Diagnosing, fast and slow.

Diagnostic error is increasingly recognised as a source of significant morbidity and mortality in medicine. In this article, we will attempt to address several questions relating to clinical decision making; How do we decide on a diagnosis? Why do we so often get it wrong? Can we improve our critical faculties?We begin by describing a clinical vignette in which a medical error occurred and resulted in an adverse outcome for a patient. This case leads us to the concepts of heuristic thinking and cognitive bias. We then discuss how this is relevant to our current clinical paradigm, examples of heuristic thinking and potential mechanisms to mitigate bias.The aim of this article is to increase awareness of the role that cognitive bias and heuristic thinking play in medical decision making. We hope to motivate clinicians to reflect on their own patterns of thinking with an overall aim of improving patient care.

Outcomes of nurse-led clinic for patients treated with percutaneous coronary intervention: A retrospective analysis.

BACKGROUND: With an increasing prevalence of coronary heart disease, secondary prevention forms a major cornerstone of management. A dedicated nurse-led clinic for patients post percutaneous coronary intervention (PCI) offers a great opportunity to address risk factors in order to reduce cardiovascular events. PURPOSE: To determine the impact of a nurse-led clinic follow up of patients post PCI in relation to the 30 day mortality rate and re-admission, and patient satisfaction. Risk factor assessment, compliance with dual antiplatelet therapy (DAPT), and interventions at the clinic visit were also assessed. METHODS: A retrospective review of parameters recorded at clinic appointments from January 2015-December 2017. The data of patients were examined for baseline characteristics, risk factor assessment, and interventions at the clinic visit. Thirty day mortality and re-admission rates and patient satisfaction were major outcomes. RESULTS: 1325 individual patient records were retrospectively reviewed in our clinic. Mean age was 64 and 78% were males. The indications for PCI were STEMI (22.7%), NSTEMI (21.9%), and unstable and stable angina (43.1%). 5 patients (0.4%) died and 132 patients (10%) were re-admitted within 30 days after the follow-up visit. However, only 24 (1.8%) of the re-admissions were due to cardiac reasons. At the clinic appointment, 852 (64.3%) patients had non-pharmacological intervention and 473 (35.7%) patients had a pharmacological intervention. 712 (53.7%) patients had LDL-C above target and their statin therapy was amended accordingly. CONCLUSION: Nurse-led PCI clinics provide satisfactory assessment and management of risk factors achieving high patient satisfaction rates without increased risk of poor outcomes.

Left distal trans-radial access facilitates earlier discharge post-coronary angiography.

AIMS: In 2017, Kiemeneij published a paper on distal trans-radial artery access for coronary angiography in 62 patients. This paper proposed several advantages to this method. Since this paper was published, several other papers have been published describing this technique, with less than 200 cases in total described. We performed a non randomized control study of left distal trans-radial access in patients undergoing coronary angiography in our center. METHODS: We prospectively identified patients presenting for coronary angiography to our center for enrolment in this study. We recruited 94 patients (47 ldTRA, 47 age and sex matched controls). Pre-defined endpoints for the study were as follows: time until radial compression device (RCD) removal, procedural time, radiation dose, fluoroscopy time, and contrast dose. RESULTS: Patient and procedural characteristics did not differ significantly between the two groups. With regard to our primary endpoint, patients undergoing ldTRA required, on average, 69 min less time until removal of the RCD (167.8 ± 30 vs 236.6 ± 63.9 min, P < 0.0001). Procedural length did not vary between groups (28.95 ± 5.89 vs 29.76 ± 8.16 min, P = 0.5824). Similarly, there was no statistically significant difference in radiation dose area product (5032.66 ± 2740 vs 4826 ± 2796 Gy/cm2 , P = 0.7191), contrast dose (82.93 ± 23 vs 92.1 ± 33 mL, P = 0.1215), and fluoroscopy time between the two groups (5.41 ± 3.42 vs 4.82 ± 2.97 min, P = 0.3742). CONCLUSIONS: Our study confirms that ldTRA is a feasible technique for diagnostic coronary angiography in a modern cardiac catheterization laboratory. It results in decreased post-procedure radial artery compression time without increasing procedural time or radiation dose.

Pulmonary valve papillary fibroelastoma: a rare tumor and rare location.

Although rare, papillary fibroelastomas (PFEs) are considered the third most common cause of primary cardiac neoplasm. They are usually asymptomatic and are found during routine echocardiography. PFEs of the pulmonary valve are extremely rare. They are usually benign; however, because of their potential to embolize to the pulmonary circulation, it is often recommended that they be removed. This article reviews a case of an asymptomatic PFE of the pulmonary valve, incidentally found in a patient who presented with three-vessel coronary artery disease.

Contemporary management of infective endocarditis in pregnancy.

INTRODUCTION: Infective endocarditis (IE) during pregnancy is a rare condition that is associated with a high level of morbidity and mortality. The epidemiology, diagnosis, treatment, and prognosis have changed significantly in the last two decades. The declining incidence of rheumatic heart disease, improved life expectancy with congenital heart disease, advances in cardiac surgery and cardiac devices, rise in resistant microorganisms, complications of the opioid epidemic, and increasing maternal age are some of the many factors contributing to these changes. AREAS COVERED: This article explores existing literature on the topic including case reports, case series, registry data, and clinical guidelines. The focus of this article is the evolving epidemiology, predisposing factors and preventative measures, clinical presentation, investigation, management, and potential complications of IE in pregnancy. EXPERT OPINION: Robust prospective data on the management of IE in pregnancy is lacking, and obtaining these data will be very challenging. It is imperative that international registries are used to provide data on best clinical practices and inform future clinical guidelines. Multimodal imaging should be incorporated in the investigation of complicated cases. A multidisciplinary approach to the management of this rare and life-threatening condition is essential to ensure the best outcomes for both the mother and the fetus.

Severe Aortic Valvular Incompetence From IgG4-Related Disease: An Unusual Entity.

IgG4-related disease (IgG4-RD) is a new clinical entity characterized by lymphoplasmacytic lesions rich in IgG4-positive plasma cells. Myocardial involvement is extremely rare and not a typical cardiovascular manifestation of IgG4-RD. We report a rare case of IgG4-RD-associated myocardial mass causing severe aortic incompetence, successfully treated with surgery and corticosteroids. (Level of Difficulty: Intermediate.).

Endovascular management of acute limb ischemia.

Despite major advances in pharmacologic and endovascular therapies, acute limb ischemia (ALI) continues to result in significant morbidity and mortality. The incidence of ALI may be as high as 13-17 cases per 100,000 people per year, with mortality rates approaching 18% in some series. This review will address the contemporary endovascular management of ALI encompassing pharmacologic and percutaneous interventional treatment strategies.

Intravascular lithotripsy during percutaneous coronary intervention: current concepts.

INTRODUCTION: Coronary artery calcification (CAC) is commonly encountered by interventional cardiologists. Severe CAC may impair stent delivery or result in stent underexpansion, stent thrombosis and/or in-stent restenosis (ISR). Multiple tools have been developed to help overcome the challenges associated with CAC and improve outcomes for these patients. Intravascular shockwave lithotripsy (IVL) is a novel therapy that uses acoustic pressure waves for the modification of CAC. AREAS COVERED: This review discusses the growing body of evidence to support the safety and efficacy of IVL in the setting of de novo severely calcified coronary arteries prior to stenting. We also discuss international real-world experience with the coronary IVL system. This includes the use of IVL in the setting of acute coronary syndrome (ACS), ISR and in combination with other tools for calcium modification. EXPERT OPINION: IVL is a safe and effective therapy that results in the fracture of coronary calcium and facilitates optimal stent delivery and expansion. Longer term follow-up is essential to shed light on the durability and late outcomes of an IVL strategy. Randomized control trials are warranted to compare IVL to alternative methods of calcium modification and to explore further the use of IVL for ACS.

Total ischaemic time in STEMI: factors influencing systemic delay.

Total ischaemic time in ST-elevation myocardial infarction (STEMI) has been shown to be a predictor of mortality. The aim of this study was to assess the total ischaemic time of STEMIs in an Irish primary percutaneous coronary intervention (pPCI) centre. A single-centre prospective observational study was conducted of all STEMIs referred for pPCI from October 2017 until January 2019. There were 213 patients with a mean age 63.9 years (range 29-96 years). The mean ischaemic time was 387 ± 451.7 mins. The mean time before call for help (patient delay) was 207.02 ± 396.8 mins, comprising the majority of total ischaemic time. Following diagnostic electrocardiogram (ECG), 46.5% of patients had ECG-to-wire cross under 90 mins as per guidelines; 73.9% were within 120 mins and 93.4% were within 180 mins. Increasing age correlated with longer patient delay (Pearson's r=0.2181, p=0.0066). Women exhibited longer ischaemic time compared with men (508.96 vs. 363.33 mins, respectively, p=0.03515), driven by a longer time from first medical contact (FMC) to ECG (104 vs. 34 mins, p=0.0021). The majority of total ischaemic time is due to patient delay, and this increases as age increases. Women had longer ischaemic time compared with men and longer wait from FMC until diagnostic ECG. This study suggests that improved awareness for patients and healthcare staff will be paramount in reducing ischaemic time.

Difference in outcome among women and men after percutaneous mitral valvuloplasty.

OBJECTIVE: To analyze the differences in anatomical, clinical and echocardiographic characteristics of women and men undergoing PMV and to evaluate the relationship between sex, PMV success, and immediate and long-term clinical outcome. BACKGROUND: Rheumatic mitral stenosis (MS) is predominantly a disease of middle-aged women. Percutaneous mitral valvuloplasty (PMV) has become the standard of care for suitable patients. However little is known about the relationship between sex, PMV success, and procedural outcome. METHODS AND RESULTS: We evaluated measures of procedural success and clinical outcome in consecutive patients (839 women and 176 men) who underwent PMV. Despite a lower baseline echocardiographic score (7.47 ± 2.15 vs. 8.02 ± 2.18, P = 0.002), women were less likely to achieve PMV success (69% vs. 83%, adjusted OR 0.44, 95% CI 0.27-0.74, P = 0.002), and had a smaller post-procedural MV area (1.86 ± 0.7 vs. 2.07 ± 0.7 cm(2), P < 0.001). Overall procedural and in-hospital complication rates did not differ significantly between women and men. However, women were significantly more likely to develop severe MR immediately post PMV (adjusted OR 2.41, 95% CI 1.0-5.83, P = 0.05) and to undergo MV surgery (adjusted HR 1.54, 95% CI 1.03-2.3, P = 0.037) after a median follow-up of 3.1 years. CONCLUSIONS: Compared to men, women with rheumatic MS who undergo PMV are less likely to have a successful outcome and more likely to require MV surgery on long-term follow-up despite more favorable baseline MV anatomy.

Advances in endovascular treatment of critical limb ischemia.

Critical limb ischemia (CLI) represents the most severe clinical manifestation of peripheral arterial disease. In the absence of timely revascularization, CLI carries high risk of mortality and amputation. Over the past decade, endovascular revascularization has rapidly become the preferred primary treatment strategy for CLI, especially for the treatment of below-the-knee disease. Advances in percutaneous devices and techniques have expanded the spectrum of patients with CLI who are deemed candidates for revascularization. This review will focus on advances in endovascular options for the treatment of CLI, in particular for below-the-knee disease.

Interhospital and interindividual variability in secondary prevention: a comparison of outpatients with a history of chronic coronary syndrome versus outpatients with a history of acute coronary syndrome (the iASPIRE Study).

BACKGROUND: Studying variability in the care provided to secondary prevention coronary heart disease (CHD) outpatients can identify interventions to improve their outcomes. METHODS: We studied outpatients who had an index CHD event in the preceding 6-24 months. Eligible CHD events included acute coronary syndrome (ACS) and coronary revascularisation for stable chronic coronary syndrome (CCS). Site training was provided by a core team and data were collected using standardised methods. RESULTS: Between 2017 and 2019, we enrolled 721 outpatients at nine Irish study sites; 81% were men and mean age was 63.9 (SD ±8.9) years. The study examination occurred a median of 1.16 years after the index CHD event, which was ACS in 399 participants (55%) and stable-CCS in 322. On examination, 42.5% had blood pressure (BP) >140/90 mm Hg, 63.7% had low-density lipoprotein cholesterol (LDL-C) >1.8 mmol/L and 44.1% of known diabetics had an HbA1c >7%. There was marked variability in risk factor control, both by study site and, in particular, by index presentation type. For example, 82% of outpatients with prior-ACS had attended cardiac rehabilitation versus 59% outpatients with prior-CCS (p<0.001) and there were also large differences in control of traditional risk factors like LDL-C (p=0.002) and systolic BP (p<0.001) among outpatients with prior-ACS versus prior-CCS as the index presentation. CONCLUSIONS: Despite international secondary prevention guidelines broadly recommending the same risk factor targets for all adults with CHD, we found marked differences in outpatient risk factor control and management on the basis of hospital location and index CHD presentation type (acute vs chronic). These findings highlight the need to reduce hospital-level and patient-level variability in preventive care to improve outcomes; a lesson that should inform CHD prevention programmes in Ireland and around the world.

Treatment of renal artery in-stent restenosis with sirolimus-eluting stents.

The objective of this study was to analyze the use of sirolimus-eluting stent (SES) placement for the treatment of renal artery in-stent restenosis (RA-ISR). The optimal treatment of RA-ISR has not been fully elucidated to date. We retrospectively analyzed consecutive patients from our institution who underwent treatment of RA-ISR with a SES from May 2004 to June 2006. Using duplex ultrasound, RA-ISR (> 60% diameter) was determined by peak systolic velocity (PSV) > 300 cm/s and renal aortic ratio (RAR) > 4.0. Renal function (creatinine) and blood pressure were measured at baseline and follow-up. SESs were implanted in 16 patients (22 renal arteries) during the study period. The study cohort was predominantly female (75%) with a mean age of 68 +/- 12 years. RA-ISR was treated with SESs with a mean diameter of 3.5 mm and mean length of 17.9 +/- 3.8 mm. The mean post-dilation balloon diameter was 4.8 +/- 0.6. The baseline renal artery PSV was 445 +/- 131 cm/s with a mean RAR of 5.0 +/- 1.6. Follow-up information was available in 21 renal arteries. During a median follow-up of 12 months (range: 9-15 months), 15 renal arteries (71.4%) developed recurrence of ISR by ultrasonographic criteria. Univariate analysis revealed that female sex was an independent predictor of recurrence of ISR after SES implantation (p < 0.05). In conclusion, placement of a SES for the treatment of ISR in renal arteries is associated with high initial technical success but significant restenosis on duplex ultrasonography at follow-up.

May-Thurner syndrome in patients with cryptogenic stroke and patent foramen ovale: an important clinical association.

BACKGROUND AND PURPOSE: We aimed to investigate the incidence of May-Thurner syndrome in patients with cryptogenic stroke with patent foramen ovale. METHODS: This was a retrospective study. All consecutive patients with cryptogenic stroke having undergone patent foramen ovale closure from January 1, 2002, to December 31, 2007, at our institute were included in this study. Pelvic magnetic resonance venography studies of all patients were reviewed to determine if features of May-Thurner syndrome were present. Medical records and invasive venography studies of all patients were reviewed when available. All patients with May-Thurner syndrome features on magnetic resonance venography were reviewed by a vascular medicine specialist to define any previous incidence of deep vein thrombosis or any signs of chronic venous insufficiency. All patients also had lower limb venous duplex performed to rule out lower limb venous thrombosis. RESULTS: A total of 470 patients from January 1, 2002, until December 31, 2007, with cryptogenic stroke underwent patent foramen ovale closure at our institute. Thirty patients (6.3%) had features consistent with May-Thurner syndrome on magnetic resonance venography. These patients were predominantly female (80%) with a mean age of 43.6+/-11.9 years. Twelve patients (40%) had abnormalities in their laboratory thrombophilia evaluation and 13 females (54.1%) were taking hormone-related birth control pills. Only 2 patients had a history and signs of chronic venous insufficiency. All patent foramen ovales demonstrated right-to-left shunting on transesophageal echocardiography. Atrial septal aneurysms/hypermobile atrial septa were present in 70% of patients with May-Thurner syndrome. CONCLUSIONS: May-Thurner syndrome has an important clinical association with cryptogenic stroke and patent foramen ovale.

Vasoprotective effects of human CD34+ cells: towards clinical applications.

BACKGROUND: The development of cell-based therapeutics for humans requires preclinical testing in animal models. The use of autologous animal products fails to address the efficacy of similar products derived from humans. We used a novel immunodeficient rat carotid injury model in order to determine whether human cells could improve vascular remodelling following acute injury. METHODS: Human CD34+ cells were separated from peripheral buffy coats using automatic magnetic cell separation. Carotid arterial injury was performed in male Sprague-Dawley nude rats using a 2F Fogarty balloon catheter. Freshly harvested CD34+ cells or saline alone was administered locally for 20 minutes by endoluminal instillation. Structural and functional analysis of the arteries was performed 28 days later. RESULTS: Morphometric analysis demonstrated that human CD34+ cell delivery was associated with a significant reduction in intimal formation 4 weeks following balloon injury as compared with saline (I/M ratio 0.79 +/- 0.18, and 1.71 +/- 0.18 for CD34, and saline-treated vessels, respectively P < 0.05). Vasoreactivity studies showed that maximal relaxation of vessel rings from human CD34+ treated animals was significantly enhanced compared with saline-treated counterparts (74.1 +/- 10.2, and 36.8 +/- 12.1% relaxation for CD34+ cells and saline, respectively, P < 0.05) CONCLUSION: Delivery of human CD34+ cells limits neointima formation and improves arterial reactivity after vascular injury. These studies advance the concept of cell delivery to effect vascular remodeling toward a potential human cellular product.

Antiplatelet therapy for the primary and secondary prevention of cerebrovascular events in patients with extracranial carotid artery disease.

Cerebrovascular disease is a leading cause of morbidity and mortality in developed countries around the world. In the United States, there are an estimated 700,000 cases of stroke annually (of which over 85% are ischemic), costing an estimated $56.8 billion in associated treatment. Large vessel internal carotid artery stenosis is an important cause of ischemic stroke. Population-based studies have shown that the prevalence of carotid stenosis is approximately 0.5% in the sixth decade of life and increases to approximately 10% in the ninth decade. The majority of patients are asymptomatic. Asymptomatic carotid stenosis with 75%, the combined stroke and transient ischemic attack risk increases to approximately 11% annually, with 75% of events ipsilateral to the affected artery. Other studies have also shown that the risk of stroke increases proportionately to the severity of stenosis. The risk is higher for those patients who are symptomatic. In this review, we will discuss antiplatelet agents to prevent cerebrovascular events in the context of extracranial carotid artery disease. It is beyond the scope of this article to discuss antiplatelet treatment for other etiologies of stroke.

High-sensitivity troponin assays: development and utility in a modern health-care system.

Introduction: The introduction of cardiac troponin (cTn) assays have revolutionized the diagnosis and management of acute myocardial infarction in Emergency Departments worldwide. Its success has led to significant research and development investment in this area culminating in the development of newer high-sensitivity cardiac troponin assays (hs-cTn). While these newer assays allow for more rapid diagnosis by decreasing the time interval between serial data points, there is an inevitable trade off between increasing sensitivity and specificity. This review examines in detail the introduction and implementation of hs-cTN and its implications for clinical practice.Areas covered: This article reviews the history and development of high-sensitivity troponin assays and their application to clinical practice and current evidence base. It also discusses both the positive and negative aspects of the continuing increasing sensitivity of biochemical assays and the translation of this into clinical practice. Potential future developments are also discussed.Expert commentary: It is clear that there are many benefits to detecting extremely low concentration of cardiac troponin including the development of rapid rule out algorithms and the cost and time-saving advantages associated with the quicker movement of patients through the health-care system. It is important to note however that detecting troponin at very low concentrations also dramatically increases the false-positive rates and leads to a potentially large increase in invasive testing and diagnosis of myocardial infarction.

Coronary no-reflow in the modern era: a review of advances in diagnostic techniques and contemporary management.

Introduction: Atherosclerotic coronary artery disease, in particular acute myocardial infarction (AMI), is a leading cause of morbidity and mortality globally. Percutaneous coronary intervention (PCI) is the mainstay of treatment for obstructive coronary artery disease and AMI through the restoration of TIMI III flow. Despite good macrovascular flow, the myocardium can remain hypoperfusion due to poor microvascular perfusion, and this is referred to as 'no-reflow'. Various treatments have been studied with variable success in both prevention and treatment of no-reflow. Areas covered: This review outlines the cutting-edge diagnostic investigations which have been explored in no-reflow, allowing a deeper understanding of mechanism and microvascular pathological processes involved in its genesis. These include utility of novel MRI techniques and perfusion echo in conjunction with traditional approaches. Detailed review has been undertaken of both pharmacological and non-pharmacological techniques to prevent and manage microvascular dysfunction associated with no-reflow. Particular attention was paid to the evolution and successes of various mechanical protection devices. Expert opinion: Most promising innovations in the diagnosis and management of no-reflow are evaluated, and future outlook is explored. Emerging advances in acute coronary syndrome have their findings applied a role in modifying the pathophysiology of no-reflow.

Acute pericarditis: a review of current diagnostic and management guidelines.

This review examined the relevance of chest pain, pericardial friction rub, pericardial effusion and ECG changes in regard to the diagnosis of acute pericarditis. It also assessed the evidence for the management and therapeutic guidelines, specifically nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids. Overall, there appears to be a lack of research into pericarditis. The bulk of high-quality research seems to have been carried out prior to the publication of the European Society of Cardiology guidelines of 2015. Diagnostically, the current combination of symptoms, clinical signs and investigations offer reasonable criteria for diagnosis, but they are not a gold standard. Research into its therapeutic treatment options is required to address the effects of specific nonsteroidal anti-inflammatory drugs (NSAIDs).

Insight into the perioperative management of direct oral anticoagulants: concerns and considerations.

INTRODUCTION: Direct oral anticoagulants (DOACs) have gained momentum in recent years in patients requiring anticoagulation for the prevention and management of venous thromboembolism and thromboembolic events caused by atrial fibrillation. The use of these agents involves potential bleeding complications, particularly during invasive procedures. With increasing use of DOACs, adequate knowledge regarding the perioperative management of patients on DOACs has become indispensable. AREAS COVERED: This review covers the indications, mechanism of action, and pharmacokinetics of DOACs and their management in different perioperative settings based on various current guidelines and practices. The role of bridging therapy with heparin and the recently developed reversal agents are also discussed. EXPERT OPINION: The perioperative management of DOACs is influenced by drug pharmacokinetics, potential comorbidities of the patient and perioperative thrombotic and bleeding risk. In low bleeding risk and minor procedures, continuing DOACs seems to be safe. Interrupting DOACs in high-risk procedures might be necessary and should be based on the elimination half-life of the drug and renal function of the patient. Further research is needed to better clarify the role of recently developed reversal agents in the perioperative setting and to identify specific laboratory tests to guide the perioperative management of DOACs.