Myocardial infarction with non-obstructive coronary arteries (MINOCA) is an intriguing clinical entity that is being increasingly recognized with the more common use of coronary angiography during ...acute myocardial infarction. This review systematically addresses the contemporary understanding of MINOCA, including, (1) what are the diagnostic criteria, (2) when the diagnosis should be considered, (3) who is at risk, (4) why this new syndrome should be diagnosed, (5) how these patients should be managed, and (6) where to next? (Circ J 2016; 80: 11–16)
Objectives: To characterise management of suspected acute coronary syndrome (ACS) in Australia and New Zealand, and to assess the application of recommended therapies according to published ...guidelines.
Design, setting and patients: All patients hospitalised with suspected or confirmed ACS between 14 and 27 May 2012 were enrolled from participating sites in Australia and New Zealand, which were identified through public records and health networks. Descriptive and logistic regression analysis was performed.
Main outcome measures: Rates of guideline‐recommended investigations and therapies, and inhospital clinical events (death, new or recurrent myocardial infarction MI, stroke, cardiac arrest and worsening congestive heart failure).
Results: Of 478 sites that gained ethics approval to participate, 286 sites provided data on 4398 patients with suspected or confirmed ACS. Patients’ mean age was 67 years (SD, 15 years), 40% were women, and the median Global Registry of Acute Coronary Events (GRACE) risk score was 119 (interquartile range, 96–144). Most patients (66%) presented to principal referral hospitals. MI was diagnosed in 1436 patients (33%), unstable angina or likely ischaemic chest pain in 929 (21%), unlikely ischaemic chest pain in 1196 (27%), and 837 patients (19%) had other diagnoses not due to ACS. Of the patients with MI, 1019 (71%) were treated with angiography, 610 (43%) with percutaneous coronary intervention and 116 (8%) with coronary artery bypass grafting. Invasive management was less likely with increasing patient risk (GRACE score < 100, 90.1% v 101–150, 81.3% v 151–200, 49.4% v > 200, 36.1%; P < 0.001). The inhospital mortality rate was 4.5% and recurrent MI rate was 5.1%. After adjusting for patient risk and other variables, significant variations in care and outcomes by hospital classification and jurisdiction were evident.
Conclusion: This first comprehensive combined Australia and New Zealand audit of ACS care identified variations in the application of the ACS evidence base and varying rates of inhospital clinical events. A focus on integrated clinical service delivery may provide greater translation of evidence to practice and improve ACS outcomes in Australia and New Zealand.
PCAD possesses a public health challenge resulting in years of productive life lost and an escalating burden on health systems. Objective of this review is to compare modifiable and non-modifiable ...risk factors for PCAD compared to those without PCAD. This review will include all comparative observational studies conducted in adults aged
>18 years with confirmed diagnosis of PCAD (on angiography) compared to those without PCAD. Databases to be searched include; PubMed, CINAHL, Embase, Web of Science, and grey literature (Google Scholar). All identified studies will be screened for title and abstract and full-text against the inclusion criteria on Covidence software. Data relevant to exposures and outcomes will be extracted from all included studies. All studies selected for data extraction will be critically appraised for methodological quality. Meta-analysis using random-effects model will be performed using Review Manager 5.3. Effect sizes for categorical risk factors will be expressed as odds ratios with 95% confidence intervals. For risk factors measured in continuous form, mean difference (if units are consistent) otherwise standardized mean difference (if units are different across studies) will be reported. Heterogeneity between
studies will be assessed using I
2 test statistics. GRADE will be used to assess the certainty of the findings.
Systematic review registration number: PROSPERO Registration # CRD42020173216
Background A delayed Door-to-Balloon (DTB) time in women with ST-elevation myocardial infarction (STEMI) has been associated with an increased mortality. The objectives of this study were to (a) ...quantify the components of the delayed DTB time in women and (b) assess the independent effect of gender on DTB time in patients undergoing percutaneous coronary intervention (PCI) for STEMI. Methods Clinical parameters were prospectively collected for 735 STEMI patients undergoing primary PCI from 2006 to 2010, with particular attention to the components of DTB time, including the onset of chest pain and the ‘code’ notification of the STEMI team by the Emergency Department. Results Women were significantly older with more co-morbidity. Upon hospital arrival they also experienced delays in Door-to-Code (23 vs. 17 min, P = .012), Code-to-Balloon (63 vs. 57 min, P = .001) and thus DTB time (88 vs. 72 min, P = .001). After multivariate adjustment, independent determinants of DTB time included female gender (ratio of geometric means RGM = 1.13; 95% CI 1.02–1.26; P = .022), hypertension (RGM = 1.12, 95% CI 1.02–1.23, P = .014), maximum ST-elevation (RGM = 0.97, 95% CI 0.94–0.98, P < .001), office hours (RGM = 0.84, 95% CI 0.78–0.92, P < .001) and triage category (RGM = 1.23, 95% CI 1.09–1.40, P = .001). Conclusions Women experience delays in identification of the STEMI diagnosis and also in the PCI process. Thus a multifaceted approach addressing both the diagnosis and management of STEMI in women is required.
Patients with coronary microvascular disorders often experience recurrent angina for which there are limited evidence-based therapies. These patients have been found to exhibit increased plasma ...levels of endothelin; thus, selective endothelin-A (Et-A) receptor blockers such as zibotentan may be an effective anti-anginal therapy in these patients. The study evaluated the impact of a 10 mg daily dose of zibotentan on spontaneous angina episodes in patients with the coronary slow-flow phenomenon who had refractory angina (i.e., experiencing angina at least three times/week despite current anti-anginal therapy).
Using a randomized, double-blind, placebo-controlled, crossover trial design with 4-week treatment periods, 18 patients (63.2 ± 9.9 years, 33% females) were recruited. The primary endpoint was angina frequency as measured by an angina diary, with secondary endpoints including nitrate consumption, angina duration/severity and the Seattle Angina Questionnaire (SAQ) domains.
During the 4 weeks of therapy, angina frequency significantly improved with zibotentan therapy (placebo 41.4 (58.5) vs. zibotentan 29.2 (31.6),
< 0.05), and sublingual nitrate consumption significantly reduced (placebo 11.8 (15.2) vs. zibotentan 8.8 (12.9),
< 0.05.
Zibotentan improved the frequency of spontaneous angina episodes and reduced sublingual nitrate consumption in patients unresponsive to standard anti-anginal therapy.
The universal definition of acute myocardial infarction (MI) requires both evidence of myocardial injury and myocardial ischaemia. In MINOCA (MI with non-obstructive coronary arteries), patients must ...fulfil this MI criteria, but is their chest pain similar to those who have MI with obstructive CAD (MICAD)? This study compares prospectively collected chest pain features between patients with MINOCA and MICAD. Utilising the Coronary Angiogram Database of South Australia (CADOSA), consecutive MI patients were categorized as MINOCA or MICAD based on angiographic findings. Chest pain data were collected via direct patient interviews by trained staff members. Of 6811 consecutive patients fulfilling a clinical MI diagnosis, 411 (6.0%) were MINOCA, and 5948 MICAD. The MINOCA patients were younger, more often female and had less cardiovascular risk factors than those with MICAD. There were no significant differences in chest pain characteristics between the MINOCA and MICAD cohorts in relation to pain location, quality, associated symptoms, or duration. In conclusion, MINOCA patients have chest pain characteristics that are indistinguishable from MICAD patients, suggesting that their pain is ischaemic in nature. Thus, in the presence of positive myocardial injury markers, ischaemic chest pain fulfils the universal criteria for MI, despite the absence of obstructive coronary artery disease.
Angina and Non-Obstructive Coronary Artery (ANOCA) patients often lack a clear explanation for their symptoms, and are frequently discharged with the label of “unspecified chest pain”, despite the ...availability of functional coronary angiography (provocative spasm and microvascular function testing) to identify potential underlying coronary vasomotor disorders. This study compared the outcomes of ANOCA patients with a coronary vasomotor disorder diagnosis post elective coronary angiography to patients discharged with unspecified chest pain. Using the CADOSA (Coronary Angiogram Database of South Australia) registry, consecutive symptomatic patients (n = 7555) from 2012 to 2018 underwent elective angiography; 30% had ANOCA (stenosis <50%). Of this cohort, 9% had documented coronary vasomotor disorders diagnosed, and 91% had unspecified chest pain. Patients with coronary vasomotor disorders were younger and had a similar female prevalence compared with those with unspecified chest pain. New prescriptions of calcium channel blockers and long-acting nitrates were more common for the coronary vasomotor cohort at discharge. In the 3 years following angiography, both groups had similar all-cause mortality rates. However, those with coronary vasomotor disorders had higher rates of emergency department visits for chest pain (39% vs. 15%, p < 0.001) and readmissions for chest pain (30% vs. 10%, p < 0.001) compared with those with unspecified chest pain. This real-world study emphasizes the importance of identifying high-risk ANOCA patients for personalized management to effectively address their symptoms.
Gaps in Cardiac Rehabilitation Referral Tavella, Rosanna, BSc (Hons), PhD; Arstall, Margaret, MBBS, PhD; Beltrame, John F., BSc, BMBS, PhD
Journal of the American College of Cardiology,
12/2015, Letnik:
66, Številka:
22
Journal Article
Recenzirano
Odprti dostop
ST-segment elevation MI (odds ratio: 2.7, 95% confidence interval: 2.2 to 3.2; p < 0.01) or non-ST-segment elevation MI (odds ratio: 1.5, 95% confidence interval: 1.3 to 1.8; p < 0.01) were key ...predictors in multivariable analyses; and 3) insurance status: irrelevant in this public system. ...the CR referral gap appears to be a universal phenomenon with similar characteristics.
IntroductionDespite extensive evidence of its benefits and recommendation by guidelines, cardiac rehabilitation (CR) remains highly underused with only 20%–50% of eligible patients participating. We ...aim to implement and evaluate the Country Heart Attack Prevention (CHAP) model of care to improve CR attendance and completion for rural and remote participants.Methods and analysisCHAP will apply the model for large-scale knowledge translation to develop and implement a model of care to CR in rural Australia. Partnering with patients, clinicians and health service managers, we will codevelop new approaches and refine/expand existing ones to address known barriers to CR attendance. CHAP will codesign a web-based CR programme with patients expanding their choices to CR attendance. To increase referral rates, CHAP will promote endorsement of CR among clinicians and develop an electronic system that automatises referrals of in-hospital eligible patients to CR. A business model that includes reimbursement of CR delivered in primary care by Medicare will enable sustainable access to CR. To promote CR quality improvement, professional development interventions and an accreditation programme of CR services and programmes will be developed. To evaluate 12-month CR attendance/completion (primary outcome), clinical and cost-effectiveness (secondary outcomes) between patients exposed (n=1223) and not exposed (n=3669) to CHAP, we will apply a multidesign approach that encompasses a prospective cohort study, a pre-post study and a comprehensive economic evaluation.Ethics and disseminationThis study was approved by the Southern Adelaide Clinical Human Research Ethics Committee (HREC/20/SAC/78) and by the Department for Health and Wellbeing Human Research Ethics Committee (2021/HRE00270), which approved a waiver of informed consent. Findings and dissemination to patients and clinicians will be through a public website, online educational sessions and scientific publications. Deidentified data will be available from the corresponding author on reasonable request.Trial registration numberACTRN12621000222842.
We hypothesized that there is an influence of socioeconomic status (SES) on association between pregnancy complications and premature coronary artery disease (PCAD) risk.
This project involved a data ...linkage approach merging three databases of South Australian cohorts using retrospective, age-matched case-control study design. Cases (
= 721), that is, women aged <60 years from Coronary Angiogram Database of South Australia (CADOSA) were linked to South Australian Perinatal Statistics Collection (SAPSC) to ascertain prior pregnancy outcomes and SES. Controls (
= 194) were selected from North West Adelaide Health Study (NWAHS), comprising women who were healthy or had health conditions unrelated to CAD, age matched to CADOSA (±5 years), and linked to SAPSC to determine prior pregnancy outcomes and SES. This project performed comparative analysis of SES using socioeconomic indexes for areas-index of relative socioeconomic advantage and disadvantage (SEIFA-IRSAD) scores across three databases.
Findings revealed that SEIFA-IRSAD scores at the time of pregnancy (
-value = 0.005) and increase in SEIFA-IRSAD scores over time (
-value = 0.040) were significantly associated with PCAD. In addition, when models were adjusted for SEIFA-IRSAD scores at the time of pregnancy and age, risk factors including placenta-mediated pregnancy complications such as preterm birth (odds ratio OR = 4.77, 95% confidence interval CI: 1.74-13.03) and history of a miscarriage (OR = 2.14, 95% CI: 1.02-4.49), and cardiovascular disease (CVD) risk factors including smoking (OR = 8.60, 95% CI: 3.25-22.75) were significantly associated with PCAD. When the model was adjusted for change in SEIFA-IRSAD scores (from CADOSA/NWAHS to SAPSC) and age, pregnancy-mediated pregnancy complications including preterm birth (OR = 4.40, 95% CI: 1.61-12.05) and history of a miscarriage (OR = 2.09, 95% CI: 1.00-4.35), and CVD risk factor smoking (OR = 8.75, 95% CI: 3.32-23.07) were significantly associated with PCAD.
SES at the time of pregnancy and change in SES were not associated with PCAD risk.
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