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The bibliography has been updated over at the ECG blog…

The Emergency Cardiology Group

… was to get the bibliography up to date!

The links go to the full article where possible, but some of these remain behind paywalls.

For individual reprint requests for academic/educational use please leave a message and we will provide these wherever possible according to copyright restrictions.

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Cross blogged from our Emergency Cardiology Site…

The Emergency Cardiology Group

There has been lots of media interest in our paper ‘Validation of high-sensitivity troponin I in a 2-h diagnostic strategy to assess 30-day outcomes in emergency-department patients with possible acute coronary syndrome‘ that went online in in the Journal of the American College of Cardiology in the last few days.

Those in Queensland may have heard reference to the study on the ABC Radio news this morning and Louise Cullen has been interviewed today by ABC Radio National and Channel Nine.

We may have lost out to Black Caviar on the Channel Nine News though…

A copy of the press release from the Queensland Government is available here: RBWH media release – improved testing for potential heart attack patient.

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The Emergency Cardiology Group

A/Prof Louise Cullen writes…

The minefield of differences in troponin assays confuses clinicians, in an area of medicine that is already complex. Determining which patients presenting to Emergency Departments (EDs) with symptoms of possible Acute Coronary Syndromes actually have this underlying diagnosis is challenging. Current guidelines recommend lengthy assessment processes generally not achievable in acceptable time frames for patients to remain in the ED, and thus encourage Emergency Physicians to admit ‘all’ who present with possible symptoms of ACS.

Add to this mix the variability in analytical characteristics between troponin assays and information on change values (deltas) and it seems to many clinicians that this is simply getting too tough.

Our latest paper Delta troponin for the early diagnosis of AMI in emergency patients with chest pain’ in the International Journal of Cardiology highlights how early (0 and 2hr post ED presentation) troponin values may be used to…

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This sort of thing has been bugging me for ages…

Old CardioBrief

Don’t believe the the hype! That’s the cardinal rule to obey when reading health news. “Breakthroughs” and “cures” are rare, and should always be viewed with caution and skepticism.

This week was a great example. Last Sunday, the New York Times, the major networks, and a host of other media outlets (including this one) reported on a paper in  Nature Medicine about the discovery of a novel and potentially significant pathway linking red meat to heart disease. Briefly, the research suggested that carnitine, which is found naturally in high concentrations in red meat, can lead to atherosclerosis when it is converted by gut bacteria to a chemical called TMAO. Almost immediately I received a lot of comment from experts who raised serious questions about the research. Then today, a separate study was published with an entirely different perspective on carnitine. Although the two studies don’t directly contradict each other, they…

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Nothing to help recover from an overseas better than a brisk ride on my bike at 5 am and a couple of favourable replies from journal editors – Our Emergency Cardiology Group has a few ‘In Press…’ now and you can check this out here.

The Emergency Cardiology Group

All that writing is beginning to pay off.

I’ve had to update the ‘In Press…’ page again…

and Jaimi’s Bio is on line!

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This post refers to

‘Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology’ by Jolien Roos-Hesselink, Titia Ruys, Jörg Stein and others on behalf of the ROPAC Investigators published online in the European Heart Journal on September 11th 2012 http://www.ncbi.nlm.nih.gov/pubmed/22968232

I’ve posted previously about the importance of heart disease in pregnancy. Even in developed countries like our own, where maternal mortality rates are extremely low, cardiac disease remains the single most common cause of indirect maternal mortality* in many series.

Many countries do not have a strategic approach to the delivery of cardiac care to pregnant patients and Australia is no different. Cardiac symptoms are not uncommonly overlooked in pregnant women where the confounding effects of normal pregnancy must be taken into account (shortness of breath, ankle swelling and palpitations are common ‘symptoms’ of ‘normal’ pregnancy but equally may be the first indication of a cardiac problem). Where problems are suspected access to appropriate investigations may be difficult and there are few teams specialising in the management of cardiac disease in pregnancy. Perhaps for similar reasons the 2011 UK report ‘Saving Mothers Lives’ concerning maternal deaths between 2006 and 2008 found that

‘The assessors considered that some degree of substandard care was present in 27 of the 53 (51%) deaths…’

and that…

‘In 13 deaths, there were major lessons to be learnt, and, if the care had been better, the outcome may have been different.’

Despite the rarity of the combination of pregnancy and heart disease this publication in the European Heart Journal emphasises that it is not a problem that should be ignored. In the largely European ROPAC registry the overall maternal mortality of women with heart disease was 1% compared with 0.007% of a comparable population. So whilst in the developed world maternal deaths are very rare, pregnancy remains a significant risk for women with pre-exisiting heart disease or for those who are diagnosed with heart disease during pregnancy.

One other observation is of note. The first is the dramatic change in the profile of maternal heart disease. In the last substantial description of maternal heart disease in Australia from the Royal Women’s Hospital, Melbourne and concerning women and pregnancies between 1950 and 1975 over 80% of the case concerned rheumatic heart disease and only 13% had relatively uncomplicated congenital lesions. By contrast, our own registry recently presented at the 2012 European Society of Cardiology now reveals congenital disease to be overwhelmingly the most common cause of presentation to the clinic – with complex lesions such as repaired Tetralogy of Fallot and Transposition of the great arteries fairly common. This observation is shared by the European registry.

The 2011 report of the Queensland Maternal and Perinatal Quality Council included the recommendation that…

‘When pregnant women present with common symptoms such as chest pain, palpitations, syncope and shortness of breath, there should be a low threshold for considering significant cardiovascular disease and referral for specialist opinion and investigation within a clinically appropriate time frame.’

Which only make sense if those services are available. The UK report goes further…

‘Women with a known history of cardiac disease must be referred for consultant-led obstetric care in a maternity unit where there is a joint obstetric/cardiology clinic or a cardiologist with expertise in the care of women with heart dis- ease in pregnancy.’

Advice, it seems, we should take heed of…

 

 

* Indirect maternal mortality refers to women dying during pregnancy or within 42 days of the end of pregnancy due to causes other than those directly related to the pregnancy itself. So, for example, postpartum haemorrhage would be considered a direct cause but pulmonary embolus or heart failure due to mitral stenosis indirect. Maternal mortality rates are usually expressed as deaths per 100000 live births or per 100000 maternities (which includes live births and stillbirths).

This post refers to

‘2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker : The ADAPT Trial’  by Martin Than, Louise Cullen, Sally Aldous, William Parsonage and others published online in The Journal of the American College of Cardiology http://dx.doi.org/10.1016/j.jacc.2012.02.035

Last year I wrote under this title about the growing body of work accumulating around more rapid and safe approaches to the assessment of patients presenting with acute chest pain.

Here is a paper that takes this further and is based on a large study of an Australasian cohort of patients with undifferentiated chest pain presenting to emergency. The study refines the groups previous work published in The Lancet last year. The main refinement has been to reconfigure the accelerated diagnostic protocol (ADP) to use cardiac troponin as the only biomarker as opposed to the multi marker approach used in the earlier ASPECT study. This eliminates some of the ‘noise’ introduced by the additional biomarkers and therefore grows the size of the group that can rapidly be shown to be at low risk of a short term adverse cardiac outcome to about 20% of all comers whilst still maintaining an extremely high level of safety (a negative predictive value of >99%).

Of considerable importance is the fact that this was all achieved with testing at only 2 hours after presentation using contemporary sensitive (but not highly sensitive) troponin assays.

It’s clear that while many labs have already switched to new highly sensitive troponin assays there is still a lot to be learnt about how even the contemporary assays can be best utilised. It’s even more clear that the prevailing diagnostic paradigms for chest pain that advocate 6-8 hours of observation and testing with contemporary assays or unvalidated approaches to small changes in high sensitivity troponin assays are already in need of updating.

For additional commentary see theheart.org here