- Email: [email protected]
Quantitative Evaluation of Aortic Regurgitation in Asymptomatic Patients Using Cardiac MRI Predicts Long-Term Outcome
Abstracts
8 LONG TERM CLINICAL OUTCOMES OF TREATMENT OF IN-STENT RESTENOSIS WITH DRUG ELUTING STENTS S Cherian 1,∗ , C Devlin 2
Sebastian 2 , A
Puri 2 , M
Liang 2 , G
1 University 2 Waikato
of Adelaide, Adelaide, Australia Hospital, Hamilton, New Zealand
Background: Optimal treatment for instent restenosis (ISR) is an enigma, with drug eluting stents (DES) currently regarded as the treatment of choice. We report the clinical outcome of patients undergoing treatment of ISR with DES over a 5-year period among other treatment modalities. Method: Patients with symptomatic ISR (diameter stenosis of >50%) from January 2003 to January 2008 were analysed for long term clinical outcomes of Readmission MI and Death. Results: 215 ISR lesions were recorded in 207 patients. 199 (92.6%) were bare metal stent (BMS) ISR and 16 (7.4%) were DES ISR. The mean follow up was 30.6 ± 17.5 months. The ISR lesion classification was Type I in 67%; II in 16%; III in 8% and IV in 9%. Treatment of ISR was DES in 130 (60.5%), BMS in 12 (5.6%), Plain Balloon Angioplasty (POBA) in 27 (12.6%), CABG in 17 (7.9%) and medical in 29 (13.5%) patients. A total of 24 deaths occurred in the group. Treatment/ Outcomes
ReReMI restenosis admission
DES (n = 130) 13 (10%) BMS (n = 12) 2 (17%) POBA (n = 27) 5 (18%) CABG (n = 17) 0 Medical (n = 29) 3 (10%)
24 (19%) 4 (33%) 8 (30%) 2 (12%) 6 (21%)
10 (8%) 2 (17%) 3 (11%) 1 (6%) 4 (14%)
Death
Cardiac Death
Death, MI, Readmision
12 (9%) 4 (33%) 4 (15%) 2 (12%) 2 (7%)
5 (4%) 2 (17%) 3 (11%) 2 (12%) 2 (7%)
46 (35%) 10 (83%) 15 (56%) 5 (29%) 12 (41%)
Conclusion: Management of ISR remains problematic, with ongoing morbidity and mortality, regardless of treatment with DES. doi:10.1016/j.hlc.2009.04.011 9 NURSE-LED OUTPATIENT CHEST PAIN CLINIC: SAFETY AND EFFICACY KL Chow ∗ , L Ball, E Griner, C Edwards, G Armstrong North Shore Hospital, Auckland, New Zealand Background: We established an outpatient nurse-led chest pain clinic to assess chest pain referrals from GPs. The aim was to reduce waiting times and to decrease utilisation of resources and personnel. This novel approach was evaluated for safety and efficacy. Methods: Patients judged to be at low-medium risk of coronary disease filled out a questionnaire. The nurse then took a history, carried out a cardiovascular examination and undertook treadmill exercise ECG. This entire evaluation, together with the planning of subsequent management, was carried out by one nurse without assistance. A cardiologist was available for advice but did
S5
not routinely see the patients or discuss management. The first 149 patients seen at the clinic were followed up at 6 months by telephone and review of hospital records. Results: The nurse’s final diagnosis was non-cardiac chest symptoms in 60%, possible angina in 13%, probable angina in 22% and invalid entry in 5%. Final disposition was discharge in 55%, coronary angiography in 20%, echocardiography in 7%, stress imaging study in 8%, other test in 3%. At six-month follow-up, two patients had further unplanned medical attendances. Study Endpoints: There were no deaths, myocardial infarctions or positive stress imaging studies. Admission with angina occurred in 3% of patients, all of whom had been wait-listed for coronary angiography. Coronary stenosis >70% occurred in 11% of the total patients, i.e. 59% of those referred for coronary angiography. Conclusions: Nurse-led outpatient chest pain evaluation appears safe and efficacious at 6-month follow-up. doi:10.1016/j.hlc.2009.04.012 10 QUANTITATIVE EVALUATION OF AORTIC REGURGITATION IN ASYMPTOMATIC PATIENTS USING CARDIAC MRI PREDICTS LONG-TERM OUTCOME JP Christiansen ∗ , C Edwards, G Armstrong, H Patel, T Scott, HH Hart Cardiovascular Division, North Shore Hospital, Auckland, New Zealand Background: Aortic valve replacement (AVR) after LV decompensation may result in suboptimal outcomes. Timing of AVR in asymptomatic patients with aortic regurgitation (AR) is currently determined by LV dimensions. Cardiac MRI (CMR) measures ventricular volumes, regurgitant volume (Rvol ) and fraction (Rfr ) reproducibly. We assessed the value of quantitative CMR in predicting prognosis in significant AR. Methods: Twenty-seven asymptomatic patients with isolated moderate or greater AR were identified at initial CMR. Ventricular and regurgitant volumes were quantified. Clinical records were subsequently reviewed for up to 5 years follow-up. Death or AVR were the primary endpoint. CMR results were not used to determine timing of AVR. Results: Seven patients (26%) underwent AVR during follow-up, all for the development of important symptoms. There was one death in a patient who was declined surgery. Average follow-up was 3 years. Average Rvol was 39 ± 21 mL and Rfr 25 ± 10%. On ROC analysis, Rvol ≥ 45 mL and Rfr > 28% predicted the need for AVR with 78% sensitivity and 83% specificity (Area = 0.95). Rvol and Rfr (0.83) were more predictive of AVR than indexed LVEDV (0.81), LVESV (0.73) and EF% (0.51). Kaplan–Meier analysis demonstrates the significant long-term risk of AVR/death in patients with Rvol ≥ 45 mL (p < 0.05) (Graph shown).
ABSTRACTS
Heart, Lung and Circulation 2009;18S:S1–S31
S6
Abstracts
ABSTRACTS
Conclusion: Quantification of AR by CMR strongly predicts the future likelihood of AVR/death. Both Rvol < 45 mL and Rfr < 28% predict a low need for AVR over up to 5 years follow-up in asymptomatic patients with moderate or greater AR.
Heart, Lung and Circulation 2009;18S:S1–S31
(77%) referred for coronary angiography, 33 (20%) were referred for further procedures. Of patients who underwent angiography 56 (43%) underwent revascularisation, 33 (59%) Percutaneous Coronary Intervention, 23 (41%) Coronary Artery Bypass Grafts. Of patients discharged from the CPC service with negative tests 2 (1%) reattended with atypical chest pain, none had acute coronary syndromes. Conclusion: Nurse led CPC’s provide safe access to noninvasive assessment for IHD. doi:10.1016/j.hlc.2009.04.014 12 ASSESSMENT OF ASYMPTOMATIC HEART MURMURS IN ADULT OUTPATIENTS HA Coverdale Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
doi:10.1016/j.hlc.2009.04.013 11 REPORT ON THE FIRST TWELVE MONTHS ACTIVITY OF NEW ZEALANDS FIRST SPECIALIST CARDIAC NURSE-LED CHEST PAIN CLINIC SM Clayton ∗ , NP Lucic ∗ , KJ de Bruijn, A Hamer, DE Hampson, CA Johansen, TM Lawson, N Fisher Nelson Hospital, Nelson, New Zealand Background: World-wide there is increasing demand to screen populations for Ischaemic Heart Disease (IHD) with consequent increased utilisation of cardiology services. We report on New Zealand’s first Specialist Cardiac Nurse (SCN) led Chest Pain Clinic (CPC). Method: Patients referred with chest pain were screened by a consultant cardiologist for suitability and priority of access to a SCN led service. CP clinics occurred in parallel to a consultant led cardiology clinic. Using a custom made questionnaire and directed history, cardiovascular examination was undertaken by SCN. Exercise tolerance testing (ETT) was performed in accordance with normal safety and performance guidelines in the presence of SCN and Cardiac technologist. ETT results were reviewed by SCN and cardiologist. Patients had results explained and risk-factor modification implemented with both lifestyle education and medication augmentation. Patients were referred for further investigation according to a predetermined protocol. Results were contained within a SCN dictated correspondence. Results: Between 01 July 2007 and 30 June 2008 434 patients were referred for non-invasive assessment of chest pain, 386 (89%) underwent assessment with ETT. 168 (44%) had positive or equivocal ETT. Of these, 129
Background: A clinic was established in 2006 for the assessment of adult community patients with asymptomatic heart murmurs, using a targeted bedside echocardiogram (echo) on a discretionary basis. The results are reported to December 2008. Methods: All patients (pts) were examined by one cardiologist. Previous echo reports (19) and chest X-rays were occasionally available at the clinic. Firm reassurance was provided to patients when appropriate. Results: There were 345 pts (71% female) with age range 14–91 years (mean 49, median 49). An echo was performed in 50% of pts, with no significant age difference between those who did or did not have echoes. Systolic murmurs assumed to be innocent or due to a trivial aortic valve lesion were present in 160 pts (46%), of whom 51 had echoes. Systolic murmurs due to definite aortic valve lesions, from trivial to severe, were confirmed in 70 pts: leaflet thickening and maximum systolic velocities <2.5 m/s in 48 (11 pts ≤ 50 years), 2.5–2.9 m/s in 10 and ≥3 m/s in 12. Mitral regurgitation murmurs, mostly due to leaflet prolapse, were found in 21 pts (10 > mild). Other pts had murmurs that were either continuous (3) or due to isolated aortic regurgitation (2), tricuspid regurgitation (2), atrial and ventricular septal defect (7), pulmonary stenosis (3) or other significant lesions (7). Audible murmurs were absent in 68 pts (20%). Conclusion: Many patients with asymptomatic heart murmurs could be firmly reassured. Lesions requiring further follow-up or treatment were identified in at least one in five patients. doi:10.1016/j.hlc.2009.04.015
8 LONG TERM CLINICAL OUTCOMES OF TREATMENT OF IN-STENT RESTENOSIS WITH DRUG ELUTING STENTS S Cherian 1,∗ , C Devlin 2
Sebastian 2 , A
Puri 2 , M
Liang 2 , G
1 University 2 Waikato
of Adelaide, Adelaide, Australia Hospital, Hamilton, New Zealand
Background: Optimal treatment for instent restenosis (ISR) is an enigma, with drug eluting stents (DES) currently regarded as the treatment of choice. We report the clinical outcome of patients undergoing treatment of ISR with DES over a 5-year period among other treatment modalities. Method: Patients with symptomatic ISR (diameter stenosis of >50%) from January 2003 to January 2008 were analysed for long term clinical outcomes of Readmission MI and Death. Results: 215 ISR lesions were recorded in 207 patients. 199 (92.6%) were bare metal stent (BMS) ISR and 16 (7.4%) were DES ISR. The mean follow up was 30.6 ± 17.5 months. The ISR lesion classification was Type I in 67%; II in 16%; III in 8% and IV in 9%. Treatment of ISR was DES in 130 (60.5%), BMS in 12 (5.6%), Plain Balloon Angioplasty (POBA) in 27 (12.6%), CABG in 17 (7.9%) and medical in 29 (13.5%) patients. A total of 24 deaths occurred in the group. Treatment/ Outcomes
ReReMI restenosis admission
DES (n = 130) 13 (10%) BMS (n = 12) 2 (17%) POBA (n = 27) 5 (18%) CABG (n = 17) 0 Medical (n = 29) 3 (10%)
24 (19%) 4 (33%) 8 (30%) 2 (12%) 6 (21%)
10 (8%) 2 (17%) 3 (11%) 1 (6%) 4 (14%)
Death
Cardiac Death
Death, MI, Readmision
12 (9%) 4 (33%) 4 (15%) 2 (12%) 2 (7%)
5 (4%) 2 (17%) 3 (11%) 2 (12%) 2 (7%)
46 (35%) 10 (83%) 15 (56%) 5 (29%) 12 (41%)
Conclusion: Management of ISR remains problematic, with ongoing morbidity and mortality, regardless of treatment with DES. doi:10.1016/j.hlc.2009.04.011 9 NURSE-LED OUTPATIENT CHEST PAIN CLINIC: SAFETY AND EFFICACY KL Chow ∗ , L Ball, E Griner, C Edwards, G Armstrong North Shore Hospital, Auckland, New Zealand Background: We established an outpatient nurse-led chest pain clinic to assess chest pain referrals from GPs. The aim was to reduce waiting times and to decrease utilisation of resources and personnel. This novel approach was evaluated for safety and efficacy. Methods: Patients judged to be at low-medium risk of coronary disease filled out a questionnaire. The nurse then took a history, carried out a cardiovascular examination and undertook treadmill exercise ECG. This entire evaluation, together with the planning of subsequent management, was carried out by one nurse without assistance. A cardiologist was available for advice but did
S5
not routinely see the patients or discuss management. The first 149 patients seen at the clinic were followed up at 6 months by telephone and review of hospital records. Results: The nurse’s final diagnosis was non-cardiac chest symptoms in 60%, possible angina in 13%, probable angina in 22% and invalid entry in 5%. Final disposition was discharge in 55%, coronary angiography in 20%, echocardiography in 7%, stress imaging study in 8%, other test in 3%. At six-month follow-up, two patients had further unplanned medical attendances. Study Endpoints: There were no deaths, myocardial infarctions or positive stress imaging studies. Admission with angina occurred in 3% of patients, all of whom had been wait-listed for coronary angiography. Coronary stenosis >70% occurred in 11% of the total patients, i.e. 59% of those referred for coronary angiography. Conclusions: Nurse-led outpatient chest pain evaluation appears safe and efficacious at 6-month follow-up. doi:10.1016/j.hlc.2009.04.012 10 QUANTITATIVE EVALUATION OF AORTIC REGURGITATION IN ASYMPTOMATIC PATIENTS USING CARDIAC MRI PREDICTS LONG-TERM OUTCOME JP Christiansen ∗ , C Edwards, G Armstrong, H Patel, T Scott, HH Hart Cardiovascular Division, North Shore Hospital, Auckland, New Zealand Background: Aortic valve replacement (AVR) after LV decompensation may result in suboptimal outcomes. Timing of AVR in asymptomatic patients with aortic regurgitation (AR) is currently determined by LV dimensions. Cardiac MRI (CMR) measures ventricular volumes, regurgitant volume (Rvol ) and fraction (Rfr ) reproducibly. We assessed the value of quantitative CMR in predicting prognosis in significant AR. Methods: Twenty-seven asymptomatic patients with isolated moderate or greater AR were identified at initial CMR. Ventricular and regurgitant volumes were quantified. Clinical records were subsequently reviewed for up to 5 years follow-up. Death or AVR were the primary endpoint. CMR results were not used to determine timing of AVR. Results: Seven patients (26%) underwent AVR during follow-up, all for the development of important symptoms. There was one death in a patient who was declined surgery. Average follow-up was 3 years. Average Rvol was 39 ± 21 mL and Rfr 25 ± 10%. On ROC analysis, Rvol ≥ 45 mL and Rfr > 28% predicted the need for AVR with 78% sensitivity and 83% specificity (Area = 0.95). Rvol and Rfr (0.83) were more predictive of AVR than indexed LVEDV (0.81), LVESV (0.73) and EF% (0.51). Kaplan–Meier analysis demonstrates the significant long-term risk of AVR/death in patients with Rvol ≥ 45 mL (p < 0.05) (Graph shown).
ABSTRACTS
Heart, Lung and Circulation 2009;18S:S1–S31
S6
Abstracts
ABSTRACTS
Conclusion: Quantification of AR by CMR strongly predicts the future likelihood of AVR/death. Both Rvol < 45 mL and Rfr < 28% predict a low need for AVR over up to 5 years follow-up in asymptomatic patients with moderate or greater AR.
Heart, Lung and Circulation 2009;18S:S1–S31
(77%) referred for coronary angiography, 33 (20%) were referred for further procedures. Of patients who underwent angiography 56 (43%) underwent revascularisation, 33 (59%) Percutaneous Coronary Intervention, 23 (41%) Coronary Artery Bypass Grafts. Of patients discharged from the CPC service with negative tests 2 (1%) reattended with atypical chest pain, none had acute coronary syndromes. Conclusion: Nurse led CPC’s provide safe access to noninvasive assessment for IHD. doi:10.1016/j.hlc.2009.04.014 12 ASSESSMENT OF ASYMPTOMATIC HEART MURMURS IN ADULT OUTPATIENTS HA Coverdale Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
doi:10.1016/j.hlc.2009.04.013 11 REPORT ON THE FIRST TWELVE MONTHS ACTIVITY OF NEW ZEALANDS FIRST SPECIALIST CARDIAC NURSE-LED CHEST PAIN CLINIC SM Clayton ∗ , NP Lucic ∗ , KJ de Bruijn, A Hamer, DE Hampson, CA Johansen, TM Lawson, N Fisher Nelson Hospital, Nelson, New Zealand Background: World-wide there is increasing demand to screen populations for Ischaemic Heart Disease (IHD) with consequent increased utilisation of cardiology services. We report on New Zealand’s first Specialist Cardiac Nurse (SCN) led Chest Pain Clinic (CPC). Method: Patients referred with chest pain were screened by a consultant cardiologist for suitability and priority of access to a SCN led service. CP clinics occurred in parallel to a consultant led cardiology clinic. Using a custom made questionnaire and directed history, cardiovascular examination was undertaken by SCN. Exercise tolerance testing (ETT) was performed in accordance with normal safety and performance guidelines in the presence of SCN and Cardiac technologist. ETT results were reviewed by SCN and cardiologist. Patients had results explained and risk-factor modification implemented with both lifestyle education and medication augmentation. Patients were referred for further investigation according to a predetermined protocol. Results were contained within a SCN dictated correspondence. Results: Between 01 July 2007 and 30 June 2008 434 patients were referred for non-invasive assessment of chest pain, 386 (89%) underwent assessment with ETT. 168 (44%) had positive or equivocal ETT. Of these, 129
Background: A clinic was established in 2006 for the assessment of adult community patients with asymptomatic heart murmurs, using a targeted bedside echocardiogram (echo) on a discretionary basis. The results are reported to December 2008. Methods: All patients (pts) were examined by one cardiologist. Previous echo reports (19) and chest X-rays were occasionally available at the clinic. Firm reassurance was provided to patients when appropriate. Results: There were 345 pts (71% female) with age range 14–91 years (mean 49, median 49). An echo was performed in 50% of pts, with no significant age difference between those who did or did not have echoes. Systolic murmurs assumed to be innocent or due to a trivial aortic valve lesion were present in 160 pts (46%), of whom 51 had echoes. Systolic murmurs due to definite aortic valve lesions, from trivial to severe, were confirmed in 70 pts: leaflet thickening and maximum systolic velocities <2.5 m/s in 48 (11 pts ≤ 50 years), 2.5–2.9 m/s in 10 and ≥3 m/s in 12. Mitral regurgitation murmurs, mostly due to leaflet prolapse, were found in 21 pts (10 > mild). Other pts had murmurs that were either continuous (3) or due to isolated aortic regurgitation (2), tricuspid regurgitation (2), atrial and ventricular septal defect (7), pulmonary stenosis (3) or other significant lesions (7). Audible murmurs were absent in 68 pts (20%). Conclusion: Many patients with asymptomatic heart murmurs could be firmly reassured. Lesions requiring further follow-up or treatment were identified in at least one in five patients. doi:10.1016/j.hlc.2009.04.015