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.

Development and pretesting of "Becoming Breastfeeding Friendly": Empowering governments for global scaling up of breastfeeding programmes.

Scaling up breastfeeding programmes has not been highly prioritized despite overwhelming evidence that breastfeeding benefits the health of mothers and children. Lack of evidence-based tools for scaling up may deter countries from prioritizing breastfeeding. To fill this gap, Becoming Breastfeeding Friendly (BBF) was developed to guide countries in effectively scaling up programmes to protect, promote, and support breastfeeding. BBF includes an evidence-based toolbox that consists of a BBF Index, case studies, and a 5-meeting process. These three interrelated components enable countries to assess their breastfeeding scaling up environment, identify gaps, propose policy recommendations, develop a scaling up plan, and track progress. The toolbox was developed based on current evidence and expert guidance from a Technical Advisory Group, which was composed of global breastfeeding and metric experts with experience in the scaling up of health and nutrition programmes in low-, middle-, and high-income countries. The BBF toolbox required a step-by-step iterative approach to describe and systematize each component, thus an operational manual was developed. The BBF toolbox and BBF operational manual underwent intensive pretesting in two countries, Ghana and Mexico, resulting in the modification of each component plus the operational manual. Pretesting continues in six additional countries demonstrating that BBF is a robust and dynamic multi-sectoral process that, with relatively minor adaptations, can be successfully implemented in countries across world regions.

Becoming Breastfeeding Friendly Index: Development and application for scaling-up breastfeeding programmes globally.

Global efforts to further improve exclusive breastfeeding rates have not been successful, in part because effective scaling-up frameworks and roadmaps have not been developed. The Becoming Breastfeeding Friendly (BBF) toolbox includes an evidence-based index, the BBF Index (BBFI), to guide the development and tracking of large scale, well-coordinated, multisector national breastfeeding promotion programmes. This paper describes the development of the BBFI, which is grounded in the Breastfeeding Gear Model complex adaptive systems framework. The BBFI was developed by the BBF Steering Committee in collaboration with a high-level Technical Advisory Group following the Delphi consensus methodology. Key benchmarks and definitions were informed by evidence-based health, nutrition, and newborn survival initiatives identified from the academic and grey literature. The BBFI consists of 8 gears (54 benchmarks): Advocacy (4); Political Will (3); Legislation and Policies (10); Funding and Resources (4); Training and Program Delivery (17); Promotion (3); Research and Evaluation (10); and Coordination, Goals, and Monitoring (3). Scores are generated for 8 gear scores plus a total country score to gauge the scaling-up enabling environment. The BBFI provides an evidence-based index to assist countries in (a) assessing their readiness to scale up breastfeeding programmes and (b) tracking scaling-up progress.

Pulmonary hypertension due to fibrosing mediastinitis treated successfully with stenting of pulmonary vein stenoses.

We describe a patient with fibrosing mediastinitis after childhood histoplasmosis who presented with severe pulmonary hypertension secondary to pulmonary vein stenoses. Stenting of 2 stenosed pulmonary veins via a transseptal approach resulted in an immediate decrease in systolic pulmonary artery pressure from 90 to 68 mm Hg and improvement in dyspnea and cardiac index, which was sustained at 6 months. This case highlights the importance of routinely assessing the pulmonary veins during workup for pulmonary hypertension.

Low gradient aortic stenosis.

OPINION STATEMENT: Severe low-gradient (LG) aortic stenosis (AS) [aortic valve area (AVA) ≤ 1.0 cm(2), mean pressure gradient (MG) < 40 mmHg] represents a frequently encountered and challenging clinical dilemma. A systematic approach, which often requires several imaging modalities, should be undertaken to confirm the hemodynamic findings and rule out measurement error. Low-flow conditions often account for the discrepancy and can be present whether the left ventricular ejection fraction (LVEF) is depressed or normal. In patients with classical low-flow (LF), LG AS in which LVEF is reduced (<40-50 %), dobutamine stress echocardiography (DSE) should be used to distinguish patients with true severe AS and pseudo-severe AS, as well as to evaluate for the presence of left ventricular contractile or flow reserve. Surgical or transcatheter aortic valve replacement (AVR) should likely be reserved for those patients with true severe AS. Patient outcome with medical or surgical management generally relates to patient functional capacity, stenosis severity, and left ventricular functional reserve. Patients with severe LG AS with preserved LVEF can have a stroke volume that is either normal (>35 mL/m(2)) or low (<35 mL/m(2)). New data suggest that DSE can identify pseudo-severe AS in up to 30 % of patients with severe LF-LG AS with preserved LVEF. AVR should likely be restricted to those patients with true severe AS, although there is currently little data to support this strategy. Symptomatic patients with severe LG AS with preserved LVEF, whether they have normal or low flow, should be offered AVR. Transcatheter AVR provides an alternative therapeutic option in the high-risk patient.

Cardiogenic shock in Takotsubo cardiomyopathy: a focus on management.

Takotsubo cardiomyopathy has become a well recognized mimicker of acute coronary syndrome. Patients generally do well, although a minority can develop life-threatening complications. We present a case of 1 such patient in a branched self-assessment format designed to challenge the reader's clinical management skills.