Testing For Coronary Heart Disease Research Articles

Abstract 10822: Familial Hypercholesterolemia in the EMERGE Network: 1-Year Outcomes After Return of Results

Introduction: Relatively little is known about outcomes following return of secondary findings detected in large scale sequencing projects. We assessed 1-year outcomes following return of pathogenic/likely pathogenic (P/LP) variants associated with familial hypercholesterolemia (FH) in phase III of the eMERGE network (2015-2019). Methods: Adult participants (n=18,544) at 7 sites were enrolled in a prospective cohort study to study the clinical impact of returning results from targeted sequencing of 68 actionable genes, including LDLR , APOB , and PCSK9 . Process, intermediate, and/or clinical outcomes within 1-year after return of results (RoR) were ascertained by electronic health record (EHR) review. A process outcome was defined as referral to a specialist or ordering new tests, including lipid profile and screening tests for coronary heart disease. An intermediate outcome was defined as new diagnosis of FH or atherosclerotic cardiovascular disease. A clinical outcome was defined as initiation or change in lipid-lowering medication. The primary outcomes were a new diagnosis of FH and modification of lipid lowering therapy. Results: Results were returned to 134 individuals, and data for 119 participants were available for the outcomes analysis. Process (86%), intermediate (49%), and/or clinical (26%) outcomes occurred in 92% of participants. Process outcomes included 72% with new tests ordered and 61% referred to a specialist. Before RoR, 86.5% of individuals with FH associated P/LP variants had a diagnosis of hypercholesterolemia but only 17.6% had a diagnosis of FH; 89% were on a statin but only 58% were on a high intensity statin. Following RoR, 44% (52/119) received a new diagnosis of FH. Lipid lowering treatment was modified in 26% (31/119), including initiation of a statin in 5%, increasing statin dose in 13%, and adding ezetimibe or a PCSK9 inhibitor in 12.6%. Conclusions: In a multisite cohort of EHR-linked biobanks, monogenic FH was underdiagnosed (only 17.6% had a specific diagnosis) and undertreated (only 58% were on a high intensity statin); 44% of participants received a new diagnosis of FH and 26% had lipid lowering treatment modified after RoR. These results highlight the clinical utility of returning FH variants in EHR-linked biobanks.

Systematic Review: Position Changes After Transfemoral Percutaneous Coronary Intervention

Background. Percutaneous Coronary Intervention (PCI) is the gold standard diagnostic test for Coronary Heart Disease (CHD). To minimize complications after PCI, patient activity is limited to bedrest for 2-24 hours. But the long bedrest can cause complaints of back pain and discomfort. This systematic review aims to identify the position changes in the first 6 hours after PCI for back pain and discomfort. Metode. Three electronic databases were used to carry out systematic searches namely Pubmed, CINAHL ebsco and ProQuest. The keyword combination is 'percutaneous coronary intervention' AND 'position change' OR 'changing position' OR 'early mobilization' NOT 'Literature Review' OR 'review of the literature' OR 'overview' OR 'Systematic Review' OR 'meta analysis’. The inclusion criteria used were articles with the last 12 years of research 2007 - 2019, quantitative research, English and Indonesian, peer review, randomized controlled trial and quasi experiment. The article search results found 49 articles on CINAHL ebsco, 81 articles on PubMed and 273 articles on ProQuest. A total of 13 articles met the inclusion criteria and were analyzed. Results. From 13 articles, 6 articles reported a decrease in complaints of back pain and discomfort after changing positions in the first 6 hours in bed. 4 articles indicate the same thing after a change of position made the first 6 hours then walking beside the bed. And 3 articles reported a decrease in complaints of back pain and discomfort after ambulation in the first 6 hours. Conclusion. Changes in position within a period of 6 hours after PCI can reduce the incidence of back pain and discomfort that is felt by patients.Keywords: position changes, percutaneous coronary intervention

Association between Time of Ambulation and Clinical Outcome of Patients after Cardiac Catheterization

Cardiac catheterization is the gold standard diagnostic test for coronary heart disease. The aim: the present study was conducted to assess the association between time of ambulation and clinical outcomes of patients after cardiac catheterization. Methodology: Setting: the study was conducted at the cardiac catheterization units at Ain Shams University Hospital and Ain Shams University Specialized Hospital. Design:The descriptive exploratory research design was utilized in this study. Subject: A purposive sample of 150 patients was used in the study. Tools: 1) Patients’ interview questionnaire to assess patients' demographic characteristics data and patients' medical history. 2) Patient post cardiac catheterization clinical outcomes which included Vital signs: (temperature, blood pressure, respiration, pulse), O2 saturation, lower peripheral perfusion and cardiac catheterization site assessment. 3) Visual Analogue Pain Scale to assess pain intensity. 4) Anxiety Scale to measure the level of anxiety. Results: there was a highly statistically significant relation between patients' age and vital signs reading at the fourth hour after ambulation p value is 0.05. Conclusion: Patients on supine position with restricted on bed rest increased the intensity of back pain level at a time (1h) and then decreased at the time third and fourth hour after cardiac catheterization. Recommendation: early ambulation after cardiac catheterization is safe and its' suggested to improve patients' outcomes.

Recherche de l’ischémie myocardique chez les femmes

Screening of myocardial ischemia refers to the use of one or more diagnostic tests for coronary heart disease with a dual objective of appropriateness and promptness. In women, as compared to men, the accuracy of the different tests is worse. Thus, to overcome this sex-related penalty, we must define a diagnosis strategy based on risk stratification, enabling the identification of patients requiring invasive investigations. This review discusses various non-invasive diagnostic tests focusing on a female-specific approach and defines the use of numerous diagnostic tests with respect to both risk stratification and symptoms.

Women and NCDs: Overcoming the neglect

Two in every three deaths among women are caused by non-communicable diseases (NCDs) – largely heart disease, stroke, cancer, diabetes and chronic respiratory diseases. The global discourse on health, however, largely views women in terms of their reproductive capacity, a persisting myth reflecting gender bias that shifts the focus away from NCDs, violence, and other injuries. Risk factors for NCDs are similar for men and women. Because fewer women actively smoke than men, and drink in less harmful ways, in most parts of the world, the impact of major NCD risk factors is far less in women than in men. In the area of diagnosis and treatment, gender bias can result in women being asked fewer questions, and receiving fewer examinations and fewer diagnostic tests for coronary heart disease and other NCDs compared with men with similar symptoms. In response to a UN meeting in September 2011, member states of WHO have agreed to a global goal to reduce avoidable NCD mortality by 25% by 2025 (‘25 by 25’). A set of voluntary targets and indictors have been agreed upon, although none of them are gender specific. Most require changes at the policy level that will ensure that women – and children – will also benefit. As the 2015 deadline for the Millennium Development Goals approaches, women and NCDs should be central to the sustainable human development agenda.

Introducing genetic testing for cardiovascular disease in primary care: a qualitative study.

While primary care systematically offers conventional cardiovascular risk assessment, genetic tests for coronary heart disease (CHD) are increasingly commercially available to patients. It is unclear how individuals may respond to these new sources of risk information. To explore how patients who have had a recent conventional cardiovascular risk assessment, perceive additional information from genetic testing for CHD. Qualitative interview study in 12 practices in Nottinghamshire from both urban and rural settings. Interviews were conducted with 29 adults, who consented to genetic testing after having had a conventional cardiovascular risk assessment. Individuals' principal motivation for genetic testing was their family history of CHD and a desire to convey the results to their children. After testing, however, there was limited recall of genetic test results and scepticism about the value of informing their children. Participants dealt with conflicting findings from the genetic test, family history, and conventional assessment by either focusing on genetic risk or environmental lifestyle factors. In some participants, genetic test results appeared to reinforce healthy behaviour but others were falsely reassured, despite having an 'above-average' conventional cardiovascular risk score. Although genetic testing was acceptable, participants were unclear how to interpret genetic risk results. To facilitate healthy behaviour, health professionals should explore patients' understanding of genetic test results in light of their family history and conventional risk assessment.

Effect of Positioning on Patient Outcomes After Coronary Angiography

Restoring patient homeostasis after coronary angiography, the gold standard diagnostic test for coronary heart disease is usually achieved by manual compression of the puncture site using a sandbag and prolonged bed rest. However, this process frequently results in patient complaints of back pain and discomfort. The aim of study was to assess the effect of positioning on patient outcomes after coronary angiography. This study used a single-blind randomized control trial approach. The sample consisted of 80 patients who had undergone a nonemergency coronary angiography via the femoral artery. Balanced block randomization was used to allocate participants into intervention and control groups. Routine care for the intervention group (n = 40) was adjusted to include the following: (1) intermittent changes to patient body and head position in bed during first 6 hours after catheterization, (2) reduction of sandbag compression time on the puncture site to 1 hour, and (3) regular examination for bleeding during the first 6 hours after catheterization. Intervention group participants were allowed to ambulate without restriction 6 hours after catheterization. Patients in the control group (n = 40) received routine care, consisting of (1) 6-24 hours of bed rest in the supine position with the affected leg fixed straight and immobilized and (2) sandbag compression on the puncture site for 6 hours. The main outcomes used in this study were level of back pain, discomfort, foot pain, bleeding, and hematoma. Intervention group patients had significantly less back pain and foot pain and higher comfort than the control group at the second, third, and sixth hour after catheterization (p = .00). There was no significant difference between the two groups in terms of amount of bleeding and hematoma (p > .05). Findings suggest that changes in patient position may be safer in the early period of postcatheterization bed rest than currently indicated in standard practice protocols. Furthermore, limiting sandbag compression to 1 hour has no measurable effect on the incidence and severity of vascular complications.

Correlation between clinical prediction tests for coronary heart disease and findings on spect myocardial perfusion scintigraphy and coronary angiography

Predictive clinical tests are important diagnostic tools in determining groups of patients who should undergo further diagnostic methods for detection of coronary artery disease. The aim of this study was to determine the correlation between the probability of the existence of the coronary heart disease (CHD) obtained with Duke's clinical prediction tests for the existence of coronary artery disease and the results obtained by SPECT myocardial perfusion scintigraphy and coronary angiography. Patients and methods: The study included 56 patients with symptoms of angina pectoris (AP), 35 men and 21 women, aging 32-78 years. In all patients, the probability of the existence of coronary artery disease was calculated, i.e. the need for other diagnostic methods, by means of Duke clinical prediction (DCS). The patients subsequently underwent SPECT myocardial perfusion scintigraphy (SPECT MPI) with exercise stress test and with calculating Duke treadmill score (DTS), followed by coronary angiography (CA). The results were statistically analyzed using SPSS statistical tools, nonparametric statistical tests. Results: DCS showed a low CHD probability in 10 (17.9%), while in 46 (82.1%) there was moderate probability. DTS showed low probability in 8 (14.3%) and in 48 (85.7%) high probability of CHD. SPECT MPI resulted in 22 (39.3%) normal and 34 (60.7%) pathologilal states. CA was negative in 21 (37.5%), while in 35 (62.5%) showed significant coronary artery stenosis. In the group with low DCS and DTS probability for CHD there were no perfusion defects in SPECT MPI and no coronary artery stenosis in CA. Conclusion: Predictive clinical tests DCS and DTS, which confirm or reject suspicion of CHD, represent an important diagnostic tool that avoids unnecessary exposure of patients to further diagnostic methods which mean either an invasive diagnostic approach or any unnecessary exposure of patients to ionizing radiation. DCS and DTS have high negative predictive value and are reliable tools for selection of AP patients for further diagnostic modalities.

Relevance of Screening Symptom-Free Population for Coronary and Noncoronary Calcification Burden

Early detection of arterial disease in the preclinical stage may improve cardiovascular disease sequelae, such as myocardial infarction and stroke.1 At present, the optimal imaging technique to detect subclinical arterial disease has not been determined.2 Calcium-based imaging by noncontrast computed tomography (CT) is widely used to detect noninvasively coronary calcification, an established surrogate of coronary atherosclerosis.3 In this issue of Hypertension , Jensky et al4 performed “whole body” noncontrast CT imaging of the arterial tree from the skull to the pubic symphysis in a large free-living, middle-aged, and mostly asymptomatic population to detect calcium deposit4 not only within the coronary bed but also in several noncoronary territories, including carotid, subclavian, and iliac arteries and the thoracic and abdominal aorta. The prevalence of any calcification ranged from 32% in the carotid and subclavian arteries to 57% in the coronary arteries.4 Other than expected associations of arterial calcium with aging, male sex, smoking, dyslipidemia, and diabetes mellitus, calcification was strongly and independently associated with hypertension in all of the vascular beds except the distal iliac and subclavian arteries.4 Association of calcification and hypertension was stronger in older than in younger subjects and in men than in women, and its magnitude was greater when pulsatile components of hypertension, that is, pulse and systolic pressures, were considered.4 Beyond the demonstration of the close link …

Combining Carotid Intima-media Thickness with Carotid Plaque on Screening for Coronary Heart Disease

Ultrasound-detected carotid artery intima-media thickness (IMT) and carotid plaque are possible screening tests for coronary heart disease (CHD) among asymptomatic individuals. To assess the increase in screening performance of combining carotid IMT and plaque compared with each measurement alone in the identification of individuals with CHD. Ultrasound examination of left and right carotid arteries was performed on 100 individuals (median age 57), 55 with a history of CHD (unstable angina or myocardial infarction) and 45 without. IMT measurements were taken from the common carotid artery and plaque was identified above, at and below the carotid bifurcation. Associations between IMT and plaque were determined using logistic regression, and screening performance was assessed from the distributions of IMT and plaque among cases and controls. At a false-positive rate of 5%, IMT (cut-off >0.75 mm) identified 30% (95% CI 14-58) of affected individuals. There was an increase in the detection rate of 8 percentage points (1-33%) using IMT and plaque combined compared with IMT alone. As the false-positive increased, the difference in the detection rate increased, up to a maximum of 20 percentage points (5-38%) at a false-positive rate of 20%. The comparison of IMT and plaque combined with plaque alone could only be estimated for the false-positive rate observed using plaque alone (18%); at this point the detection rate was 72% for plaque and 75% for plaque and IMT combined, an increase of 3 percentage points (0-4%). In screening for CHD, combining carotid IMT measurement with plaque assessment is better than using either measurement alone, but the improvement in discrimination is not sufficient to make carotid ultrasound screening for CHD worthwhile.

Should we treat all patients with coronary heart disease or the equivalent with statins?

Statins have proven benefit in preventing cardiovascular events and should be prescribed for almost all patients with coronary heart disease (CHD) or equivalent. However, evidence is lacking to support treating all such individuals. Potential exceptions include those in the initial days of acute coronary syndrome, those with symptomatic systolic heart failure, those with very low low-density lipoprotein cholesterol, diabetic patients without associated metabolic syndrome, and those with high CHD risk calculated mainly on the basis of advanced age. In these cases, the decision to prescribe statins depends on clinical judgment, and surrogate tests for CHD may be useful.

Performance of Subclinical Arterial Disease Detection as a Screening Test for Coronary Heart Disease

Traditional risk factors are poor screening tests for coronary heart disease, whereas clinical arterial disease represents its strongest predictor. This raises the question whether subclinical arterial disease may also predict coronary disease. Using published data of prospective studies of subclinical arterial disease, we calculated the incidence of coronary event associated with the absence or presence of atherosclerosis as defined by dichotomous characterization of the following markers: low or high intima-media thickness or the absence or presence of plaque, assessed by carotid ultrasound; zero or high total coronary artery calcium score assessed by computed tomography; normal or decreased ankle-arm index pressure assessed by Doppler stethoscope; and low or high aortic pulse wave velocity assessed by mecanography. A dose-response relationship was found between the absence and presence of atherosclerosis and coronary event incidence. Yearly incidence was <1% in the absence of atherosclerosis regardless of the marker used. Coronary event incidence was >1% in the presence of atherosclerosis and increased in a gradual way, depending on the marker tested, to reach 3% maximum with massive coronary calcifications. The relation between clinically overt arterial disease, such as angina, transient ischemic attack, stroke, or myocardial infarct, and yearly incidence of subsequent events reported in the literature prolonged the dose-response curve of subclinical disease. Therefore, detection of arterial disease, not only clinically overt but also subclinical asymptomatic, is a worthwhile screening test for future coronary event.

520: Inflammatory Markers as a Worksite Screening Test for Coronary Heart Disease among Women

520: Inflammatory Markers as a Worksite Screening Test for Coronary Heart Disease among Women

Genetics and Coronary Heart Disease

Genetic analysis is absolutely required to understand the architecture of complex diseases such as coronary heart disease, and such knowledge may lead to important advances in the diagnosis and treatment of the disease. On the other hand, there is presently little theoretical and empirical evidence supporting the idea that large-scale diagnostic and prognostic genetic testing for coronary heart disease might be medically useful. The situation may change however, as recent technological and population genomics advances are progressively incorporated in new appropriately designed studies.

Myocardial scintigraphy with I-123 heptadecanoic acid as a test for coronary heart disease.

We have evaluated 123I-heptadecanoic acid for myocardial scintigraphy in the diagnosis of coronary heart disease by comparing the results obtained with it in subject groups with high and low probabilities of disease. We conclude that although some patients in the former group can be identified, the test is neither sufficiently sensitive nor specific for routine clinical use.

Gold 195m in the assessment of the cold pressor test by first pass radionuclide ventriculography.

First pass radionuclide ventriculography was performed with gold 195m in a sequential evaluation of left ventricular ejection fraction during cold pressor stimulation. We studied 10 normal controls, 10 patients with angina pectoris who had proven coronary artery disease and normal left ventricular function during contrast angiography and 10 patients with dilated cardiomyopathy with normal coronary arteries and impaired left ventricular function at contrast angiography. Mean resting ejection fraction was similar in controls and patients with coronary heart disease (57 +/- 2 vs 58 +/- 3) but was significantly lower in the cardiomyopathic subjects (27 +/- 4, P less than 0.001). After 30 seconds cold pressor stimulation, mean left ventricular ejection fraction fell in the normal controls (57 +/- 2 to 52 +/- 2, P less than 0.05) but was unchanged in those with coronary heart disease and dilated cardiomyopathy (58 +/- 3 to 55 +/- 3 and 27 +/- 4 to 24 +/- 4, both NS). No further significant change occurred after 2.5 minutes stimulation (53 +/- 1, 58 +/- 3 and 23 +/- 3, respectively). There was no difference in the pattern of left ventricular ejection fraction response between the groups. Six controls, 4 patients with coronary heart disease and 4 patients with dilated cardiomyopathy had a significant fall in left ventricular ejection fraction and 4, 5 and 6, respectively, developed a new or further deterioration in regional wall motion. Thus neither changes in regional wall motion nor left ventricular ejection fraction response distinguished either patient group from the normal controls. We do not recommend cold pressor stimulation as a diagnostic test for coronary heart disease.

A self-scoring five-question risk test for coronary heart disease.

SUMMARY Asimple, five-question risk test forcoronary heart disease (CHD)ispresented. Thetest allows a persontoestimate his orherrelative risk ofCHD,based onanswerstoquestions onsmoking habits, history ofdiagnosis andtreatment forhighblood pressure, weight, pulse rateandfamily history ofheart disease. The scoring system, developed fromthe17-year CHD mortality study of1899white males age40-55yearsfrom theChicago Western Electric Companystudy, isapplied tothemen ofthatstudy andpredictively to1158 white men age40-59 yearsfollowed 15yearsintheChicago Peoples GasCompany study. Inthese twostudies, themen with thehighest quintile ofrisk scoreshadmorethanfourtimes theobserved numbers ofCHD deaths asthemen inthelowest quintile ofrisk scores.Inaddition, atest that usesactual blood pressure instead of treatment status, andincludes serumcholesterol level, isalsopresented foruseincaseswherethevalues of these variables areavailable. Although thescoringsystems forthese tests arebased on themortality experience ofmiddle-aged white males, thetests should haveapproximate validity forallage-sex-race groups because thescoresarea measureofrelative risk. THE NATIONAL Broadcasting Company(NBC) requested ustodevelop aself-scoring risk test forcoronaryheart disease (CHD)toallow aperson toestimate hisorherrelative riskofCHD.Theselfscoring test wepresent isamodification ofthetest originally usedandprepared with NBC.This test asks theperson toscorehimself/herself onquestions regarding smoking habits, history ofdiagnosis and treatment forhighblood pressure, weight, pulse rate, andfamily history ofheart disease. A second risk test that substitutes aquestion onactual blood pressure for thequestion ondiagnosis andtreatment forhigh blood pressure ontheself-scoring test, andadds asixth question onserumcholesterol, isalso given. Inthis report wepresent thequestions that makeup thetests andtheassociated scoring systems anddiscusshowthesystems weredeveloped statistically and therationale that wentinto that development.