Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient.

Patients who are comatose after cardiac arrest continue to be a challenge, with high mortality. Although there is an American College of Cardiology Foundation/American Heart Association Class I recommendation for performing immediate angiography and percutaneous coronary intervention (when indicated) in patients with ST-segment elevation myocardial infarction, no guidelines exist for patients without ST-segment elevation. Early introduction of mild therapeutic hypothermia is an established treatment goal. However, there are no established guidelines for risk stratification of patients for cardiac catheterization and possible percutaneous coronary intervention, particularly in patients who have unfavorable clinical features in whom procedures may be futile and affect public reporting of mortality. An algorithm is presented to improve the risk stratification of these severely ill patients with an emphasis on consultation and evaluation of patients prior to activation of the cardiac catheterization laboratory.

Ad hoc percutaneous coronary intervention: a consensus statement from the Society for Cardiovascular Angiography and Interventions.

Percutaneous coronary interventions (PCI) may be performed during the same session as diagnostic catheterization (ad hoc PCI) or at a later session (delayed PCI). Randomized trials comparing these strategies have not been performed; cohort studies have not identified consistent differences in safety or efficacy between the two strategies. Ad hoc PCI has increased in prevalence over the past decade and is the default strategy for treating acute coronary syndromes. However, questions about its appropriateness for some patients with stable symptoms have been raised by the results of recent large trials comparing PCI to medical therapy or bypass surgery. Ad hoc PCI for stable ischemic heart disease requires preprocedural planning, and reassessment after diagnostic angiography must be performed to ensure its appropriateness. Patients may prefer ad hoc PCI because it is convenient. Payers may prefer ad hoc PCI because it is cost-efficient. The majority of data confirm equivalent outcomes in ad hoc versus delayed PCI. However, there are some situations in which delayed PCI may be safer or yield better outcomes. This document reviews patient subsets and clinical situations in which one strategy is preferable over the other.

Recognition of noncardiac findings on cardiac computed tomography examination.

Multislice computed tomography (CT) is rapidly emerging as a novel technique for the evaluation of coronary artery disease. It is anticipated that with increasing acceptance of this imaging technique, CT for calcium scores and CT angiography will be performed in ever greater numbers. Thus, it is all but inevitable that clinicians will stumble upon incidental findings given the sheer number of vital organs and blood vessels that are imaged in the field of view. This article reviews the literature on incidental findings on cardiac CT with a focus on pulmonary nodules, ethical aspects of following up such findings, and cost implications.

Ethical trials to determine the risks and benefits of radiation exposure from coronary CT angiography.

This essay discusses the ethical implications of medical research using ionizing radiation in the diagnostic imaging range. Coronary CT angiography will be used as an example. Since coronary artery disease is the most common cause of death in the United States, any change in the work-up or management of patients with coronary artery disease has enormous clinical and economic implications. Risks of diagnostic radiation differ from those encountered in routine medical research as radiation-related cancers and heritable genetic damage can manifest in the irradiated individual or in subsequent generations. The risk to research subjects is ethically troubling because the research may not offer direct benefit to participants, although the benefits to society and future patients could be considerable. The American College of Radiology has a mandate to lead in the discussion of how to best minimize the risks of diagnostic radiation exposure in clinical research while encouraging studies likely to maximize benefits for future patients.

Ethical considerations in CT angiography.

The rapid development and clinical deployment of CT angiography raises several important issues, including assurance of professional competence and technical quality, self-referral, the relative role of radiologists and cardiologists, appropriateness and proper indications, the detection and disposition of unexpected or incidental findings and the concern for the rapidly increasing costs of health care and imaging. These questions are properly addressed within the framework of medical ethics, including principles of beneficence, autonomy and justice.

Ethics in interventional cardiology: combining coronary intervention with diagnostic catheterization.

As coronary intervention procedures have become more common, their performance at the time of diagnostic coronary arteriography has become more routine. Combined arteriography and coronary intervention may be slightly less costly and, for some patients, more dangerous than staged intervention. Combined intervention is appropriate in selected patients if they are well informed and it can be done safely; however, a combined strategy should not be applied to all patients.

Ethical issues for invasive cardiologists: Society for cardiovascular angiography and interventions.

In view of the major impact of medical economic forces, rapidly changing technology, and other pressures on invasive cardiologists, the Society for Cardiovascular Angiography and Interventions determined that a statement of the ethical issues confronting the modern invasive cardiologist was needed. The various conflicts presented to the cardiologist in his or her roles as practicing clinician, administrator of the catheterization laboratory, educator, or clinical researcher were reviewed. In all instances, the major concern was determined to be the welfare of the patient no matter how forceful the pressures from various outside force or concerns for personal advancement might be.

The cardiac access longitudinal study. A study of access to invasive cardiology among African American and white patients.

OBJECTIVES: We sought to identify factors contributing to racial disparity in the receipt of coronary angiography (CA). BACKGROUND: Numerous studies have demonstrated that African American patients are less likely to receive needed diagnostic and therapeutic coronary procedures than white patients. This report summarizes the methods and findings of a study linking medical records with patient and physician interviews to address racial disparities in the utilization of CA. METHODS: This is a retrospective, cross-sectional study conducted in three urban hospitals in Maryland. A total of 9,275 medical records were reviewed, representing all 7,058 cardiac patients admitted in a two-year period. We identified 2,623 patients who, according to American College of Cardiology guidelines, were candidates for receiving CA. A total of 1,669 patients (721 African Americans and 948 whites) and 74% of their physicians were successfully interviewed. Multivariate and hierarchical multivariate logistic regression were used to construct a model of receipt of CA within one year of the hospitalization. RESULTS: The unadjusted odds of white patients receiving CA was three times greater than the odds for African American patients (odds ratio [OR] 3.0, 95% confidence interval [CI] 2.4 to 3.7). Adjusting for patients' clinical and social characteristics resulted in a 13% reduction in the OR for race. Adjusting for physician and health care system characteristics reduced the OR by 43%, to 1.7 (95% CI 1.3 to 2.4). CONCLUSIONS: Racial disparity in the utilization of CA is a function of differences in the health care system "context" in which African American and white patients obtain care, combined with differences in the specific clinical characteristics of patients.