Individual preferences on the balancing of good and harm of cardiovascular disease screening.

OBJECTIVE: Transition towards value-based healthcare requires insight into what makes value to the individual. The aim was to elicit individual preferences for cardiovascular disease screening with respect to the difficult balancing of good and harm as well as mode of delivery. METHODS: A discrete choice experiment was conducted as a cross-sectional survey among 1231 male screening participants at three Danish hospitals between June and December 2017. Participants chose between hypothetical screening programmes characterised by varying levels of mortality risk reduction, avoidance of overtreatment, avoidance of regretting participation, screening duration and location. A multinomial mixed logit model was used to model the preferences and the willingness to trade mortality risk reduction for improvements on other characteristics. RESULTS: Respondents expressed preferences for improvements on all programme characteristics. They were willing to give up 0.09 (95% CI 0.08 to 0.09) lives saved per 1000 screened to avoid one individual being over treated. Similarly, respondents were willing to give up 1.22 (95% CI 0.90 to 1.55) or 5.21 (95% CI 4.78 to 5.67) lives saved per 1000 screened to upgrade the location from general practice to a hospital or to a high-tech hospital, respectively. Subgroup analysis revealed important preference heterogeneity with respect to smoking status, level of health literacy and self-perceived risk of cardiovascular disease. CONCLUSIONS: Individuals are able to express clear preferences about what makes value to them. Not only health benefit but also time with health professionals and access to specialised facilities were important. This information could guide the optimal programme design in search of value-based healthcare.

Feasibility, symptoms, adverse effects, and complications associated with noninvasive assessment of coronary flow velocity reserve in women with suspected or known coronary artery disease.

BACKGROUND: Microvascular coronary impairment, defined as reduced coronary flow reserve, represents the predominant etiologic mechanism of ischemia in women with chest pain and no obstructive coronary artery disease. Transthoracic echocardiography (TTE) is a noninvasive method for assessing coronary flow velocity reserve (CFVR) in the left anterior descending coronary artery (LAD). The purpose of this investigation was to define the safety profile, feasibility, adverse events, and rate of complications of the test in women with suspected CAD. METHODS: We evaluated CFVR in LAD with TTE during adenosine infusion in 1455 women aged 66.4±11.9 years. RESULTS: A complete CFVR study was achieved in 1429 pts (feasibility 98.2%), the test being performed also in the early phase of acute coronary syndrome and on obese patients. Minor symptoms or adverse effects occurred in 43.7% of patients not requiring test termination: hyperpnea (16.7%), flushing (9.4%), atypical chest pain (9.9%), headache (6.6%), minor arrhythmias (2.9%), chest pain with EKG changes (1.5%) were the symptoms reported. No major complications were observed. CONCLUSIONS: Noninvasive assessment of CFVR in LAD by TTE is a very feasible method with very low incidence of adverse events and complications in women with suspected or known CAD. It is safe and can be used when evaluating female patients with atherosclerotic LAD disease or with coronary microvascular impairment.

Índice de conicidad y su utilidad para detectar riesgo cardiovascular y metabólico / Conicity index and its usefulness for detection of cardiovascular and metabolic risk

Antecedentes: desarrollar formas diagnósticas de fácil aplicación, buena precisión y bajo costo, con la finalidad de predecir el riesgo cardiometabólico en nuestros pacientes, nos lleva a la necesidad de identificar medidas y relaciones antropométricas que nos resulten de utilidad en su detección. Objetivo: describir la utilidad del índice de conicidad, como predictor de riesgo cardiovascular y metabólico, y compararlo con algunas de las medidas y relaciones antropométricas utilizadas con este fin. Métodos: se revisaron 80 artículos, de los cuales 51 cumplieron con los criterios de calidad esperados por los autores. La búsqueda se realizó a través de algunas de las bases de datos y de los buscadores habituales. Resultados: las características fisiológicas del tejido adiposo abdominal son significativas, e incluso, posibles determinantes del aumento de riesgo cardiometabólico asociado a la obesidad visceral. El índice de conicidad es una relación que involucra varias medidas antropométricas, como la circunferencia de la cintura, la talla y el peso corporal. Este índice ha sido utilizado para indicar el aumento de la grasa abdominal, y en la predicción del riesgo cardiovascular y metabólico. Entre los resultados de los diferentes estudios realizados, se han observado diversos criterios con respecto a su utilidad y empleo, en comparación con otras medidas e índices antropométricos, que en el mejor de los casos, en un futuro, debemos intentar esclarecer, a través de investigaciones diseñadas con este objetivo. Conclusiones: el índice de conicidad es una relación útil, para determinar la existencia de obesidad abdominal, aunque no parece ser el mejor predictor de riesgo cardiovascular y/o metabólico, al compararlo con el resto de las medidas y relaciones antropométricas utilizadas con este fin(AU)

Background: developing diagnosing forms of easy use, good precisión and low cost, with the objective of predicting the cardiometabolic risk in our patients, leads us to the task of identifying anthropometric measurements and ratios that may be useful for the risk detection. Objective: to describe the usefulness of the conicity index as a predictor of cardiovascular and metabolaic risk and compare it with some of the anthropometric measurements and ratios used to this end. Methods: eighty aritcles, 51 of which met the expected quality criteria of the authors, were reviewed. The search was made in some of the regular databases and searchers. Results: the physiological characteristics of the abdominal fatty tissue were significant and even they may be possible determinants of the increased cardiometabolic risk associated to visceral obesity. The conicity index is a ratio that involves several anthropometric measurements such as waist circumference, height and body weight. This index has been used to show increase of abdominal fat and in prediction of the cardiovascular and the metabolic risk. Among the results of the different studies, there have been observed various criteria about the usefulness and applications of the index in comparison with other anthropometric measurements and indexes; something that at the very best should be clarified in the future through research studies designed for this end. Conclusions: the conicity index is a useful ratio to determine the existence of abdominal obesity, although it does not seem to be the best predictor of the cardiovascular and/or metabolic risk when making a comparison with the rest of the anthropometric measurements and ratios that have been so far used(AU)

High mortality rate in hemodialysis patients who undergo invasive cardiovascular procedures related to peripheral artery disease - community-based observational study in Kumamoto Prefecture - .

BACKGROUND: Cardiovascular disease is a major cause of mortality in hemodialysis patients. The aim was to assess the relationship of various invasive cardiovascular procedures (ICP) to clinical outcome in hemodialysis patients. METHODS AND RESULTS: A total of 5,813 patients at 76 facilities were on maintenance hemodialysis in Kumamoto Prefecture. Of these, 4,807 patients at 58 institutions were enrolled. Of 4,807 patients, 212 ICP (4.4%) were performed for various cardiovascular diseases in 189 patients (3.9%). ICP included PCI (n=80), endovascular treatment (n=59), radiofrequency catheter ablation (n=8), implantation of permanent pacemaker (n=15) and ICD (n=5), thoracotomy for valvular diseases (n=16), CABG (n=14), bypass surgery for peripheral artery disease (PAD; n=8), and artificial vessel replacement for aneurysm or aortic dissection (n=7). The overall mortality rate was 10.1% (19/189 patients). The mortality rate was highest in patients who underwent ICP for PAD, compared with other ICP (PAD, 18.2%; non-PAD, 6.7%, P=0.017). Infection and PAD were significant predictors of mortality (infection: OR, 8.30; 95% CI: 1.29-65.13, P=0.027; PAD: OR, 3.76; 95% CI: 1.35-10.48, P=0.012). The presence of inflammation/malnutrition factors was associated with high mortality (OR, 15.49; 95% CI: 3.22-74.12, P=0.0006). CONCLUSIONS: In this community-based registry study of 4,807 hemodialysis patients, the mortality rate of PAD patients was high despite ICP.

Is defibrillation testing necessary?

With advancements in implantable cardioverter defibrillator (ICD) technology, the practice of performing defibrillation threshold (DFT) testing at the time of implantation has been questioned. With availability of biphasic waveforms, active cans, and high-output devices, opponents claim that DFT testing is no longer necessary. Clinical trials demonstrating the efficacy of ICDs in prevention of sudden cardiac death have, however, all used some form of defibrillation testing. This debate is fueled by the absence of data from randomized prospective trials evaluating the role of DFT testing in predicting clinical shock efficacy or survival. This review discusses both sides of the argument.

[Appropriateness of diagnostic tests in cardiovascular prevention: what can we skip?]. / Appropriatezza delle procedure diagnostiche in prevenzione cardiovascolare: di che cosa possiamo fare a meno?

In recent years, a huge increase in the use of cardiac procedures, both invasive and non-invasive, was observed. Diagnostic tests, mainly non-invasive tests, are often prescribed inappropriately, in most cases replacing the clinical evaluation. The rate of inappropriate tests in cardiology is largely variable, depending on regional issues and different medical approach. When the test entails radiation exposure, the biological risk for both the patient and the environment must be taken into account. For this reason, the test that results in less biological risk should always be preferred as a first step.Moreover, it has not been clearly demonstrated that some diagnostic tests help to improve the outcome, that is to prevent cardiovascular events. As many as one sixth of the patients who undergo stress imaging are not taking proper medication, and very frequently no change in therapy is made after the test, regardless of the outcome. Since the appropriateness of diagnostic evaluation requests is mandatory, we focused on the diagnostic tests usually performed in primary and secondary prevention that carry no contribution to the clinical management of patients. This review addresses the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models.

Medical imaging: the radiation issue.

The collective doses of ionizing radiation to Western populations have risen dramatically in the past three decades. Preliminary data on changes in radiation dose to the US population indicate that this increase has been driven largely by medical imaging, to which cardiovascular imaging modalities-such as nuclear stress testing, invasive coronary angiography, and cardiovascular CT-contribute greatly. Given the putative association between low-dose radiation exposure and cancer risk, which most experts agree is supported by the available evidence, the 'radiation issue' in medical imaging has garnered increasing interest. This opinion piece focuses on changes in the use of and doses from medical imaging, the relationship between radiation dose and cancer risk and the controversy surrounding this subject, and clinical implications of radiation exposure from imaging tests.

Adverse drug reactions in patients with cardiovascular disease.

Adverse drug reactions (ADRs) occur frequently in modern medical practice, increasing morbidity and mortality and inflating the cost of care. Patients with cardiovascular disease are particularly vulnerable to ADRs due to their advanced age, polypharmacy, and the influence of heart disease on drug metabolism. The ADR potential for a particular cardiovascular drug varies with the individual, the disease being treated, and the extent of exposure to other drugs. Knowledge of this complex interplay between patient, drug, and disease is a critical component of safe and effective cardiovascular disease management. The majority of significant ADRs involving cardiovascular drugs are predictable and therefore preventable. Better patient education, avoidance of polypharmacy, and clear communication between physicians, pharmacists, and patients, particularly during the transition between the inpatient to outpatient settings, can substantially reduce ADR risk.

[Risk-benefit balance in cardiovascular imaging: the radiation issue]. / Rischio-beneficio nella diagnostica per immagini: impatto dell'utilizzo di radiazioni ionizzanti.

Every year 5 billion diagnostic imaging procedures are performed worldwide, and about 1 out of 2 tests are cardiovascular examinations. According to recent estimates, 30% to 50% of all examinations are partially or totally inappropriate. This represents a potential damage in patients undergoing imaging tests (who take the acute risks of a stress test procedure and/or a contrast study without a commensurable benefit), an exorbitant cost for the society, and an excessive delay in the waiting lists for other patients needing the examination. In case of ionizing radiation, the reduction of useless imaging tests would improve the quality of care also through abatement of the long-term risks related to the dose employed. The radiation dose equivalent of common cardiological imaging examinations corresponds to about 500, 750 and 1000 chest X-rays for stress sestamibi testing, multislice cardiac computed tomography and coronary stenting, respectively. Although direct evaluation of the incidence of cancer in patients submitted to these procedures is not available, according to the latest 2006 Biological Effects of Ionizing Radiation Committee VII the estimated risk of cancer is about 1 in 750 for a computed tomography scan - higher in women (1/500), lower in the elderly (1/1500), and the highest in children (1/100 in female children aged <1 year). Such a risk is probably not acceptable when a diagnostic procedure is inappropriately applied for mass screening (when the risk side of the risk-benefit balance is not considered) or when similar information can be obtained by other means. By contrast, it is fully acceptable in appropriately selected groups as a filter to more invasive, risky and costly procedures.

[Sustainability of medical imaging in cardiology]. / La sostenibilità della diagnosi per immagini in cardiologia.

Every year, 5 billion imaging testing are performed worldwide, and about 1 out of 2 are cardiovascular examinations. According to recent estimates, 30 to 50% of all examinations are partially or totally inappropriate. This represents a potential damage for patient undergoing imaging (who takes the acute risks of a stress procedure and/or a contrast study without a commensurable benefit), an exorbitant cost for the society and an excessive delay in the waiting lists for other patients needing the examination. Economic induction, medico-legal concern, and specialist guidelines, which do not quantitate the potential benefits against the risks of a given procedure, boost inappropriateness of all imaging techniques. In case of ionizing tests, the reduction of useless imaging testing would improve the quality of care also through abatement of long-term risks, which are linked to the dose employed. The radiation dose equivalent of common cardiological imaging examinations corresponds to more than 1000 chest x rays for a thallium scan and to more than 500 chest x-rays for a multislice computed tomography. Although a direct evaluation of incidence of cancer in patients submitted to these procedures is not available, the estimated risk (often ignored by cardiologists) of cancer according to the latest 2005 Biological Effects of Ionizing Radiation Committee VII is about one in 500 exposed patients for a Thallium scintigraphy scan, and one in 750 for a CT scan. Such a risk is probably not acceptable when a scintigraphic or radiological procedure is applied for mass screening (when the risk side of the risk-benefit balance is not considered) or when a similar information can be obtained by other means. By contrast, it is fully acceptable in appropriately selected groups as a filter to more invasive, risky and costly procedures (for instance, coronary angiography and anatomy-driven revascularization). At this point, the cardiological community, that faces the reality of limited resources, should do every effort in order to minimize inappropriate testing, since they induce an exorbitant increase in health care costs with no improvement, and possibly with a reduction in care quality.

[Pseudoaneurysms due to iatrogenic arterial injuries--observations at a vascular surgery worksite]. / Pseudoaneuryzma po iatrogenním postizení tepny--poznatky z angiochirurgického pracoviste.

With advancing care of patients with cardiovascular diseases the number of invasive cardiological operations is increasing. Although effective methods are involved, these procedures are also associated with certain risks for the patient. From the aspect of vascular surgery the most frequent complications include iatrogenic pseudoaneurysms and extensive haematomas. The objective of the present work is to evaluate the development of the number of pseudoaneurysms which occurred after puncture of the femoral artery during coronarography or PTCA, and verification of the hypothesis of the declining trend of the ratio of pseudoaneurysms in the total number of performed invasive cardiological diagnostic and therapeutic operations. The author submits in his paper the retrospectively assessed number of invasive operations performed at the 1st Medical Cardioangiological Clinic of the St. Ann Faculty Hospital Brno in 1996-2001. It summarizes the number of PA dealt with during the same period by physicians of the 2nd Surgical Clinic of the St. Ann Hospital in Brno. It analyzes also the treated complications of cardiological operations in 2001.

Preoperative cardiac risk management.

Numerous strategies exist for preoperative cardiac testing before patients undergo vascular operations. Potential adverse effects of evaluation and cardiac intervention should be considered before undertaking screening studies. We recently analyzed the adverse outcomes of preoperative cardiac evaluation and intervention before vascular operations in patients treated at the Denver Department of Veterans Affairs Medical Center. During the 12 month study period, 161 patients were scheduled to undergo major vascular operations; 153 patients came to operation. The decision to pursue a cardiac evaluation was made without a defined protocol. Forty two men, aged 68+/-9 years underwent comprehensive preoperative cardiac evaluations Sixteen (38%) patients had untoward events related to cardiac evaluation, including eight patients (19%) who refused vascular surgery after cardiac screening and/or intervention. Other complications included prosthetic graft infection, pseudoaneurysms (2), sternal wound infections (2) amputations (2), renal failure and brain anoxia. Extensive cardiac evaluation prior to vascular operations can result in morbidity, delays, and refusal to undergo vascular surgery. The underlying indication for vascular operations and the local iatrogenic cardiac complication rates must be considered before ordering special studies.

Importancia de la protección radiológica y del control de calidad en las instalaciones de cardiología intervencionista / The role of the X-ray protection and the quality control program in the equipment of interventional cardiology laboratories

Se describen los aspectos básicos relacionados con la protección radiológica de los especialistas médicos y del personal auxiliar en las instalaciones de cardiología intervencionista. La protección radiológica del paciente se plantea como un compromiso entre la información necesaria que depende de la calidad de las imágenes y las dosis de radiación que se deben impartir para obtener dicha información. Se citan las recomendaciones internacionles más relevantes y las acciones programadas de investigación que se están desarrollando para mejorar el nivel de protección y calidad en las instalaciones de cardiología. Se describe la influencia de las características de los equipos de rayos X y de las salas en las que están instalados, la complejidad de los procedimientos, la formación en protección radiológica de los diferentes grupos profesionales y la disponibilidad de elementos de protección. En algunos casos, la falta de programas de control de calidad adecuados ha contribuido a que se produzcan lesiones graves en la piel de los pacientes. Se discuten los procedimientos para reducir los riesgos de los especialistas y de los pacientes sin comprometer la calidad de los procedimientos destacando que al proteger al paciente se mejora también el nivel de protección de los especialistas médicos. Estos procedimientos se deben incorporar a los programas de garantía de calidad, incluyendo los aspectos de formación en protección radiológica, revisión de los dispositivos de protección, dosimetría personal, medidas de dosis a los pacientes y evaluación de la calidad de imagen, control de calidad de equipos de rayos X e introducción de medidas correctoras cuando proceda y su seguimiento. Se debe prestar especial atención a la detección y seguimiento de los casos de posibles dosis altas en piel