Safety of intravenous ß-adrenoceptor blockers for computed tomographic coronary angiography.

AIMS: To assess the safety of our clinical practice using off-label intravenous metoprolol to facilitate computed tomographic (CT) coronary angiography. METHODS: A retrospective analysis of scan reports and hospital admissions data was conducted to identify adverse events occurring following CT coronary angiography in patients who had received intravenous metoprolol prior to the scan. RESULTS: A total of 3098 patients were included, of whom 1871 received intravenous metoprolol. Nine hundred and one patients received more than 15 mg and 129 patients received metoprolol despite a resting heart rate <65 beats min(-1) . There was a single adverse incident, comprising transient loss of consciousness. CONCLUSIONS: The use of intravenous metoprolol to facilitate cardiac CT scanning appears safe. Dose limits recommended for other indications, generally in acutely unwell patients, may not need to be as stringent in this population.

Evaluation of stable chest pain following emergency department presentation: Impact of first-line cardiac computed tomography diagnostic strategy in an Australian setting.

OBJECTIVE: International guidelines provide increasing support for computed tomography coronary angiography (CTCA) in investigating chest pain. A pathway utilising CTCA first-line for outpatient stable chest pain evaluation was implemented in an Australian ED. METHODS: In pre-post design, the impact of the pathway was prospectively assessed over 6 months (August 2021 to January 2022) and compared with a 6-month pre-implementation group (February 2021 to July 2021). CTCA was recommended first-line in suspected stable cardiac chest pain, followed by chest pain clinic review. Predefined criteria were provided recommending functional testing in select patients. The impact of CTCA versus functional testing was evaluated. Data were obtained from digital medical records. RESULTS: Three hundred and fifteen patients were included, 143 pre-implementation and 172 post-implementation. Characteristics were similar except age (pre-implementation: 58.9 ± 12.0 vs post-implementation: 62.8 ± 12.3 years, P = 0.004). Pathway-guided management resulted in higher first-line CTCA (73.3% vs 46.2%, P < 0.001), lower functional testing (30.2% vs 56.6%, P < 0.001) and lower proportion undergoing two non-invasive tests (4.7% vs 10.5%, P = 0.047), without increasing investigation costs or invasive coronary angiography (ICA) (pre-implementation: 13.3% vs post-implementation: 9.3%, P = 0.263). In patients undergoing CTCA, 40.7% had normal coronaries and 36.2% minimal/mild disease, with no difference in disease burden post-implementation. More medication changes occurred following CTCA compared with functional testing (aspirin: P = 0.005, statin: P < 0.001). In patients undergoing ICA, revascularisation to ICA ratio was higher following CTCA compared with functional testing (91.7% vs 18.2%, P < 0.001). No 30-day myocardial infarction or death occurred. CONCLUSIONS: The pathway increased CTCA utilisation and reduced downstream investigations. CTCA was associated with medication changes and improved ICA efficiency.

A streamlined Emergency Department approach to moderate risk chest pain in patients with no pre-existing coronary artery disease: A pilot study.

OBJECTIVE: Moderate risk patients with chest pain and no previously diagnosed coronary artery disease (CAD) who present to ED require further risk stratification. We hypothesise that management of these patients by ED physicians can decrease length of stay (LOS), without increasing patient harm. METHODS: A prospective pilot study with comparison to a pre-intervention control group was performed on patients presenting with chest pain to an ED in Perth, Australia between May and October 2021, following the introduction of a streamlined guideline consisting of ED led decision making and early follow up. Patients had no documented CAD and were at moderate risk of major adverse cardiac events (MACE). Electronic data was used for comparison. Primary outcomes were total LOS and LOS following troponin. RESULTS: One hundred eighty-six patients were included. Median total LOS was reduced by 62 min, but this change was not statistically significant (482 [360-795] vs 420 [360-525] min, P = 0.06). However, a significant 60 min decrease in LOS was found following the final troponin (240 (120-571) vs 180 (135-270) min, P = 0.02). There was no difference in the rate of MACE (0% vs 2%, P = 0.50), with no myocardial infarction or death. CONCLUSIONS: Our study suggests that patients with no pre-existing CAD can be safely managed by emergency physicians streamlining their ED management and decreasing LOS. This pathway could be used in other centres following confirmation of the results by a larger study.

Extracellular proteins OSM-7 and OSM-8 are required for stress response gene regulation at all post-embryonic stages.

Nematode cuticles are extracellular matrices (ECMs) that function as structural support and permeability barriers. Genetic disruption of specific cuticle collagen structures or secreted epidermal proteins in C. elegans activates stress response genes in epithelial cells suggesting the presence of an extracellular damage signaling mechanism. Cuticles are replaced during development via molting but investigations of extracellular signaling to stress responses have focused on adults. In our current study, we measured cuticle phenotypes and stress response gene expression in all post-embryonic stages of mutant strains for a collagen and two secreted epidermal proteins to gain insights into developmental patterns.

Pictorial review: computed tomography features of cardiovascular emergencies and associated imminent decompensation.

Multi-detector computed tomography (MDCT) scanner is available in most hospitals and is increasingly being used as the first line imaging in trauma and suspected cardiovascular emergencies, such as acute coronary syndrome, pulmonary artery thrombo-embolism, abdominal aortic aneurysm and acute haemorrhage (Ryan et al. Clin Radiol 60:599-607, 2005). A significant number of these patients are haemodynamically unstable and can rapidly progress into shock and death. Recognition of computed tomography (CT) signs of imminent cardiovascular decompensation will alert the clinical radiologist to the presence of shock. In this review, the imaging findings of cardiovascular emergencies in both acute traumatic and non-traumatic settings with associated signs of imminent decompensation will be described and illustrated.

Sarcoidosis--the greatest mimic.

Little is known regarding the exact pathogenesis of sarcoidosis, but it is widely recognized that it affects multiple organs. The presentation and imaging features can be nonspecific, and this is the reason why it is a great mimic of other diseases. Diagnosis of sarcoidosis is often prompted initially by clinical suspicion. Imaging plays a crucial role in both detection and monitoring of disease process. This review is a case-based systemic approach looking at various systemic manifestation of the disease presenting real clinical encounters using various imaging modalities.

Heterogeneity of myocardial iron distribution in response to chelation therapy in patients with transfusion-dependent anemias.

The purpose of this study is to examine the effect of different iron chelation regimens on the distribution of myocardial iron in patients with transfusion-dependent anemias. Institutional review board approval was obtained. Patients treated with iron chelation therapy who had undergone baseline and 1-year follow-up cardiac T2* MR studies in a four-year period were identified retrospectively. One hundred and eight patients (44 % male, mean age 31.6 ± 9.7 years) were included. The interventricular septum on three short-axis slices (basal, mid and apical) was divided into anterior and inferior regions of interest for T2* analysis. Cardiac iron concentration (CIC) was calculated from T2* values. Statistical analysis included analysis of variance and paired t-test, using Bonferroni adjustment in all pairwise comparisons. At baseline, T2* measurements varied significantly across all six regions (p < 0.001): lowest in the mid anteroseptum (mean 22.3 ± 10.1 ms) and highest in the apical inferoseptum (mean 26.2 ± 12.8 ms). At follow-up, T2* and CIC values improved significantly in all segments [mean change of 3.78 ms (95 % CI (2.93, 4.62), p < 0.001) and 0.23 mg/g (95 % CI (0.16, 0.29), p < 0.001), respectively]. Change in T2* values varied significantly between segments (p < 0.001) with greatest improvement in the apical inferoseptum [4.26 ms, 95 % CI (2.42, 6.11)] and least improvement in the basal anteroseptum [2.95 ms, 95 % CI (1.37, 4.54)]. The largest improvement in T2* values was noted in patients treated with deferiprone [4.96 ms, 95 % CI (2.34, 7.58)]. There was a statistically significant difference in improvement in CIC values between chelation regimens (p = 0.016). This is the first study to report heterogeneity in response to iron chelating drugs with variable segmental changes in T2* values.