Radiation protection training for cardiologists in the era of multiple imaging techniques and complex interventions.

Cardiologists are among the heaviest medical users of ionising radiation. This usage is growing in proportion to the expanding range of cardiac diagnostic tests and interventional treatments. The primary focus of cardiologists is achieving clear diagnoses as well as technically and clinically successful treatments. That has to be set alongside strong awareness of the properties of ionising radiation and associated safety issues. This article illustrates some of the interplay between contemporary cardiology, radiological techniques, cardiology training and ionising radiation regulations and aims to set context for training and accreditation of cardiologists who use ionising radiation.

Adverse events following percutaneous and surgical coronary revascularisation: Analysis of non-MACE outcomes in the Stent or Surgery (SoS) Trial.

OBJECTIVES: To analyse adverse events requiring or prolonging hospitalisation in the Stent or Surgery (SoS) trial. BACKGROUND: Many adverse events following coronary revascularisation are non-major adverse cardiovascular events (non-MACE). Trials comparing percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) have reported rates of mortality and MACE only. MATERIAL AND METHODS: Comparisons between PCI and CABG groups in the SOS trial were by intention to treat. For patients with non-fatal/non-MACE, number of events per 100 patient years follow-up and duration of hospital stay were assessed. Competing risk analysis was used to illustrate temporal pattern of adverse outcomes. RESULTS: During 2 y median follow up, 1 one or more adverse event occurred in 47.3% (231) of the PCI group and 53% (265) of the CABG group (p=0.086). Non-fatal/non-MACE occurred in 11.9% of the PCI group and 38.6% of the CABG group (p<0.001). Non-fatal/non-MACE per 100 patient years follow-up was 17.49 (PCI) and 35.04 (CABG), rate ratio 2.0, 95% CI 1.7 to 2.4, p<0.001. Cumulative non-fatal/non-MACE associated hospital stays were 1387 and 3287 days in PCI and CABG groups respectively. Median duration of hospitalisation per non-fatal/non-MACE was 5 days (interquartile range 2 to 11.75 days) in the PCI group and 6 days (interquartile range 2 to 12 days) in the CABG group, p=0.245. CONCLUSIONS: CABG had lower cumulative incidence of fatal or MACE outcomes, higher cumulative incidence of non-fatal/non-MACE outcomes, and longer cumulative hospitalisation periods compared to the PCI group.

Use of a single Q guide catheter for complete assessment and treatment of both coronary arteries via radial access during acute ST elevation myocardial infarction: a review of 40 consecutive cases.

BACKGROUND: It is normally necessary to use more than 1 coronary catheter in primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI). We explored the utility of a single guide catheter (Q) strategy for complete coronary assessment and treatment in PPCI. METHODS: Fifty-seven consecutive STEMI cases undergoing invasive management were included. Radial access was the default route (6 cases via femoral access). Among radial cases, a TIG catheter was used first on 6 occasions (perceived low likelihood of subsequent PCI) and a Judkins right followed by an EBU catheter on three occasions (stock issue). A Q guide was used as initial default in the remaining 42 cases. Two anterior STEMI cases had recently undergone angiography and did not require right coronary reinspection. Procedural and outcomes data were recorded prospectively. RESULTS: The Q catheter allowed complete assessment and treatment in 33 cases, 6 cases requiring a second catheter and one patient dying prior to right coronary imaging. Territories of infarction were: anterior (n = 18), inferior (n = 14), inferoposterior (n = 3), lateral (n = 1), inferolateral (n = 2), inferoposterolateral (n = 2). Sixty-three out of 65 lesions were treated successfully. Median catheterization laboratory door to balloon time was 18 minutes (IQR 15-21 minutes). There were no catheter-related complications. CONCLUSIONS: A default Q guide catheter allows rapid effective imaging and treatment of both left and right coronaries in the majority of STEMI cases suitable for radial access PPCI.

Management of radial artery perforation during coronary angiography and angioplasty--a report of two cases.

Perforation and disruption of the artery used for access is a recognized complication of coronary angiography. There is an increasing trend toward use of the radial artery for angiography and angioplasty, particularly in the primary angioplasty setting, because of the reduced risk of hemorrhagic complications. On the rare occasions when radial artery perforation occurs, operators have had a tendency to switch to a second arterial access route. This article describes a technique for managing peri-procedural perforation which does not require use of a second artery for access. We show two cases where this technique was used successfully, demonstrating an angiographically normal radial artery at the end of the procedure.

Predicting angiographic outcome in contemporary percutaneous coronary intervention: a lesion-specific logistic model.

BACKGROUND: Previous angiographic lesion classification systems were derived from analysis of outcomes and lesion complexity in the early stent era. Advances in equipment design and techniques have altered the association between lesion and target vessel characteristics and procedural outcome in modern percutaneous coronary intervention (PCI). We evaluated the precise relationship between lesion characteristics and technical outcome on a lesion by lesion basis in a large dataset. We developed a multivariate model to predict technical failure in PCI. METHODS: Analysis of prospectively collected data on 10,800 lesions in 6,719 consecutive PCI cases between January 2000 and December 2004. Multivariate logistic regression was undertaken to identify predictors of angiographic outcome at each treated lesion (success/failure). Statistical model validation was carried out using data from a further 3,340 treated lesions in 1,940 consecutive cases. RESULTS: Independent variables associated with an increased risk of technical failure included total occlusion, severe calcification, proximal vessel tortuosity >90 degrees, lesion in a degenerate vein graft, and lesion angulation > or =90 degrees. The receiver operating characteristics (ROC) curve for the predicted probability of technical failure was 0.85. Failure occurred in 2.2% of treated lesions in the validation set (ROC curve 0.82, model predicted 2.5%). CONCLUSIONS: We have re-evaluated the association between lesion characteristics and technical outcome in modern PCI. We have thereby developed a contemporary prediction model for angiographic outcome at each treated lesion.

"First-hit" heart attack risk calculators on the world wide web: implications for laypersons and healthcare practitioners.

BACKGROUND: Heart attack risk calculators are readily accessible on the world wide web, offering potentially powerful means of health education and risk awareness. Laypersons may be unaware of differences in applicability, risk calculation algorithms and output formats among such calculators. This study assesses the impact of basic web searching terms on type of calculator accessed and on the resulting risk score. DESIGN: Observational study. METHODS: Seventy-two notional individual risk factor profiles were constructed, based on six combinations of presence or absence of smoking habit, hypercholesterolaemia, mixed hyperlipidaemia, hypertension and family history of premature coronary disease among males and females in age groups 30, 40, 50, 60, 70 and 80 years. The term heart attack risk calculator was entered into the Google, Yahoo, MSN, AltaVista and Excite search engines. RESULTS: The first five web pages purporting to contain heart attack risk calculators were included. Subpages of URLs leading to duplicate calculators were excluded. All search engines provided similar "hits" for the same search term. Framingham or PROCAM risk prediction models were the templates for all calculators. Different calculators often gave different absolute percentage risk scores for the same notional risk factor profiles. Differences were clinically insignificant in most cases when comparisons were made between bracketed risk scores within 5% of one another. One calculator gave disproportionately high risk estimates for women compared to men with the same risk factor profile and compared to other calculators into which identical risk profiles were entered. CONCLUSIONS: Simple search terms resulted in appropriate "hits". All calculators were based on reputable risk assessment models. There was broad agreement across different calculators for the range of risk factor profiles entered, but one calculator gave inconsistent risk scores.

Transulnar access for coronary angiography and intervention: an early review to guide research and clinical practice.

Access for coronary angiography and intervention is increasingly achieved via the radial artery due to the significant risks of femoral access. However, anatomical and size variation mean the radial artery is not always suitable. The ulnar artery is occasionally used as an alternative in such cases, and while ulnar artery puncture may be relatively easy, there are anatomical particulars that could lead to complications following this access route. In the absence of accepted guidelines, this paper examines the available data on ulnar access for coronary procedures. A structured literature search was undertaken to gather peer-reviewed articles and conference abstracts relating to ulnar access. Data from each source were examined in a prescribed way with reference to technical aspects, procedural success or failure, catheter size and complications. A total of 9 publications and 2 conference abstracts were identified, detailing 483 transulnar coronary procedures in 463 cases. There were no randomized, controlled trials. Success occurred in 90.9% of procedures, predominantly using catheter sizes of 4, 5 and 6 Fr, with complications of any type occurring in 4.6% of procedures. Transulnar access may be acceptable in selected cases, but larger data sets are required, preferably of registry or randomized and controlled trial formats.

Real-time myocardial contrast dobutamine stress echocardiography in coronary stenosis.

BACKGROUND: Simultaneous wall motion and myocardial perfusion analysis could offer advantages over either method alone. Diagnostic utility of combining these parameters during dobutamine stress echocardiography is evaluated in this study. METHODS: Myocardial contrast dobutamine stress echocardiography was performed on thirty-eight patients with single or double vessel coronary artery stenosis of >50%. Two-dimensional standard wall motion images were acquired at baseline, low, intermediate and peak stages of dobutamine stress echocardiography. Contrast enhanced wall motion and perfusion were assessed with Cadence Contrast Imaging (Sequoia C256, Acuson) and Optison infusion (GE Healthcare) at baseline and peak stages of the same protocol. Perfusion was analysed by identification of contrast defects and by measuring contrast replenishment time after destructive ultrasound pulses. RESULTS: The group consisted of 28 males and 10 females, mean age 60.9+/-9.7 years. Fifty-four out of one hundred and fourteen coronary arteries were affected by stenoses >50%. Standard wall motion analysis was assessable in 37 cases, one of which was inconclusive, while contrast wall motion and perfusion were assessable in 32 cases. Accuracy for coronary stenosis was 84% for standard wall motion (108 coronary territories), 82% for contrast wall motion (96 territories), 69% for peak stress contrast defects (83 territories), 91% for combined peak stress contrast defects and increased contrast replenishment time (85 territories), and 90% for all contrast modalities combined (96 territories). CONCLUSION: Combined wall motion and real-time perfusion assessment during dobutamine stress is feasible and at least equivalent to conventional stress echocardiography for detection of significant coronary stenosis.