Cardiac Care (cardiac + care)

Distribution by Scientific Domains

Selected Abstracts

A Bayesian Sensitivity Analysis of Out-of-hospital 12-lead Electrocardiograms: Implications for Regionalization of Cardiac Care

Scott T. Youngquist MD
Background The effectiveness of out-of-hospital regionalization of ST-elevation myocardial infarction (STEMI) patients to hospitals providing primary percutaneous coronary intervention depends on the accuracy of the out-of-hospital 12-lead electrocardiogram (PHTL). Although estimates of sensitivity and specificity of PHTL for STEMI have been reported, the impact of out-of-hospital STEMI prevalence on positive predictive value (PPV) has not been evaluated. Objectives To describe the relationship between varying population STEMI prevalences and PHTL predictive values, using ranges of PHTL sensitivity and specificity. Methods The authors performed a Bayesian analysis using PHTL, where values for sensitivities (60%,70%), specificities (98%), and two prevalence ranges (0.5%,5% and 5%,20%) were derived from a literature review. PPV prediction intervals were compared with three months of prospective data from the Los Angeles County Emergency Medical Services Agency STEMI regionalization program. Results When the estimated prevalence of STEMI in the out-of-hospital population is 5%,20%, the median PPV of the PHTL is 83% (95% credible interval [CrI] = 53% to 97%). However, if the population prevalence of STEMI is between 0.5% and 5%, the median PPV is 43% (95% CrI = 12% to 86%). When the PPV prediction intervals were incorporated with the Los Angeles County Emergency Medical Services Agency data, the PPV was 66%. Conclusions Even when assuming high specificity for PHTL, the false-positive rate will be considerable if applied to a population at low risk for STEMI. Before broadening application of PHTL to low-risk patients, the implications of a high false-positive rate should be considered. [source]

A cardiologist view of vascular disease in diabetes

Christopher J. Lockhart
Diabetes mellitus is a potent risk factor for the development of a wide spectrum of cardiovascular (CV) complications. The complex metabolic milieu accompanying diabetes alters blood rheology, the structure of arteries and disrupts the homeostatic functions of the endothelium. These changes act as the substrate for end-organ damage and the occurrence of CV events. In those who develop acute coronary syndromes, patients with diabetes are more likely to die, both in the acute phase and during follow-up. Patients with diabetes are also more likely to suffer from chronic cardiac failure, independently of the presence of large vessel disease, and also more likely to develop stroke, renal failure and peripheral vascular disease. Preventing vascular events is the primary goal of therapy. Optimal cardiac care for the patient with diabetes should focus on aggressive management of traditional CV risk factors to optimize blood glucose, lipid and blood pressure control. Targeting medical therapy to improve plaque stability and diminish platelet hyper-responsiveness reduces the frequency of events associated with atherosclerotic plaque burden. In patients with critical lesions, revascularization strategies, either percutaneous or surgical, will often be necessary to improve symptoms and prevent vascular events. Improved understanding of the vascular biology will be crucial for the development of new therapeutic agents to prevent CV events and improve outcomes in patients with diabetes. [source]

The impact of using different costing methods on the results of an economic evaluation of cardiac care: microcosting vs gross-costing approaches

Fiona M. Clement (Nee Shrive)
Abstract Background: Published guidelines on the conduct of economic evaluations provide little guidance regarding the use and potential bias of the different costing methods. Objectives: Using microcosting and two gross-costing methods, we (1) compared the cost estimates within and across subjects, and (2) determined the impact on the results of an economic evaluation. Methods: Microcosting estimates were obtained from the local health region and gross-costing estimates were obtained from two government bodies (one provincial and one national). Total inpatient costs were described for each method. Using an economic evaluation of sirolimus-eluting stents, we compared the incremental cost,utility ratios that resulted from applying each method. Results: Microcosting, Case-Mix-Grouper (CMG) gross-costing, and Refined-Diagnosis-Related grouper (rDRG) gross-costing resulted in 4-year mean cost estimates of $16,684, $16,232, and $10,474, respectively. Using Monte Carlo simulation, the cost per QALY gained was $41,764 (95% CI: $41,182,$42,346), $42,538 (95% CI: $42,167,$42,907), and $36,566 (95% CI: $36,172,$36,960) for microcosting, rDRG-derived and CMG-derived estimates, respectively (P<0.001). Conclusions: Within subject, the three costing methods produced markedly different cost estimates. The difference in cost,utility values produced by each method is modest but of a magnitude that could influence a decision to fund a new intervention. Copyright 2008 John Wiley & Sons, Ltd. [source]

Illness Representations According to Age and Effects on Health Behaviors Following Coronary Artery Bypass Graft Surgery

Brooks B. Gump PhD
OBJECTIVES: To determine if illness representations differ as a function of age and how these representations, in conjunction with age, predict postoperative health behaviors. DESIGN: Prospective study of patients undergoing coronary artery bypass graft (CABG) surgery. SETTING: A large metropolitan hospital providing regional cardiac care for patients in a tri-state area, located in Pittsburgh, Pennsylvania. PARTICIPANTS: All consenting patients (N = 309) from a consecutive series of patients scheduled for CABG surgery between January 1992 and January 1994. To be eligible for participation, patients could not be scheduled for any other coincidental surgery (e.g., valve replacement), and could not be in cardiac intensive care or experiencing angina at the time of the referral. Participants were predominantly male (70%) and married (80%), and averaged 62.8 years of age. MEASUREMENTS: Postoperative self-reported health behaviors. RESULTS: Older participants awaiting CABG surgery were significantly more likely to believe old age to be the cause of their coronary heart disease (CHD) and significantly less likely to believe genetics, health-damaging behaviors, health protective behaviors, and emotions to be the cause of their CHD than were younger participants awaiting surgery. Furthermore, the older participants were significantly more likely to believe they had no control over the disease and that the disease would be gone after surgery, and reported fewer postoperative health behavior changes than did younger participants. CONCLUSION: These findings demonstrate significant differences in illness representations as a function of age. Furthermore, differences in postoperative health behaviors were consistent with differing illness representations. [source]

Cardiac veins: A review of the literature

Marios Loukas
Abstract Cardiac veins have long stood in the shadow of their more extensively studied counterparts, the coronary arteries. The clinical importance of the coronary venous system, nonetheless, should not be underestimated. Intricate and beneficial therapeutic options are increasingly being developed that depend on knowledge of the structure of this venous network. Such interventions have been shown greatly to promote cardiac health, and to enhance the efficacy of cardiac pacing. A comprehensive appreciation of the architecture of the coronary venous system, therefore, is crucial to optimal cardiac care. It is possible to provide an overview of the arrangement of the cardiac veins, with the larger veins draining to the coronary sinus, and thence to the right atrium, but with smaller and minimal veins draining directly to the cavities of the atrial chambers. The venous pathways, nonetheless, are highly variable, making exceptions the commonly accepted rule. As such, unique solutions for imaging, and simple attentiveness to possible venous variations, can greatly enhance clinical outcomes. For example, identifying the diameter, course, and valves of the cardiac veins allows for anticipation of impediments during interventional procedures, and allows for informed clinical decision-making. Also of significance is awareness of alternate arrangements that may be encountered in terms of venous drainage, and the importance of intramural venous collecting spaces in these patterns. The objective of our review, therefore, is to explore and describe the anatomical distribution of the coronary veins Clin. Anat. 22:129,145, 2009. 2008 Wiley-Liss, Inc. [source]

Disparities in the Emergency Department Evaluation of Chest Pain Patients

Liliana E. Pezzin PhD
Background The existence of race and gender differences in the provision of cardiovascular health care has been increasingly recognized. However, few studies have examined whether these differences exist in the emergency department (ED) setting. Objectives To evaluate race, gender, and insurance differences in the receipt of early, noninvasive diagnostic tests among persons presenting to an ED with a complaint of chest pain. Methods Data were drawn from the U.S. National Hospital Ambulatory Health Care Survey of EDs. Visits made during 1995,2000 by persons aged 30 years or older with chest pain as a reason for the visit were included. Factors affecting the likelihood of ordering electrocardiography, cardiac monitoring, oxygen saturation measurement using pulse oximetry, and chest radiography were analyzed using multivariate probit analysis. Results A total of 7,068 persons aged 30 years or older presented to an ED with a primary complaint of chest pain during the six-year period, corresponding to more than 32 million such visits nationally. The adjusted probability of ordering a test was highest for non,African American patients for all tests considered. African American men had the lowest probabilities (74.3% and 62% for electrocardiography and chest radiography, respectively), compared with 81.1% and 70.3%, respectively, among non,African American men. Only 37.5% of African American women received cardiac monitoring, compared with 54.5% of non,African American men. Similarly, African American women were significantly less likely than non,African American men to have their oxygen saturation measured. Patients who were uninsured or self-pay, as well as patients with "other" insurance, also had a lower probability than insured persons of having these tests ordered. Conclusions This study documents race, gender, and insurance differences in the provision of electrocardiography and chest radiography testing as well as cardiac rhythm and oxygen saturation monitoring in patients presenting with chest pain. These observed differences should catalyze further study into the underlying causes of disparities in cardiac care at an earlier point of patient contact with the health care system. [source]