Noninvasive Cardiac Testing Research Articles

Abstract 394: Effect Of Introduction Of Non Invasive Risk Stratification On Cardiac Catheterization Referrals In A Community Hospital.

Background: Appropriate use criteria recommend against unwarranted cardiac catheterization (caths) in low risk patients. Reporting of risk stratification on non-invasive cardiac stress test reports was implemented at our institution to reduce low risk cardiac cath referrals. Methods: We performed a retrospective study to compare the effect of introduction of risk stratification in cardiac stress test reports. The percentages of low risk patients by nuclear stress, who underwent cardiac cath, before and after application of risk stratification were compared. Chi-square and Mann-Whitney-Wilcoxon tests were used for analysis. Results: There were significantly fewer low risk referrals after risk stratification, 43.2% of patients of low-risk patients were referred for catheterization before, compared to 28.3% of low-risk patients after risk stratification (p value 0.01). There was reduction in the percentage of normal cardiac caths in the low risk category after introduction of risk stratification (61.5% vs 33.3%, p value 0.05). Conclusion: Risk stratification led to a decrease in the percentage of low-risk patients referred for cath following a stress test.

Pre-operative Cardiovascular Evaluation in elective Noncardiac Surgery, Risk Scores, and Managerial Insight for Patients with Different Cardiac Morbidities

Cardiac pre-operative evaluation must aim to estimate the perioperative cardiovascular risk, taking into consideration the individual clinical setting along with the type of surgery. Pre-operative assessment and management comprise evaluation of risk scores and the potential performance of some paraclinical tests to better prepare the patient for surgery. Pain management, adequate hydration, and thromboembolic prophylaxis constitute the main axis to decrease perioperative cardiovascular complications; moreover, the presence of previous cardiac conditions along with hypersympathetic activity is involved in a significant percentage of perioperative morbidity. Patients with minimal perioperative risk may not require systematically a cardiology consultation, whereas patients with moderate or high surgical risk often require a multidisciplinary approach for better perioperative management. The use of paraclinical tests to evaluate cardiac condition, such as cardiac biomarkers, echocardiogram, and other noninvasive or invasive cardiac testing, should be tailored on a case-by-case basis. Such professional practice aims to limit unnecessary healthcare expenses without compromising clinical outcome. Pre-operative surgical risk is not only based on cardiovascular condition but also on other factors and comorbidities such as diabetes, renal function, and functional status. In this regard, the role of the anesthesiologist is essential to evaluate the pre-operative risk (mild, moderate, or high), also to manage the whole perioperative period.

Impact of Physician-Patient Language Concordance on Patient Outcomes and Adherence to Clinical Chest Pain Recommendations.

The objective was to evaluate if there is an association between patient-physician language concordance and adverse patient outcomes or physician adherence to clinical recommendations for emergency department (ED) patients with chest pain. We conducted a retrospective observational study of adult ED chest pain encounters with a troponin order from May 2016 to September 2017 across 15 community EDs. Outcomes were 30-day acute myocardial infarction or all-cause mortality, hospital admission/observation, or noninvasive cardiac testing. To assess patient outcomes, we used the overall cohort. To assess adherence to clinical recommendations, we used a subgroup of patients with a low-risk HEART score. A mixed-effects logistic regression model was used to compare the odds of the outcomes between language concordant and discordant patient-physician pairs, controlling for patient characteristics. Overall, 52,014 ED encounters were included (10,791 low-risk HEART encounters). Of those 6,452 (12.4%) encounters were language discordant and 1.7% in each group had an adverse outcome. Adjusted models demonstrated no increased risk for language discordant ED encounters when comparing adverse outcomes (odds ratio [OR]=0.96, 95% confidence interval [CI]=0.6 to 1.5) for all patients or recommended care (OR=1.02, 95% CI= 0.87 to 1.2) for low-risk patients. No associations were found between patient-physician language concordance and outcomes or physician adherence to clinical recommendations for ED patients with chest pain. Accessible and effective interpretation services, combined with a decision support tool with standard clinical recommendations, may have contributed to equitable care.

Automated Identification and Extraction of Exercise Treadmill Test Results.

BackgroundNoninvasive cardiac tests, including exercise treadmill tests (ETTs), are commonly utilized in the evaluation of patients in the emergency department with suspected acute coronary syndrome. However, there are ongoing debates on their clinical utility and cost‐effectiveness. It is important to be able to use ETT results for research, but manual review is prohibitively time‐consuming for large studies. We developed and validated an automated method to interpret ETT results from electronic health records. To demonstrate the algorithm's utility, we tested the associations between ETT results with 30‐day patient outcomes in a large population.Methods and ResultsA retrospective analysis of adult emergency department encounters resulting in an ETT within 30 days was performed. A set of randomly selected reports were double‐blind reviewed by 2 physicians to validate a natural language processing algorithm designed to categorize ETT results into normal, ischemic, nondiagnostic, and equivocal categories. Natural language processing then searched and categorized results of 5214 ETT reports. The natural language processing algorithm achieved 96.4% sensitivity and 94.8% specificity in identifying normal versus all other categories. The rates of 30‐day death or acute myocardial infarction varied (P<0.001) by categories for normal (0.08%), ischemic (1.9%), nondiagnostic (0.77%), and equivocal (0.58%) groups achieving good discrimination (C‐statistic, 0.81; 95% CI, 0.7–0.92).ConclusionsNatural language processing is an accurate and efficient strategy to facilitate large‐scale outcome studies of noninvasive cardiac tests. We found that most patients are at low risk and have normal ETT results, while those with abnormal, nondiagnostic, or equivocal results have slightly higher risks and warrant future investigation.

Utility of Coronary Artery Calcium Score for Coronary Artery Disease Screening among Severely Ill Liver Transplant Candidates: Case Series

Noninvasive cardiac stress testing is essential to screen liver transplant (LT) candidates for the presence of coronary artery disease (CAD). However, cardiac stress testing may not be clinically feasible in some patients, especially among those who require intensive care for an extended period of time, before being listed for LT. The utility of coronary artery calcium (CAC) score as a potential noninvasive screening test for CAD in place of cardiac stress testing among critically ill intensive care unit (ICU)-bound LT recipients has not been well studied. We report 4 LT recipients who were screened for CAD only with CAC score before listing for LT. Our results suggest that CAC score may be a useful test to screen for CAD in severely ill ICU-bound LT recipients with low risk for coronary heart disease, who are not candidates for cardiac stress testing. Such recipients requiring intensive care, with CAC score of 0A may safely forgo cardiac stress testing prior to LT. Future prospective studies with a bigger sample size and longer follow-up would be helpful to validate our findings.

Diagnosis and Management of Silent Myocardial Ischemia in Patients Undergoing Carotid Endarterectomy

Coronary artery disease (CAD) is the primary cause of death in patients with carotid artery disease, and silent myocardial ischemia is a marker for adverse coronary events. Prospective, randomized trial evidence shows that invasive coronary angiography with selective coronary revascularization before carotid endarterectomy (CEA) reduces postoperative myocardial infarction (MI) and improves long-term survival of CEA patients with no evidence of CAD (Illuminati, EJVES 2015). A noninvasive cardiac diagnostic test, coronary computed tomography (CT) and computed fractional flow reserve (FFRCT), can reliably identify ischemia-producing coronary stenosis in stable patients with symptoms of CAD, but its value in CEA patients in unknown.

UK perspective on the changing landscape of non-invasive cardiac testing

ObjectiveTo document UK rates of exercise treadmill testing, functional stress testing and CT coronary angiography (CTCA). Specific aims were to determine how rates have changed in the context of changing...

The Case of Noninvasive Cardiac Testing—For Every Action There Is a Reaction

The Case of Noninvasive Cardiac Testing—For Every Action There Is a Reaction

Intractable stokes adams attack with myriad of ventricular arrythmias masquerading acute myocarditis

Convulsive syncope can be difficult to distinguish from seizures at times. Misdiagnosis can result in unnecessary, and usually unsuccessful, treatment with antiepileptic drugs. A detailed history taking and physical examination along with continuous cardiac monitoring can help in making the correct diagnosis. Our patient was eventually found to have viral myocarditis. Moredetailed studies for the role of noninvasive cardiac testing such as Cardiac MRI (CMR) and newer treatment modalities such as anti-thymocyte immunoglobulin are required for the management of Viral Myocarditis.

Use of Initial Noninvasive Cardiac Testing and Association with Downstream Healthcare Resource: A Retrospective Review of Resources Used Across a 12-Month Window for Probable Type I Myocardial Infarction Patients.

BackgroundClinical guidelines provide clinicians with substantial discretion in the use of noninvasive cardiac testing for patients with suspected coronary artery disease. Repeat testing, frequent emergency department (ED) visits, and increases in other cardiac-related procedures can be a burden on patients and payers and can complicate treatment planning. We assessed downstream healthcare resource utilization (HCRU) for patients undergoing initial single-photon emission computed tomography (SPECT), myocardial perfusion imaging (MPI), stress echocardiography (ECHO), or exercise treadmill testing (ETT) with probable type I myocardial infarction (MI).MethodsElectronic medical records data from 12,130 patients with probable type I MI presenting to EDs within a large healthcare system comprised of 11 adult hospitals were retrospectively analyzed. Logistic and linear regression determined the individual contribution of SPECT-MPI, ETT, and ECHO on repeat cardiovascular (CV) testing, inpatient visits, outpatient visits, and cardiac-related costs within 12 months of the index visit.ResultsThe majority of patients received SPECT-MPI for the index-testing event (56.5%), followed by ETT (29.2%) and ECHO (14.3%). Patients who had SPECT-MPI at the index visit were less likely to have a repeat CV testing visit (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.62‒0.96; p = 0.020) or an inpatient visit (OR 0.70, 95% CI 0.49‒0.98; p = 0.039) than those who underwent ETT or ECHO. ETT and ECHO were not predictive of any outcome.ConclusionsSPECT-MPI does not result in more downstream HCRU than ETT or ECHO and is associated with a lower likelihood of repeat non-invasive CV testing and inpatient visits.Electronic supplementary materialThe online version of this article (10.1007/s41669-019-0128-1) contains supplementary material, which is available to authorized users.

MON-LB071 Panhypopituitarism Causing a Life Threatening Prolonged QT Interval Which Can Be Reversible with Treatment of Underlying Endocrine Disorders

Introduction: Panhypopituitarism can lead to major metabolic consequences as a result of multiple hormonal deficiencies. However, its association with life-threatening arrhythmias is not well known. Only a few cases have been reported in the literature. Case Report: A 38 year old woman with no past medical history presented with amenorrhea. She was found to have a high prolactin level and subsequent MRI showed a 2.7 cm pituitary adenoma. She underwent transsphenoidal resection and developed panhypopituitarism after surgery. She was placed on hydrocortisone, levothyroxine and desmopressin but was not been compliant with the medications. A few months later, she had a sudden onset syncopal episode without any prodromal symptom. On presentation, she had a heart rate of 43 bpm and prolonged QT/QTc of 668/564ms. Laboratory tests were significant for a troponin of 0.8ng/ml, n <0.03ng/ml, severe hypothyroidism (FT4 0.1ng/dl, n 0.8-2.2ng/dl; FT3 1.03pg/ml, n 2.77-5.27pg/ml) and adrenal insufficiency (AM cortisol <0.2mcg/dL, n 4.5-22.7mcg/dL). There were no other clinical findings to explain this. Her syncopal episode strongly suggested a VT/VF arrest. Echocardiogram showed no structural heart disease. She was treated appropriately for her hypothyroidism and adrenal insufficiency; and she wore a wearable defibrillator while the endocrine disorders were corrected. After treatment, her bradycardia resolved and her QT interval normalized. Genetic screening for underlying Long QT Syndromes was negative. Clinical Lesson: Panhypopituitarism, including hypothyroidism and adrenal insufficiency, can cause life threatening arrhythmias such as ventricular tachycardia and fibrillation. This can lead to extensive noninvasive and invasive cardiac testing and intervention. It is critical that clinicians be aware that these arrhythmias can be reversed by correcting the underlying endocrine disorders. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Evaluation of Outpatient Cardiac Stress Testing After Emergency Department Encounters for Suspected Acute Coronary Syndrome

Professional guidelines recommend 72-hour cardiac stress testing after an emergency department (ED) evaluation for possible acute coronary syndrome. There are limited data on actual compliance rates and effect on patient outcomes. Our aim is to describe rates of completion of noninvasive cardiac stress testing and associated 30-day major adverse cardiac events. We conducted a retrospective analysis of ED encounters from June 2015 to June 2017 across 13 community EDs within an integrated health system in Southern California. The study population included all adults with a chest pain diagnosis, troponin value, and discharge with an order for an outpatient cardiac stress test. The primary outcome was the proportion of patients who completed an outpatient stress test within the recommended 3 days, 4 to 30 days, or not at all. Secondary analysis described the 30-day incidence of major adverse cardiac events. During the study period, 24,459 patients presented with a chest pain evaluation requiring troponin analysis and stress test ordering from the ED. Of these, we studied the 7,988 patients who were discharged home to complete diagnostic testing, having been deemed appropriate by the treating clinicians for an outpatient stress test. The stress test completion rate was 31.3% within 3 days and 58.7% between 4 and 30 days, and 10.0% of patients did not complete the ordered test. The 30-day rates of major adverse cardiac events were low (death 0.0%, acute myocardial infarction 0.7%, and revascularization 0.3%). Rapid receipt of stress testing was not associated with improved 30-day major adverse cardiac events (odds ratio 0.92; 95% confidence interval 0.55 to 1.54). Less than one third of patients completed outpatient stress testing within the guideline-recommended 3 days after initial evaluation. More important, the low adverse event rates suggest that selective outpatient stress testing is safe. In this cohort of patients selected for outpatient cardiac stress testing in a well-integrated health system, there does not appear to be any associated benefit of stress testing within 3 days, nor within 30 days, compared with those who never received testing at all. The lack of benefit of obtaining timely testing, in combination with low rates of objective adverse events, may warrant reassessment of the current guidelines.

Abstract 248: Redesign of Order Entry to Improve Noninvasive Cardiac Test Selection

Background: CCTA offers an exceptional negative predictive value when evaluating patients with suspected coronary disease. Many non-cardiology clinicians remain unaware of this test option and patients for which CCTA is appropriate. We hypothesized that a redesign of the noninvasive imaging ordering menu in our electronic health system, paired with didactic education, could increase ordering of CCTA. Methods: We designed a new ordering menu to guide noninvasive cardiac testing. A series of yes/no questions guided clinicians through a decision tree about which test modality would be best for a given patient: CCTA, myocardial perfusion scintigraphy (MPS), or exercise treadmill test (ETT). This menu change was paired with education in the form of flyers, PowerPoint-guided lectures, and question-answer sessions. We measured the volume of each test modality (CCTA, ETT, and MPS) ordered for 6 months prior and 4 months after our intervention in two-week intervals, mapped on a runchart. We compared the median number of tests for each modality before and after the intervention. We surveyed clinicians’ opinions about ordering CCTA before and after the intervention and also asked their opinions about the change in a post-intervention survey. Results: Before the intervention, the median numbers of CCTA, ETT, and MPS ordered per two-week interval were 8.5, 10, and 60, respectively. Post-intervention, CCTA, ETT, and MPS were ordered 14, 10, and 60 times per two-week period, respectively. We saw a 67% increase in ordering of CCTA post-intervention (p=0.001, 95% CI: 3.0-12.0) while there were no significant changes in ordering patterns for ETT or MPS. Based on the surveys, 38% of clinicians were not comfortable ordering cardiac CTA prior to our intervention which decreased to 32% of clinicians after our intervention (p=0.64). 36% of providers reported that they liked the new ordering menu, while 52% were neutral, and 12% of providers expressed their dislike. Conclusion: A simple change in the ordering menu for noninvasive cardiology testing resulted in a substantial increase in CCTA ordering. A large majority of clinicians felt either neutral or positive towards the changes. We did not observe an offsetting decrease in other test modality ordering raising the question as to whether clinicians changed their test choice or increased the amount of testing being performed.

ELEVATION OF HEPATOCYTE GROWTH FACTOR CAN INDICATE CARDIAC INVOLVEMENT IN LIGHT CHAIN AND TRANSTHYRETIN AMYLOIDOSIS

Delay in diagnosis of cardiac involvement with amyloidosis (CA) is common predominantly due to nonspecific symptoms and indistinct patterns on non-invasive cardiac testing. An effective serum biomarker may improve early diagnosis of CA. Consecutive patients with light chain (AL) or transthyretin (

Effect of a HEART Care Pathway on Chest Pain Management Within an Integrated Health System

We describe the association of implementing a History, ECG, Age, Risk Factors, and Troponin (HEART) care pathway on use of hospital care and noninvasive stress testing, as well as 30-day patient outcomes in community emergency departments (EDs). We performed a prospective interrupted-time-series study of adult encounters for patients evaluated for suspected acute coronary syndrome. The primary outcome was hospitalization or observation, noninvasive stress testing, or both within 30 days. The secondary outcome was 30-day all-cause mortality or acute myocardial infarction. A generalized estimating equation segmented logistic regression model was used to compare the odds of the primary outcome before and after HEART implementation. All models were adjusted for patient and facility characteristics and fit with physicians as a clustering variable. A total of 65,393 ED encounters (before, 30,522; after, 34,871) were included in the study. Overall, 33.5% (before, 35.5%; after, 31.8%) of ED chest pain encounters resulted in hospitalization or observation, noninvasive stress testing, or both. Primary adjusted results found a significant decrease in the primary outcome postimplementation (odds ratio 0.984; 95% confidence interval [CI] 0.974 to 0.995). This resulted in an absolute adjusted month-to-month decrease of 4.39% (95% CI 3.72% to 5.07%) after 12 months' follow-up, with a continued trend downward. There was no difference in 30-day mortality or myocardial infarction (0.6% [before] versus 0.6% [after]; odds ratio 1.02; 95% CI 0.97 to 1.08). Implementation of a HEART pathway in the ED evaluation of patients with chest pain resulted in less inpatient care and noninvasive cardiac testing and was safe. Using HEART to risk stratify chest pain patients can improve the efficiency and quality of care.

Utilization and Costs of Noninvasive Cardiac Tests After Acute Coronary Syndromes: Insights From the Alberta COAPT Study

BackgroundAlthough appropriate noninvasive cardiac tests (NICTs) after an acute coronary syndrome (ACS) provide useful prognostic information, inappropriate use leads to inefficient expenditure of existing healthcare resources. By using the Alberta Contemporary Acute Coronary Syndrome Patient Invasive Treatment Strategies (COAPT) Registry, we evaluated the use and costs of NICTs among patients discharged within 1 year after ACS. MethodsAll patients discharged from the hospital with a primary diagnosis of ACS in Alberta between 2004/2005 and 2015/2016 were included. Frequency of NICTs (stress tests [± imaging] and nonstress imaging tests) was determined from linked provincial databases. Costs were obtained from the Alberta Health Care Insurance Plan Medical Procedure List. ResultsOf 55,516 patients with ACS, 30,760 had at least 1 NICT (55.4%), with 13,505 (24.3%) having > 1 NICT performed within 1 year. Temporal trends of NICT increased over time (stress tests: P trend < 0.001; nonstress imaging tests: P trend < 0.001). NICT most commonly occurred within the first 4 months after hospital discharge (stress tests at 2 months; nonstress imaging tests at 3-4 months). In 2015/2016, the total estimated costs of NICT were $1.35M, a 22.4% increase from 2004/2005 (1.10M) (P < 0.001), whereas a decrease in incidence of ACS over the same time period was noted (P = 0.008). ConclusionsRates of NICT 1 year after ACS are high and increasing over time. Estimated costs of NICT appear to be escalating out of proportion to the ACS growth. Further investigation is warranted because it is speculative whether the increase in NICT and costs results in clinical benefit after ACS.

Left ventricle ejection fraction and strain derived by three-dimensional echocardiography are associated with exercise capacity in the patients with heart failure

Background/Aim. Echocardiography represents the most commonly performed noninvasive cardiac imaging tests for the patients with heart failure (HF). The aim of this study was to assess the relationship between the exercise capacity parameters [peak oxygen consumption (VO2) and the minute ventilation-carbon dioxide production relationship (VE/VCO2)] and the three-dimensional speckle-tracking echocardiography (3D-STE) imaging of left ventricular (LV) function in the HF patients with the reduced LV ejection fraction (LVEF). Methods. This cross-sectional study included 80 patients with diagnosed ischemic LV systolic dysfunction (LVEF &lt; 45%) divided into subgroups based on the proposed values of analyzed cardiopulmonary exercise testing (CPET) variables: VO2 peak ? 15 mL/kg/min, VO2 peak &gt; 15 mL/kg/min, VE/VCO2 slope &lt; 36 and VE/VCO2 slope ? 36. All patients underwent a physical examination, laboratory testing, two-dimensional (2D) and 3DE, and CPET. Results. LVEF, global longitudinal, circumferential, radial and area strains were significantly lower in the subgroups of subjects with a peak VO2 less, or equal to 15 mL O2/kg per min and with a VE/VCO2 slope greater, or equal to 36 compared to the subgroups of subjects with a peak VO2 greater than 15 mL O2/kg per min and with a VE/VCO2 slope less than 36. There was a significantly positive correlation between the peak VO2 values and parameters of 3DE, and a significantly negative correlation between the VE/VCO2 slope values and parameters of 3DE. Conclusion. The results of this study provide further evidence that the LV function can be noninvasively and objectively measured by 3D-STE. A significant correlation between examined parameters suggests that LVEF and strain derived by 3DE are associated with exercise capacity in the patients with HF.

Relationship between interleukin-17A and isolated coronary ectasia

The aim of this study was to evaluate serum interleukin (IL)-17A levels in patients with coronary artery ectasia (CAE), the relationship between IL and 17A and CAE, and to determine the relationship between the severity of coronary ectasia and the level of IL-17A. In total, 41 patients (19 female and 22 male) with ischemic symptoms whose non-invasive cardiac tests were positive for myocardial ischemia, and in whom coronary artery ectasia were detected after coronary angiography, and 45 patients (32 female and 13 male) with normal coronary arteries were included in this study. Echocardiographic assessments were performed. Serum IL-17A levels of all patients were evaluated using an enzyme-linked immunosorbent assay. IL-17A levels of the group with isolated coronary artery ectasia were significantly higher compared with the control group (4.86 ± 3.24 and 1.37 ± 1.56 ng/ml, respectively; p < 0.001). There was no correlation between the levels of IL-17A and the extension of the CAE, but IL-17A levels were high in both groups. CAE patients have significantly increased levels of IL-17A, fibrinogen, and RDW compared to patients with normal coronary arteries. It was demonstrated that increased levels of IL-17A were associated with ectasia formation in CAE patients.

This Article Corrects: “Coronary Disease in Emergency Department Chest Pain with Recent Negative Stress Testing”

[This corrects the article on p. 384 in vol. 11, PMID: 21079714.].

Approach to the Cardiovascular Patient

The complete evaluation of the cardiovascular patient begins with a thorough history and a detailed physical examination. These two initial steps will often lead to the correct diagnosis and assist in excluding life-threatening conditions. The history and physical examination findings should be assessed in the overall clinical status of the patient, including the patient's specific complaints, lifestyle, comorbidities, and treatment expectations. This chapter discusses the cardiovascular conditions that frequently require evaluation: chest pain, dyspnea, palpitations, syncope, claudication, and cardiac murmurs; and reviews the background, history and physical examination, and diagnostic tests available for each. Diagnostic algorithms are provided, and the appropriate use of invasive and noninvasive cardiac testing for each condition is discussed. This review contains 8 highly rendered figures, 12 tables, and 52 references.