objective To describe patterns of sexual activity and function and identify indicators of the probability of loss of sexual activity in the year after AMI. Design, Setting, and Participants Data from the prospective, multicenter, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients study (conducted from August 21, 2008, to January 5, 2012) were assessed at baseline, 1 month, and 1 year. Participants were from US (n = 103) and Spanish (n = 24) hospitals and completed baseline and all follow-up interviews. Data analysis for the present study was conducted from October 15, 2014, to June 6, 2016. Characteristics associated with loss of sexual activity were assessed using multinomial logistic regression analyses. Main Outcomes and Measures Loss of sexual activity after AMI. Results Of the 2802 patients included in the analysis, 1889 were women (67.4%); median (25th-75th percentile) age was 49 (44-52) years (range, 18-55 years). At all time points, 637 (40.4%) of women and 437 (54.9%) of men were sexually active. Among people who were active at baseline, men were more likely than women to have resumed sexual activity by 1 month (448 [63.9%] vs 661 [54.5%]; P < .001) and by 1 year (662 [94.4%] vs 1107 [91.3%]; P = .01) after AMI. Among people who were sexually active before and after AMI, women were less likely than men to report no sexual function problems in the year after the event (466 [40.3%] vs 382 [54.8%]; P < .01). In addition, more women than men (211 [41.9%] vs 107 [30.5%]; P < .01) with no baseline sexual problems developed 1 or more incident problems in the year after the AMI. At 1 year, the most prevalent sexual problems were lack of interest (487 [39.6%]) and trouble lubricating (273 [22.3%]) among women and erectile difficulties (156 [21.7%]) and lack of interest (137 [18.8%]) among men. Those who had not communicated with a physician about sex in the first month after AMI were more likely to delay resuming sex (adjusted odds ratio [AOR], 1.51; 95% CI, 1.11-2.05; P = .008). Higher stress levels (AOR, 1.36; 95% CI, 1.01-1.83) and having diabetes (AOR, 1.90; 95% CI, 1.15-3.13) were significant indicators of the probability of loss of sexual activity in the year after the AMI. Conclusions and Relevance Impaired sexual activity and incident sexual function problems were prevalent and more common among young women than men in the year after AMI. Attention to modifiable risk factors and physician counseling may improve outcomes.

Sex Differences in Ischemic Heart Disease: Advances, Obstacles, and Next Steps

Evolving knowledge of sex-specific presentations, improved recognition of conventional and novel risk factors, and expanded understanding of the sex-specific pathophysiology of ischemic heart disease have resulted in improved clinical outcomes in women. Yet, ischemic heart disease continues to be the leading cause of morbidity and mortality in women in the United States. The important publication by the Institute of Medicine titled “Women’s Health Research—Progress, Pitfalls, and Promise,” highlights the persistent disparities in cardiovascular disease burden among subgroups of women, particularly women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment. These important health disparities reflect underrepresentation of women in research, with the resultant unfavorable impact on diagnosis, prevention, and treatment strategies in women at risk for cardiovascular disease. Causes of disparities are multifactorial and related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. Lack of awareness in both the public and medical community, as well as existing knowledge gap regarding sex-specific differences in presentation, risk factors, pathophysiology, and response to treatment for ischemic heart disease, further contribute to outcome disparities. There is a critical need for implementation of sex- and gender-specific strategies to improve cardiovascular outcomes. This review is tailored to meet the needs of a busy clinician and summarizes the contemporary trends, characterizes current sex-specific outcome disparities, delineates challenges, and proposes transformative solutions for improvement of the full spectrum of ischemic heart disease clinical care and research in women.

Fully automated analysis of perfusion data: The rise of the machines

Artificial Intelligence is defined as ‘‘the theory and development of computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, decision-making, and translation between languages.’’ Others have referred to it, in particular, to scenarios when a machine mimics cognitive decisions performed by the human brain, such as learning and problem solving. With the advent of computers that are increasingly capable of handling enormous amounts of data with rapid processing, there has been increasing interest that ‘‘big data’’ and ‘‘machine learning’’ can be used to facilitate everything from self-driving cars to modernizing the practice of medicine. There has been much debate about the use of artificial intelligence in medicine, particularly in radiology and image interpretation. Can we create artificial intelligence programs that can interpret cardiac nuclear scans in the same manner as a physician and if so, what role will these programs play in the future of nuclear cardiology? In the field of nuclear cardiology, a picture is worth a thousand words. Semi-quantitative visual analysis of perfusion and function has been the cornerstone of image interpretation. Quantitative analysis is now an integral part of nuclear imaging, with multiple software algorithms that can automatically segment the left ventricle, assess perfusion at rest and stress and compare to normalized databases, and quantify ejection fraction. These programs have been validated, shown to be reproducible, and have similar diagnostic accuracy to visual analysis by expert readers. Currently, these programs are used as an adjunct to clinical interpretation, given inherent needs for physician supervision to ensure proper contours, alignment, and review for artifacts. Moreover, final interpretation of a cardiac scan requires integration of multiple factors, in particular the correlation between perfusion, function and artifacts. Preliminary data have shown that increasingly less physician supervision may be needed for proper alignment for these quantitative programs and there has been increasing interest in fully automated quantification. In this issue of the Journal, Motwani et al. investigated the feasibility of a large-scale fully automated quantitative analysis of SPECT myocardial perfusion imaging to predict acute myocardial infarction (AMI). They had several notable findings. First, in review of almost 6,000 patients, they found that fully automated analysis (fully unsupervised) was indeed feasible with about 10% of studies being flagged as ‘‘potential error’’ by their left ventricular contour quality control (QC) program, requiring visual supervision by an experienced technician. After the QC step, they were able to demonstrate that batch processing could be used to quantitate stress total perfusion deficit (sTPD) and ischemic total perfusion deficit (iTPD) in these studies, with modest predictive accuracy for future AMI over long-term follow-up. Annualized AMI rates increased in proportion to the magnitude of abnormality, with automated sTPD being a stronger predictor than iTPD. Both sTPD and iTPD had better immediate (1 year) than long-term (5 year) prediction of AMI. Automated batch processing made it feasible to analyze large numbers of studies processed separately in two distinct manners: with attenuation correction (AC) and non-corrected (NC). The study showed that AC Reprint requests: Rami Doukky, MD, MSc, FASNC, Division of Cardiology, Cook County Health and Hospitals System, Chicago, IL; rdoukky@cookcountyhhs.org J Nucl Cardiol 2018;25:1361–3. 1071-3581/

Cardiology Consultation in the Emergency Department Reduces Re-hospitalizations for Low-Socioeconomic Patients with Acute Decompensated Heart Failure

34.00 Copyright 2017 American Society of Nuclear Cardiology.

Sexual Activity and Counseling in the First Month After Acute Myocardial Infarction Among Younger Adults in the United States and SpainCLINICAL PERSPECTIVE: A Prospective, Observational Study

BACKGROUND Re-hospitalization after discharge for acute decompensated heart failure is a common problem. Low-socioeconomic urban patients suffer high rates of re-hospitalization and often over-utilize the emergency department (ED) for their care. We hypothesized that early consultation with a cardiologist in the ED can reduce re-hospitalization and health care costs for low-socioeconomic urban patients with acute decompensated heart failure. METHODS There were 392 patients treated at our center for acute decompensated heart failure who received standardized education and follow-up. Patients who returned to the ED received early consultation with a cardiologist; 392 patients who received usual care served as controls. Thirty- and 90-day re-hospitalization, ED re-visits, heart failure symptoms, mortality, and health care costs were recorded. RESULTS Despite guideline-based education and follow-up, the rate of ED re-visits was not different between the groups. However, the rate of re-hospitalization was significantly lower in patients receiving the intervention compared with controls (odds ratio 0.592), driven by a reduction in the risk of readmission from the ED (0.56 vs 0.79, respectively). Patients receiving the intervention accumulated 14% fewer re-hospitalized days than controls and 57% lower 30-day total health care cost. Despite the reduction in health care resource consumption, mortality was unchanged. After accounting for the total cost of intervention delivery, the health care cost savings was substantially greater than the cost of intervention delivery. CONCLUSION Early consultation with a cardiologist in the ED as an adjunct to guideline-based follow-up is associated with reduced re-hospitalization and health care cost for low-socioeconomic urban patients with acute decompensated heart failure.

Sexual Activity and Counseling in the First Month After Acute Myocardial Infarction Among Younger Adults in the United States and Spain

Background— United States and European cardiovascular society guidelines recommend physicians counsel patients about resuming sexual activity after acute myocardial infarction (AMI), but little is known about patients’ experience with counseling about sexual activity after AMI. Methods and Results— The prospective, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, conducted at 127 hospitals in the United States and Spain, was designed, in part, to evaluate gender differences in baseline sexual activity, function, and patient experience with physician counseling about sexual activity after an AMI. This study used baseline and 1-month data collected from the 2:1 sample of women (N=2349) and men (N=1152) ages 18 to 55 years with AMI. Median age was 48 years. Among those who reported discussing sexual activity with a physician in the month after AMI (12% of women, 19% of men), 68% were given restrictions: limit sex (35%), take a more passive role (26%), and/or keep the heart rate down (23%). In risk-adjusted analyses, factors associated with not discussing sexual activity with a physician included female gender (relative risk, 1.07; 95% confidence interval, 1.03–1.11), age (relative risk, 1.05 per 10 years; 95% confidence interval, 1.02–1.08), and sexual inactivity at baseline (relative risk, 1.11; 95% confidence interval, 1.08–1.15). Among patients who received counseling, women in Spain were significantly more likely to be given restrictions than U.S. women (relative risk; 1.36, 95% confidence interval, 1.11–1.66). Conclusions— Very few patients reported counseling for sexual activity after AMI. Those who did were commonly given restrictions not supported by evidence or guidelines. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597922.

Sex Differences in Ischemic Heart Disease

Background— United States and European cardiovascular society guidelines recommend physicians counsel patients about resuming sexual activity after acute myocardial infarction (AMI), but little is known about patients’ experience with counseling about sexual activity after AMI. Methods and Results— The prospective, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, conducted at 127 hospitals in the United States and Spain, was designed, in part, to evaluate gender differences in baseline sexual activity, function, and patient experience with physician counseling about sexual activity after an AMI. This study used baseline and 1-month data collected from the 2:1 sample of women (N=2349) and men (N=1152) ages 18 to 55 years with AMI. Median age was 48 years. Among those who reported discussing sexual activity with a physician in the month after AMI (12% of women, 19% of men), 68% were given restrictions: limit sex (35%), take a more passive role (26%), and/or keep the heart rate down (23%). In risk-adjusted analyses, factors associated with not discussing sexual activity with a physician included female gender (relative risk, 1.07; 95% confidence interval, 1.03–1.11), age (relative risk, 1.05 per 10 years; 95% confidence interval, 1.02–1.08), and sexual inactivity at baseline (relative risk, 1.11; 95% confidence interval, 1.08–1.15). Among patients who received counseling, women in Spain were significantly more likely to be given restrictions than U.S. women (relative risk; 1.36, 95% confidence interval, 1.11–1.66). Conclusions— Very few patients reported counseling for sexual activity after AMI. Those who did were commonly given restrictions not supported by evidence or guidelines. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597922.