Management Of Stable Coronary Artery Disease Research Articles

The Two-Edged Sword of Shared Clinical Decision-Making in the Post-ISCHEMIA World of Stable Coronary Artery Disease Management

The Two-Edged Sword of Shared Clinical Decision-Making in the Post-ISCHEMIA World of Stable Coronary Artery Disease Management

Evaluation of a train-the-trainer program for stable coronary artery disease management in community settings: A pilot study

ObjectiveTo evaluate the feasibility and effectiveness of conducting a train-the-trainer (TTT) program for stable coronary artery disease (SCAD) management in community settings. MethodsThe study involved two steps: (1) tutors trained community nurses as trainers and (2) the community nurses trained patients. 51 community nurses attended a 2-day TTT program and completed questionnaires assessing knowledge, self-efficacy, and satisfaction. By a feasibility and non-randomized control study, 120 SCAD patients were assigned either to intervention group (which received interventions from trained nurses) or control group (which received routine management). Pre- and post-intervention, patients’ self-management behaviors and satisfaction were assessed to determine the program’s overall impact. ResultsCommunity nurses’ knowledge and self-efficacy improved (P<0.001), as did intervention group patients’ self-management behaviors (P<0.001). The satisfaction of community nurses and patients was all very positive after training. ConclusionThe TTT program for SCAD management in community settings in China was generally feasible and effective, but many obstacles remain including patients’ noncompliance, nurses’ busy work schedules, and lack of policy supports. Practice implicationsFinding ways to enhance the motivation of community nurses and patients with SCAD are important in implementing community-based TTT programs for SCAD management; further multicenter and randomized control trials are needed.

Knowledge of chronic stable coronary artery disease management among general practitioners in Shanghai Pudong New Area

Objective To survey the knowledge of chronic stable coronary artery disease management among general practitioners (GPs) in Shanghai Pudong New Area. Methods The survey was conducted among 363 GPs with at least 2-year work experiences from community health service centers in Shanghai Pudong New Area from July to September in 2014. A self-designed questionnaire based on the guidelines/consensus of chronic stable coronary artery disease management were used in the survey. The questionnaire consisted of 4 parts: diagnosis, drug therapy, revascularization and treatment of special types. Results Among 363 participants 362 questionnaires were completed. History taking, physical examination and electrocardiogram were applied for diagnosis in all participants, 49.2%(178/362)also used coronary computed tomography angiography, 26.5%(96/362)used exercise testing for assistant examination. More than 95.0% of participants recognized that smoking, obesity, hyperlipidemia, hypertension, diabetes were risk factors. 75.7% (274/362) of participants used aspirin, 91.4% (331/362) knew the dose of aspirin as 75-150 mg; for aspirin intolerance 14.6%(53/362)would use clopidogrel alternatively. 50.6%(183/362)of participants sometimes used statins; and 39.2%(142/362)did not use stain because of not knowing the contraindication. Facing increases of alanine aminotransferase or aspartate aminotransferase levels 95.3%(345/362)of participants would immediately discontinue stain; 80.4%(291/362)discontinued statins as creatine kinase increased. 32.0%(116/362)of participants gave enough drug-free period avoiding nitrates resistance. 79.6% (288/362) seldom used β-blockers and 42.5% (154/362) failed to use β-blockers because not knowing the contraindication.78.7%(285/362)knew percutaneous coronary intervention but did not know its indications; 83.1%(301/362)knew coronary artery bypass but did not know its indications. 27.6%(100/362)knew calcium antagonists were first-line drugs for variant angina and 93.6%(339/362)never heard of microvascular angina. Conclusion The survey shows that GPs from community health service centers in Shanghai Pudong are not well familiar with examination of coronary heart disease and lack of sufficient knowledge of drugs recommended by the guideline, not well understand the indications for revascularization and the diagnosis and treatment of special types of coronary heart disease. Key words: Coronary artery disease; Questiongnaires; General practitioner

Impact of Clinical Guideline Recommendations on the Application of Coronary Computed Tomographic Angiography in Patients with Suspected Stable Coronary Artery Disease.

Background:Coronary computed tomographic angiography (CCTA) has been widely used in patients who are at intermediate risk for having stable coronary artery disease (SCAD), and 2013 European Society of Cardiology Guidelines on the Management of SCAD (2013G) recommended the appropriate application of CCTA. However, 2013G has not been subjected to systematic analyses for subsequent impact on clinical practice.Methods:A total of 5320 patients suspected with SCAD were enrolled and scheduled for CCTA from March 2013 to September 2014. For each patient, pretest probability of SCAD was calculated according to updated Diamond-Forrester model (UDFM). Appropriate CCTA or appropriate stress test was determined as described in the 2013G. A generalized estimating equation model was used to determine the trends in the half-monthly rate of appropriate CCTA.Results:Overall, only 61.37% of patients received appropriate CCTA, and there was insignificant change over time (P = 0.8701). The application of CCTA in patients who should have had a stress test accounted for most of the inappropriate CCTA before (22.29%) or after (19.98%) the publication of the 2013G. In all patients or any subgroup, no significant change in the adjusted half-monthly rate of appropriate CCTA was found after the publication of the 2013G (odds ratio, 1.002; 95% confidence interval, 0.982–1.021; P = 0.8678).Conclusions:These findings suggest that the 2013G have not, to date, been fully incorporated into clinical practice, and the clinical utilization of CCTA remains unreasonable to some extent.

Flow-Based Functional Assessment of Coronary Artery Disease by Myocardial Perfusion Positron Emission Tomography in the Era of Fractional Flow Reserve

Myocardial perfusion positron emission tomography (PET) has long been regarded as a gold standard of myocardial blood flow (MBF) measurement. However, since randomized clinical trials showed the prognostic value of fractional flow reserve (FFR)-guided revascularization, FFR has rapidly become a new gold standard of functionally significant coronary artery disease (CAD). Despite the predominance of FFR in the management of stable CAD, FFR also has limitations. Overcoming hurdles by the lesion-specific MBF measurement by hybrid imaging and novel flow parameter can be a complimentary tool.

Practice Patterns for Outpatients With Stable Coronary Artery Disease: A Case Vignette-based Survey Among French Cardiologists

BackgroundAlthough medical management of patients with coronary artery disease (CAD) is often based on scientific guidelines, a number of everyday clinical situations are not specifically covered by recommendations or the level of evidence is low. The aim of this study was to assess practice patterns regarding routine management of patients with stable CAD. MethodsA survey comprising six questions on two clinical scenarios regarding stable CAD management was sent to 345 cardiologists from the Nord-Pas-de-Calais Region (France). We first assessed practice patterns globally and then searched for associations with physician characteristics (age, gender, sub-specialty, and type of practice). FindingsThe response rate was 92%. Regarding management of asymptomatic CAD, 86% of the cardiologists performed routine exercise testing, before which, 69% withdrew β-blockers. After a positive exercise test, 26% immediately performed coronary angiography and 67%, further imaging tests. In the absence of left ventricular dysfunction or history of myocardial infarction, routine β-blocker prescription for stable CAD was selected by 43%. When anticoagulation was needed for atrial fibrillation, 41% initiated direct oral anticoagulants rather than vitamin-K antagonists and 50% combined aspirin with anticoagulants. For recurrent stable angina in patients with known CAD, 24% performed coronary angiography directly, 49% requested a stress test, and 27% opted for medical therapy without further diagnostic testing. Age, gender of the cardiologist, academic environment, and practice of interventional cardiology were associated with certain management patterns. InterpretationWhen not guided by high-level recommendations, practice patterns for routine clinical situations in stable CAD vary considerably. Future clinical trials should address these clinical interrogations.

Stable coronary artery disease management: What has changed in the 2013 European Society of Cardiology guideline?

Avrupa Kardiyoloji Dernegi en son 2006 yilinda yayimlamis oldugu kararli anjina pektoris tedavi kilavuzunu yeni calismalar isiginda 2013 yilinda guncellemistir.[1] Yeni kilavuz, 2006 yilinda yayimlanan kilavuz ile karsilastirildiginda kararli koroner arter hastaligi (KAH) taniminin yeniden gozden gecirildigi, tanisal degerlendirme ve tedavi yonlendirmelerinde bir takim degisiklikler yapildigi gorulmektedir.

Trainingstherapie bei kardiologischen Patienten (Sportkardiologie)

Clinical application of physical exercise has developed into an evidence-based therapeutic option for cardiovascular diseases, especially coronary artery disease (CAD) and chronic heart failure (CHF). In CAD regular physical exercise training partially corrects endothelial dysfunction and leads to an economization of left ventricular function. Meta-analyses have shown a reduction of angina pectoris symptoms and a decrease of total and cardiovascular mortality by regular aerobic exercise training. Endurance training for CHF reduces cardiac afterload by correcting peripheral endothelial dysfunction und leads to a better left ventricular function. In addition exercise training reduces the adrenergic tone and the stimulation of the renin-angiotensin-aldosterone system in CHF. Exercise training provides positive effects on the metabolism and function of skeletal muscle (e.g. reduced inflammation and oxidative stress). Supervised regular physical exercise training in CHF is safe and has improved the morbidity in clinical studies. Thus aerobic exercise training is an important component of therapeutic management of stable CAD and CHF with a class 1a recommendation in the current guidelines.

Beneficial effects of atorvastatin on myocardial regions with initially low vasodilatory capacity at various stages of coronary artery disease

The aim of this study was to analyse non-invasively the regional effect of therapy with an HMG-CoA reductase inhibitor on myocardial blood flow in patients with coronary artery disease (CAD) with special reference to segments with initially substantially impaired vasodilation. The study included 26 patients with untreated hypercholesterolaemia. Coronary angiography revealed CAD in nine patients with stenosis >50% and wall irregularities or minimal stenosis <30% in 17 patients. Before and 4.6+/-1.8 months after atorvastatin therapy, ( 13)N-ammonia positron emission tomography (PET) studies were performed at rest and under pharmacological stress. Minimum coronary vascular resistance (MCR) and coronary flow reserve (CFR) were determined. Segments were divided into those with normal or near-normal (MBF during adenosine > or =2.0 ml/min/g) and those with abnormal (MBF<2.0 ml/min/g) vasodilator flow response. In CAD patients, 156 segments were analysed, 85 of which had abnormal MBF; in the non-obstructive group, 59 of 297 segments had abnormal MBF. LDL cholesterol decreased after atorvastatin therapy from 186+/-43 mg/dl to 101+/-26 mg/dl (p<0.001). In normal segments no significant changes in MBF, CFR and MCR were found. However, initially abnormal segments showed significant improvements in MCR (15%, p<0.0001) and MBF during adenosine (30%, p<0.0001) after therapy. The improvement in regional coronary vasodilator function after atorvastatin in patients with coronary atherosclerosis may be caused, at least in part, by increased flow-mediated (endothelium-dependent) dilation of the total arteriolar and arterial vascular system. These data further support the concept of non-invasive management of stable CAD by statin therapy and life-style modification guided by PET.