Chest Pain Evaluation: Diagnostic Testing.

Chest pain/discomfort (CP) is a common symptom and can be a diagnostic dilemma for many clinicians. The misdiagnosis of an acute or progressive chronic cardiac etiology may carry a significant risk of morbidity and mortality. This review summarizes the different options and modalities for establishing the diagnosis and severity of coronary artery disease. An effective test selection algorithm should be individually tailored to each patient to maximize diagnostic accuracy in a timely fashion, determine short- and long-term prognosis, and permit implementation of evidence-based treatments in a cost-effective manner. Through collaboration, a decision algorithm was developed (www.chowmd.ca/cadtesting) that could be adopted widely into clinical practice.

La douleur ou la gêne thoracique sont des symptômes fréquents qui peuvent poser un dilemme diagnostique pour de nombreux médecins. Les erreurs de diagnostic d'une cause aiguë ou chronique progressive d'origine cardiaque peuvent d'ailleurs entraîner un risque considérable de morbidité et de mortalité. La présente synthèse porte sur les différentes options et modalités d'établissement du diagnostic et de la gravité d'une coronaropathie. Un algorithme efficace pour le choix des tests doit être adapté à chaque patient afin de maximiser l'exactitude diagnostique dans les plus brefs délais, de déterminer le pronostic à court et à long terme, et de permettre une mise en œuvre de traitements fondés sur des données probantes tout en tenant compte des coûts. Un algorithme décisionnel a donc été conjointement mis au point (www.chowmd.ca/cadtesting) et pourrait être largement adopté dans la pratique clinique.

European Society of Cardiology Guideline-Adherent Antithrombotic Treatment and Risk of Mortality in Asian Patients with Atrial Fibrillation.

This study compared the risk of mortality in atrial fibrillation (AF) patients treated adherent to the 2012 European Society of Cardiology (ESC) guidelines for stroke prevention and those who were not treated according to guideline recommendations. This study used the Taiwan National Health Insurance Research Database. From 1996 to 2011, 354,649 newly diagnosed AF patients were identified as the study population. Among the study cohort, 45,595 and 309,054 patients were defined as Guideline-Adherent and Non-Adherent groups, respectively. During the follow up of 1,480,280 person-years, 133,552 (37.7%) patients experienced mortality. The risk of mortality was lower among AF patients whose treatment was adherent to the guideline recommendation for stroke prevention than those whose treatment was not (annual risk of mortality = 4.3% versus 10.0%) with an adjusted hazard ratio of 0.62 (95% confidence interval = 0.61-0.64, p value < 0.001) after adjusting for age, gender, CHA2DS2-VASc score and antiplatelet therapy. The findings were consistently observed after propensity matching analysis. In conclusion, the risk of mortality was lower for AF patients who were treated according to the antithrombotic recommendations of the 2012 ESC guidelines, guided by the CHA2DS2-VASc score. Better efforts to implement guidelines would lead to improved outcomes for patients with AF.

Presence of diabetic microvascular complications does not incrementally increase risk of ischemic stroke in diabetic patients with atrial fibrillation: A nationwide cohort study.

Conventional stroke risk prediction tools used in atrial fibrillation (AF) incorporate the presence of diabetes mellitus (DM) as a risk factor. However, it is unknown whether this risk is homogenous or dependent on the presence of diabetic microvascular complications, such as diabetic retinopathy, nephropathy, and neuropathy. The present study examined the risk of ischemic stroke in diabetic patients with and without microvascular complications. The present study used the National Health Insurance Research Database in Taiwan with detailed healthcare data on all-comers to the Taiwanese medical system from January 1, 1996 to December 31, 2011. AF and DM were identified when listed as discharge diagnoses or confirmed more than twice in the outpatient department. Patients on antithrombotic agents were excluded. The clinical endpoint was ischemic stroke. Among the 50,180 AF patients with DM, the majority had no microvascular complications (72.7%), while 2.6% had diabetic retinopathy, 8.4% had diabetic nephropathy, and 16.1% had diabetic neuropathy. Ischemic stroke occurred in 6003 patients, with a 4.74% annual risk of ischemic stroke. When compared with DM patients without microvascular complications, those with diabetic retinopathy, nephropathy, or neuropathy had higher incidences of ischemic stroke (4.65 vs 5.07, 4.77, or 5.20 per 100 person-years, respectively). However, after adjusting for confounding factors, the differences were no longer significant. In a large nationwide AF cohort with DM, risk of ischemic stroke was similar between patients with and without microvascular complications, suggesting that risk stratification of these patients does not require inclusion of diabetic retinopathy, nephropathy, and neuropathy.

The First Dedicated Cardiac Rehabilitation Program for Patients With Spontaneous Coronary Artery Dissection: Description and Initial Results.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction in women, but the role of rehabilitation after SCAD is unclear. METHODS: We designed a dedicated SCAD cardiac rehabilitation (SCAD-CR) program for our SCAD survivors at Vancouver General Hospital. This program encompasses a multidisciplinary approach including exercise rehabilitation, psychosocial counselling, dietary and cardiovascular disease education, and peer group support. Exercise and educational classes were scheduled weekly with a targeted participation of 6 months. Psychosocial counselling, mindful living sessions, social worker and psychiatry evaluations, and peer-group support were offered. RESULTS: We report our first consecutive cohort of 70 SCAD women who joined SCAD-CR from November 2011 to April 2015. The average age was 52.3 ± 8.4 years. Mean participation duration was 12.4 ± 10.5 weeks; 28 completed 6 months, 48 completed ≥ 1 month. At entry, 44 (62.9%) had recurrent chest pains and average metabolic equivalents on exercise treadmill test was 10.1 ± 3.3. At program exit, the proportion with recurrent chest pains was lower (37.1%) and average metabolic equivalents was higher 11.5 ± 3.5 (both P < 0.001). There was a significant improvement in the STOP-D depression questionnaire, with mean scores of 13.0 ± 1.4 before and 8.0 ± 1.7 after the SCAD-CR (P = 0.046). Twenty (28.6%) social worker referrals and 19 (27.1%) psychiatry referrals were made. Mean follow-up was 3.8 ± 2.9 years from the presenting SCAD event, and the major cardiac adverse event rate was 4.3%, lower than our non-SCAD-CR cohort (n = 145; 26.2%; P < 0.001). CONCLUSIONS: This is the first dedicated SCAD-CR program to address the unique exercise and psychosocial needs of SCAD survivors. Our program appears safe and beneficial in improving chest pain, exercise capacity, psychosocial well-being and cardiovascular events.

Spontaneous Coronary Artery Dissection Misdiagnosed as Takotsubo Cardiomyopathy: A Case Series.

Spontaneous coronary artery dissection (SCAD) and Takotsubo cardiomyopathy (TTC) can both cause myocardial infarction with subsequent normalization of wall motion abnormality. Angiograms of patients with TTC at Vancouver General Hospital were reviewed for SCAD. Clinical and investigational characteristics were recorded. Nine women with nonatherosclerotic SCAD were misdiagnosed as having TTC. Their average age was 55 years. Five patients had hypertension and 4 had emotional or physical stress. Fibromuscular dysplasia was present in 4 women. Wall motion abnormalities corresponded to dissected artery location and subsequently resolved. SCAD should be included in the differential diagnosis of patients suspected of having TTC and coronary angiograms scrutinized for subtle SCAD.

Warfarin Monotherapy in Atrial Fibrillation Patients With Stable Coronary Disease One Year After Myocardial Infarction/Stent: Two Birds With One Stone?

Patients with atrial fibrillation and stable coronary artery disease remain a therapeutic challenge because of the different antithrombotic therapies for the 2 conditions and the increase in bleeding with concomitant antiplatelet and anticoagulant medications. Current guidelines extrapolated data from studies of antithrombotic regimens of each condition separately but there is limited evidence for the optimal regimen in patients with atrial fibrillation and stable coronary artery disease beyond the first year after an acute coronary syndrome or stent implantation. In this review we suggest that warfarin monotherapy is sufficient for this patient population beyond 1 year.

Basis for sex-specific expression of Takotsubo cardiomyopathy, cardiac syndrome X, and spontaneous coronary artery dissection.

Takotsubo cardiomyopathy, cardiac syndrome X, and spontaneous coronary artery dissection are cardiovascular syndromes with a predilection for women. A complex interplay between neurohormonal factors, genetic influences, anatomic alterations, and other factors together affect cardiovascular function. Specifically, a high, variable, or deficient estrogen state leads to vasomotor instability with propensity toward vasoconstriction and endothelial dysfunction that predispose women to myocardial impairment, microvascular dysfunction, and coronary arterial wall instability. As the predominant sex hormone in women, fluctuating estrogen levels lead to a sex disparity in the expression of these cardiac entities. This review explores the research on sex-based differences of the neurohormonal, genetic, and mechanical factors in the normal cardiovascular system and in the pathophysiology of these 3 conditions. The understanding of their prevalence, pathogenesis, and sex disparity allows improved recognition, management, and support of female patients inflicted with these syndromes.

Reproductive health practices among Indian, Indo-Canadian, Canadian East Asian, and Euro-Canadian women: the role of acculturation.

OBJECTIVE: Lower rates of cervical cancer screening in Indian women have been consistently reported, and this has been attributed to cultural barriers. In Canada, the fastest-growing and largest immigrant groups are South Asian and East Asian. Since traditional values are largely retained in Indo-Canadian immigrants and their children, identifying reproductive health behaviours among these ethnic minority groups is important. Our goal was to compare reproductive health knowledge and behaviours of Indian women living in India and in Canada, East Asian women in Canada, and Euro-Canadian women. We also explored the level of acculturation in the two immigrant groups in order to understand the extent to which affiliation with Western culture may improve reproductive health knowledge. METHODS: We recruited 663 women of reproductive age from India and from a Canadian university for assessment. These women completed the Health Beliefs Questionnaire, which measures reproductive health behaviours and knowledge, and the Vancouver Index of Acculturation, which measures the level of mainstream and heritage acculturation. RESULTS: Euro-Canadian women were most likely to have ever had a Papanicolaou (Pap) test and to perform breast self-examination (BSE). There was no difference between the two Indian groups in the proportion who had ever had a Pap test, but Indo-Canadian women were more likely to have performed BSE. All women showed knowledge of reproductive health, but the three Canadian groups consistently had more accurate knowledge than the Indian group. Among the two immigrant groups, the level of acculturation was associated with reproductive health knowledge. CONCLUSION: Canadian women show reproductive health behaviours and knowledge that is superior to Indian women. Moving to a western culture did not influence Indian women's Pap testing behaviour; however, the fact that the reproductive health knowledge of Indian women who moved to Canada was better than that of women in India suggests that there may be a knowledge-behaviour desynchrony in this group of women. Efforts targeted at ethnic minority groups that aim to improve reproductive health knowledge and behaviours are greatly needed.