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OBESITY, IMPAIRED FASTING GLUCOSE AND THE METABOLIC SYNDROME ARE UNDER-RECOGNISED AND UNDER-TREATED IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION
Abstracts
S15
30 IS CARDIAC IMAGING BY 64-SLICE COMPUTED TOMOGRAPHY SAFE? ADVERSE EVENTS OBSERVED WITH 500 CONSECUTIVE PATIENTS IN A NEW ZEALAND PROGRAMME
31 DIFFERENT ANALYSERS AND VARIABLE THRESHOLDS WITH TROPONIN TESTING IN NEW ZEALAND 2002–2007: IS IT TIME FOR SOME NATIONAL STANDARDISATION?
CJ Ellis 1,∗ , ME Legget 1 , C Edwards 1 , JA Ormiston 1 , N Van Pelt 1 , J Christiansen 2 , H Winch 1 , M Osborne 3 , G Gamble 4
M Latif ∗ , A Chataline, G Gamble, HD White, CJ Ellis
1 Auckland
Heart Group, Auckland, New Zealand Cardiology, Auckland, New Zealand 3 Mercy Radiology, Mercy Hospital, Auckland, New Zealand 4 Department of Medicine, University of Auckland, Auckland, New Zealand 2 Waitemata
Background: Cardiac imaging by 64-slice computed tomography (CT) is a powerful new tool to assess cardiac anatomy and guide patient (pt) management in various heart conditions. Quality assurance is required with ongoing audit of procedures, to assess risks and outcomes. Methods: We prospectively audited our initial experience with 64-slice Cardiac CT (GE Light Speed Scanner) with a comprehensive database of pts undergoing the investigation. Adverse events (AEs) were collected and assessed. Results: From 7 August 2006 to 26 September 2007, 500 Pts, 203 (41%) female with a mean age of 57 (S.D. 9) years were scanned. 89% pts were Caucasian. 40% pts were current or previous smokers, 35% had a history of hypertension, 46% hyperlipidaemia, 6% diabetes mellitus. 40 (8%) pts had a prior history of CVS disease. The overall Framingham risk score for 500 pts was 7.3 (S.D. 5.7)%; or 7.1 (5.6)% in 460 pts without prior CVS disease. There is a recognised, very small long-term risk from the radiation dose delivered. 56 pts experienced a mild headache, resultant from the glyceryl trinitrate (GTN) spray. There were 33 observed AEs: 2 ‘severe’ (marked urticaria and severe hypertension). Grade Severe Moderate Mild
Number Events/100 pts Confidence intervals 2
0.4
0.1–1.4
4
0.8
0.2–2.0
27
5.4
3.6–7.9
Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand Background: For patients (pts) presenting with an acute coronary syndrome (ACS), serum troponin (Tpn) T and I levels are crucial for the diagnosis of a myocardial infarction (MI). We assessed the Tpn tests, analyser types and thresholds used for a ‘positive’ test in New Zealand (NZ). Methods: We reviewed the troponin tests available at all hospitals which admitted pts with an ACS in 2002 and 2007. These hospitals participated in the comprehensive NZ ACS Audit. Results: 39 hospitals participated in NZ ACS Audit in 2007 and 36 hospitals in 2002. In 2007 there were 11 different troponin analysers across NZ provided by 5 major companies: Roche (5), Abbott (3), Bayer (1), Dade Behring (1) and Beckman Coulter (1). The majority of hospitals [27/39 (70%)] used Roche Tpn T assays and 12/39 (30%) used the Tpn I assays. Different hospitals used different Tpn assay ‘cut offs’: Tpn T Roche (3), Roche Cardiac Reader (1), Tpn I Abbott (4), Tpn I Bayer (1), Tpn I Ortho (1) and Beckman Coulter (1). In comparison to 2002, there has been a considerable uptake of Roche Tpn T assays [70% (2007) vs. 53% (2002)], and consequently a reduction in Tpn I assays. 9 hospitals across NZ have changed their assays from Tpn I to Tpn T since 2002. Only 14/36 (40%) hospitals have exactly the same analyser as 2002. There has also been a general decrease in the quoted ‘cut off’ ranges used in 2007 when compared to 2002. Conclusions: There are considerable differences in the Tpn tests available across NZ hospitals. Test thresholds vary at different centres, even for the same Tpn test; hence resultant diagnostic information is variable. Some standardisation of available tests and thresholds would be likely to improve pt management and the accuracy of community wide disease rates. doi:10.1016/j.hlc.2008.03.032
Using a multivariate model, only gender was a significant independent predictor (P < 0.0001) of experiencing an AE. Females were 2.5 times more likely to have an AE than males [OR 2.5 (95% CI: 1.4–4.7)]. Conclusion: A CT cardiac angiogram programme has been established at the Mercy Hospital in Auckland which is safe and well tolerated. The clinical benefit obtained from the procedure has to be balanced against the small potential risks. doi:10.1016/j.hlc.2008.03.031
32 OBESITY, IMPAIRED FASTING GLUCOSE AND THE METABOLIC SYNDROME ARE UNDER-RECOGNISED AND UNDER-TREATED IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION F Fahrtash ∗ , S Prasad, W Thai, Y Malaiapan, J Cameron, I Meredith MonashHeart, Monash Medical Centre, Melbourne, Australia Background: Obesity, impaired fasting glucose (IFG) and the metabolic syndrome (MS) are important risk factors for coronary disease. There is minimal data on the
ABSTRACTS
Heart, Lung and Circulation 2008;17S:S1–S34
S16
Heart, Lung and Circulation 2008;17S:S1–S34
Abstracts
ABSTRACTS
prevalence and management of those entities in patients with AMI. Methods: A post-discharge folder audit was performed prospectively in 107 consecutive patients with AMI admitted to the coronary care unit of a tertiary hospital to determine rates of discharge diagnosis of obesity, MS and new IFG, and to determine if appropriate management strategies were implemented. MS was defined according to International Diabetes Federation (IDF) and National Cholesterol Education Program (NCEP) definitions. New IFG was defined as fasting glucose ≥ 5.6 mmol/l without pre-existing diabetes. Obesity was defined as BMI ≥ 30 kg/m2 . Results: The mean age was 59 (±13); 80% were males. Risk factors included pre-existing diabetes in 20 (19%), hypertension in 51 (48%), and dyslipidaemia in 43 (40%) patients, respectively. The mean BMI was 29.7 (±8.4) kg/m2 ; 37 (36%) patients had a BMI ≥ 30 kg/m2 . Obesity was coded on discharge in 8 (7%) patients. Referral for exercise or weight loss programs was undertaken in 5 (5%) patients. While 64 (60%) patients had MS by either definition (46 by both definitions, 12 by IDF definition only and 6 by NCEP definition only), it was clinically recognised on discharge in only one patient. New IFG was present in 41 (38%) patients; it was recognised on discharge in 6 (15%) patients, and only 3 (3%) were referred for follow up OGTT. Conclusions: While a high prevalence of obesity, new IFG and MS was noted in patients with AMI, rates of clinical recognition and management of these conditions remains sub-optimal. doi:10.1016/j.hlc.2008.03.033 33 TAKE HEART: A MODEL FOR PSYCHOLOGICAL REHABILITATION AFTER MYOCARDIAL INFARCTION FINDINGS FROM A DOCTORAL STUDY, RHODES UNIVERSITY, GRAHAMSTOWN, SOUTH AFRICA S Frewen Te Ngako Adult Community Mental Health Services, New Zealand Background: Extensive evidence indicates that the rehabilitation of individuals with coronary heart disease needs to include psychological components to complement the exercise and dietary recommendations that are normally provided. Method: A 12-week group intervention was developed and conducted for individuals who suffered a myocardial infarction. The intervention addressed the type A behaviour pattern, stress management, cognitive restructuring, relaxation techniques, improved communication skills, the identification and expression of emotions, an understanding of the mind–body connection and offered emotional support. The study was evaluated by means of a multiple case study design and data included weekly feedback sheets evaluating each session, repeated measures on the Profile of Mood States, the Jenkins Activity
Survey, a Spouse Rating Scale and extensive qualitative data on each participant. Findings: The 12-week intervention resulted in changes to the Type A behaviour pattern as well as mood status. However, even more significant changes resulted from follow-up individual psychotherapy sessions that addressed how and why individuals developed the Type A behaviour pattern, a pattern which has been widely associated with coronary prone individuals. The results provide evidence for the importance of conducting a developmental analysis that revealed the origins of the low self-esteem and insecurity that maintain and drive the type A behaviour pattern. Conclusion: The findings from this study are important for those interested in developing cardiac rehabilitation programmes that aim for psychological and physical wellness post infarct. This model has been used extensively by the presenter in rehabilitation programmes in South Africa. doi:10.1016/j.hlc.2008.03.034 34 CAN THE ADMISSION ECG DISTINGUISH APICAL BALLOONING SYNDROME FROM ANTERIOR ST ELEVATION MI? J Fu ∗ , A Khan, AJ Kerr Department of Cardiology, Middlemore Hospital, New Zealand Background: Apical Ballooning Syndrome (ABS) can mimic the electrocardiographic (ECG) changes of anterior ST Elevation Myocardial Infarction (STEMI) and create clinical dilemma in the immediate management of the patient as thrombolysis is not appropriate in ABS. We assessed whether the admission ECG features can distinguish ABS from anterior STEMI. Method: Thirty-one consecutive patients with ABS and 31 with anterior STEMI were studied. Standard 12-lead ECG was obtained on admission. Standard definitions were used for analysis. Result: Of the ABS patients, 11 (35%) had ST segment elevation which met thromobolysis criteria. Reciprocal changes in the inferior leads were present in 18 STEMI patients (58%) but only one ABS patient (3%). The degree of ST segment elevation was higher in the STEMI group (V1–V3 7.11 mm vs. 2.02 mm). Only one ABS patient had ST elevation ≥ 3 mm in precordial lead V3 compared with 19 (61%) of the STEMI patients. 18 patients (58%) with ABS had a prolonged QTc interval ≥ 460 ms compared with 13 patients (42%) in the STEMI group. Q-waves were present in 19 (61%) patients with STEMI and 9 (29%) of ABS patients. The presence of either ST elevation ≥ 3mm in precordial lead V3 or reciprocal changes had a sensitivity of 87% and specificity of 94% for identification of STEMI. Conclusion: The presence of reciprocal inferior changes or ST elevation ≥ 3 mm on the admission ECG make ABS very unlikely. In our cohort almost 90% of anterior STEMI patients met one of these criteria and only two ABS
S15
30 IS CARDIAC IMAGING BY 64-SLICE COMPUTED TOMOGRAPHY SAFE? ADVERSE EVENTS OBSERVED WITH 500 CONSECUTIVE PATIENTS IN A NEW ZEALAND PROGRAMME
31 DIFFERENT ANALYSERS AND VARIABLE THRESHOLDS WITH TROPONIN TESTING IN NEW ZEALAND 2002–2007: IS IT TIME FOR SOME NATIONAL STANDARDISATION?
CJ Ellis 1,∗ , ME Legget 1 , C Edwards 1 , JA Ormiston 1 , N Van Pelt 1 , J Christiansen 2 , H Winch 1 , M Osborne 3 , G Gamble 4
M Latif ∗ , A Chataline, G Gamble, HD White, CJ Ellis
1 Auckland
Heart Group, Auckland, New Zealand Cardiology, Auckland, New Zealand 3 Mercy Radiology, Mercy Hospital, Auckland, New Zealand 4 Department of Medicine, University of Auckland, Auckland, New Zealand 2 Waitemata
Background: Cardiac imaging by 64-slice computed tomography (CT) is a powerful new tool to assess cardiac anatomy and guide patient (pt) management in various heart conditions. Quality assurance is required with ongoing audit of procedures, to assess risks and outcomes. Methods: We prospectively audited our initial experience with 64-slice Cardiac CT (GE Light Speed Scanner) with a comprehensive database of pts undergoing the investigation. Adverse events (AEs) were collected and assessed. Results: From 7 August 2006 to 26 September 2007, 500 Pts, 203 (41%) female with a mean age of 57 (S.D. 9) years were scanned. 89% pts were Caucasian. 40% pts were current or previous smokers, 35% had a history of hypertension, 46% hyperlipidaemia, 6% diabetes mellitus. 40 (8%) pts had a prior history of CVS disease. The overall Framingham risk score for 500 pts was 7.3 (S.D. 5.7)%; or 7.1 (5.6)% in 460 pts without prior CVS disease. There is a recognised, very small long-term risk from the radiation dose delivered. 56 pts experienced a mild headache, resultant from the glyceryl trinitrate (GTN) spray. There were 33 observed AEs: 2 ‘severe’ (marked urticaria and severe hypertension). Grade Severe Moderate Mild
Number Events/100 pts Confidence intervals 2
0.4
0.1–1.4
4
0.8
0.2–2.0
27
5.4
3.6–7.9
Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand Background: For patients (pts) presenting with an acute coronary syndrome (ACS), serum troponin (Tpn) T and I levels are crucial for the diagnosis of a myocardial infarction (MI). We assessed the Tpn tests, analyser types and thresholds used for a ‘positive’ test in New Zealand (NZ). Methods: We reviewed the troponin tests available at all hospitals which admitted pts with an ACS in 2002 and 2007. These hospitals participated in the comprehensive NZ ACS Audit. Results: 39 hospitals participated in NZ ACS Audit in 2007 and 36 hospitals in 2002. In 2007 there were 11 different troponin analysers across NZ provided by 5 major companies: Roche (5), Abbott (3), Bayer (1), Dade Behring (1) and Beckman Coulter (1). The majority of hospitals [27/39 (70%)] used Roche Tpn T assays and 12/39 (30%) used the Tpn I assays. Different hospitals used different Tpn assay ‘cut offs’: Tpn T Roche (3), Roche Cardiac Reader (1), Tpn I Abbott (4), Tpn I Bayer (1), Tpn I Ortho (1) and Beckman Coulter (1). In comparison to 2002, there has been a considerable uptake of Roche Tpn T assays [70% (2007) vs. 53% (2002)], and consequently a reduction in Tpn I assays. 9 hospitals across NZ have changed their assays from Tpn I to Tpn T since 2002. Only 14/36 (40%) hospitals have exactly the same analyser as 2002. There has also been a general decrease in the quoted ‘cut off’ ranges used in 2007 when compared to 2002. Conclusions: There are considerable differences in the Tpn tests available across NZ hospitals. Test thresholds vary at different centres, even for the same Tpn test; hence resultant diagnostic information is variable. Some standardisation of available tests and thresholds would be likely to improve pt management and the accuracy of community wide disease rates. doi:10.1016/j.hlc.2008.03.032
Using a multivariate model, only gender was a significant independent predictor (P < 0.0001) of experiencing an AE. Females were 2.5 times more likely to have an AE than males [OR 2.5 (95% CI: 1.4–4.7)]. Conclusion: A CT cardiac angiogram programme has been established at the Mercy Hospital in Auckland which is safe and well tolerated. The clinical benefit obtained from the procedure has to be balanced against the small potential risks. doi:10.1016/j.hlc.2008.03.031
32 OBESITY, IMPAIRED FASTING GLUCOSE AND THE METABOLIC SYNDROME ARE UNDER-RECOGNISED AND UNDER-TREATED IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION F Fahrtash ∗ , S Prasad, W Thai, Y Malaiapan, J Cameron, I Meredith MonashHeart, Monash Medical Centre, Melbourne, Australia Background: Obesity, impaired fasting glucose (IFG) and the metabolic syndrome (MS) are important risk factors for coronary disease. There is minimal data on the
ABSTRACTS
Heart, Lung and Circulation 2008;17S:S1–S34
S16
Heart, Lung and Circulation 2008;17S:S1–S34
Abstracts
ABSTRACTS
prevalence and management of those entities in patients with AMI. Methods: A post-discharge folder audit was performed prospectively in 107 consecutive patients with AMI admitted to the coronary care unit of a tertiary hospital to determine rates of discharge diagnosis of obesity, MS and new IFG, and to determine if appropriate management strategies were implemented. MS was defined according to International Diabetes Federation (IDF) and National Cholesterol Education Program (NCEP) definitions. New IFG was defined as fasting glucose ≥ 5.6 mmol/l without pre-existing diabetes. Obesity was defined as BMI ≥ 30 kg/m2 . Results: The mean age was 59 (±13); 80% were males. Risk factors included pre-existing diabetes in 20 (19%), hypertension in 51 (48%), and dyslipidaemia in 43 (40%) patients, respectively. The mean BMI was 29.7 (±8.4) kg/m2 ; 37 (36%) patients had a BMI ≥ 30 kg/m2 . Obesity was coded on discharge in 8 (7%) patients. Referral for exercise or weight loss programs was undertaken in 5 (5%) patients. While 64 (60%) patients had MS by either definition (46 by both definitions, 12 by IDF definition only and 6 by NCEP definition only), it was clinically recognised on discharge in only one patient. New IFG was present in 41 (38%) patients; it was recognised on discharge in 6 (15%) patients, and only 3 (3%) were referred for follow up OGTT. Conclusions: While a high prevalence of obesity, new IFG and MS was noted in patients with AMI, rates of clinical recognition and management of these conditions remains sub-optimal. doi:10.1016/j.hlc.2008.03.033 33 TAKE HEART: A MODEL FOR PSYCHOLOGICAL REHABILITATION AFTER MYOCARDIAL INFARCTION FINDINGS FROM A DOCTORAL STUDY, RHODES UNIVERSITY, GRAHAMSTOWN, SOUTH AFRICA S Frewen Te Ngako Adult Community Mental Health Services, New Zealand Background: Extensive evidence indicates that the rehabilitation of individuals with coronary heart disease needs to include psychological components to complement the exercise and dietary recommendations that are normally provided. Method: A 12-week group intervention was developed and conducted for individuals who suffered a myocardial infarction. The intervention addressed the type A behaviour pattern, stress management, cognitive restructuring, relaxation techniques, improved communication skills, the identification and expression of emotions, an understanding of the mind–body connection and offered emotional support. The study was evaluated by means of a multiple case study design and data included weekly feedback sheets evaluating each session, repeated measures on the Profile of Mood States, the Jenkins Activity
Survey, a Spouse Rating Scale and extensive qualitative data on each participant. Findings: The 12-week intervention resulted in changes to the Type A behaviour pattern as well as mood status. However, even more significant changes resulted from follow-up individual psychotherapy sessions that addressed how and why individuals developed the Type A behaviour pattern, a pattern which has been widely associated with coronary prone individuals. The results provide evidence for the importance of conducting a developmental analysis that revealed the origins of the low self-esteem and insecurity that maintain and drive the type A behaviour pattern. Conclusion: The findings from this study are important for those interested in developing cardiac rehabilitation programmes that aim for psychological and physical wellness post infarct. This model has been used extensively by the presenter in rehabilitation programmes in South Africa. doi:10.1016/j.hlc.2008.03.034 34 CAN THE ADMISSION ECG DISTINGUISH APICAL BALLOONING SYNDROME FROM ANTERIOR ST ELEVATION MI? J Fu ∗ , A Khan, AJ Kerr Department of Cardiology, Middlemore Hospital, New Zealand Background: Apical Ballooning Syndrome (ABS) can mimic the electrocardiographic (ECG) changes of anterior ST Elevation Myocardial Infarction (STEMI) and create clinical dilemma in the immediate management of the patient as thrombolysis is not appropriate in ABS. We assessed whether the admission ECG features can distinguish ABS from anterior STEMI. Method: Thirty-one consecutive patients with ABS and 31 with anterior STEMI were studied. Standard 12-lead ECG was obtained on admission. Standard definitions were used for analysis. Result: Of the ABS patients, 11 (35%) had ST segment elevation which met thromobolysis criteria. Reciprocal changes in the inferior leads were present in 18 STEMI patients (58%) but only one ABS patient (3%). The degree of ST segment elevation was higher in the STEMI group (V1–V3 7.11 mm vs. 2.02 mm). Only one ABS patient had ST elevation ≥ 3 mm in precordial lead V3 compared with 19 (61%) of the STEMI patients. 18 patients (58%) with ABS had a prolonged QTc interval ≥ 460 ms compared with 13 patients (42%) in the STEMI group. Q-waves were present in 19 (61%) patients with STEMI and 9 (29%) of ABS patients. The presence of either ST elevation ≥ 3mm in precordial lead V3 or reciprocal changes had a sensitivity of 87% and specificity of 94% for identification of STEMI. Conclusion: The presence of reciprocal inferior changes or ST elevation ≥ 3 mm on the admission ECG make ABS very unlikely. In our cohort almost 90% of anterior STEMI patients met one of these criteria and only two ABS