Does stress echocardiography still have a role in the rapid access chest pain clinic post NICE CG95?

Introduction: The 2016 NICE clinical guideline 95 (CG95) demoted functional imaging to a second-line test following computed tomography coronary angiography (CTCA). Many cardiac CT services in the UK require substantial investment and growth to implement this. Chest pain services like ours are likely to continue to use stress testing for the foreseeable future. We share service evaluation data from our department to show that a negative stress echocardiogram can continue to be used for chest pain assessment. Methods: 1815 patients were referred to rapid access chest pain clinic (RACPC) between June 2013 and March 2015. 802 patients had stress echocardiography as the initial investigation. 446 patients had normal resting left ventricular (LV) systolic function and a negative stress echocardiogram. At least 24 months after discharge, a survey was carried out to detect major adverse cardiovascular events (MACE) (cardiac death, myocardial infarction, admission to hospital for heart failure or angina, coronary artery disease at angiography, revascularisation by angioplasty or coronary artery bypass grafting) within 2 years. Results: Overall, 351 patients were successfully followed up. The mean Diamond-Forrester (D-F) score and QRISK2 suggested a high pre-test probability (PTP) of coronary artery disease (CAD). There were nine deaths (eight non-cardiac deaths and one cardiac death). MACE occurred in four patients with a mean time of 17.5 months (11.6–23.7 months). The annual event rate was 0.6%. Conclusion: A negative stress echocardiogram can reliably reassure patients and clinicians even in high PTP populations with suspected stable angina. It can continue to be used to assess stable chest pain post CG95

An intervention to reassure patients about test results in rapid access chest pain clinic: a pilot randomised controlled trial

BACKGROUND: Most people referred to rapid access chest pain clinics have non-cardiac chest pain, and in those diagnosed with stable coronary heart disease, guidance recommends that first-line treatment is usually medication rather than revascularisation. Consequently, many patients are not reassured they have the correct diagnosis or treatment. A previous trial reported that, in people with non-cardiac chest pain, a brief discussion with a health psychologist before the tests about the meaning of potential results led to people being significantly more reassured. The aim of this pilot was to test study procedures and inform sample size for a future multi-centre trial and to gain initial estimates of effectiveness of the discussion intervention. METHODS: This was a two-arm pilot randomised controlled trial in outpatient rapid access chest pain clinic in 120 people undergoing investigation for new onset, non-urgent chest pain. Eligible participants were randomised to receive either: a discussion about the meaning and implication of test results, delivered by a nurse before tests in clinic, plus a pre-test pamphlet covering the same information (Discussion arm) or the pre-test pamphlet alone (Pamphlet arm). Main outcome measures were recruitment rate and feasibility for a future multi-centre trial, with an estimate of reassurance in the groups at month 1 and 6 using a 5-item patient-reported scale. RESULTS: Two hundred and seventy people attended rapid access chest pain clinic during recruitment and 120/270 participants (44%) were randomised, 60 to each arm. There was no evidence of a difference between the Discussion and Pamphlet arms in the mean reassurance score at month 1 (34.2 vs 33.7) or at month 6 (35.3 vs 35.9). Patient-reported chest pain and use of heart medications were also similar between the two arms. CONCLUSIONS: A larger trial of the discussion intervention in the UK would not be warranted. Patients reported high levels of reassurance which were similar in patients receiving the discussion with a nurse and in those receiving a pamphlet alone. TRIAL REGISTRATION: Current Controlled Trials ISRCTN60618114 (assigned 27.05.2011). ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/1471-2261-14-138) contains supplementary material, which is available to authorized users

Effect of Duration and Intermittency of Rifampin on Tuberculosis Treatment Outcomes: A Systematic Review and Meta-Analysis

In a systematic review of randomized controlled trials on tuberculosis treatment, Dick Menzies and colleagues find shorter courses of rifampin to be associated with poorer treatment outcomes

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Report from the Annual Conference of the British Society of Echocardiography, November 2017, Edinburgh International Conference Centre, Edinburgh

No abstract available

Cardiac disease in pregnancy

Cardiac disease is a significant cause of maternal mortality worldwide. In the last UK maternal mortality report, cardiac disease was the leading cause of maternal death (2.3 deaths per 100000 maternities). Some mothers are waiting to have a family later in life and present with a variety of acquired heart conditions. There is a 1% incidence of heart disease in pregnant patients in the UK, which has reduced from an estimated 3% incidence due in part to a reduction in rheumatic heart disease. However, it is expected to increase as the number of patients with corrected congenital heart disease surviving to childbearing age increases and may also increase further as immigration patterns change. The incidence of cardiac disease is in the order of 0.2–4% in the Western industrialized countries and is about 4% in the United States. Congenital heart disease accounts for 75–80% of cardiac disease in pregnancy in the western world. Outside Western Europe and North America congenital heart disease accounts for only 9–19% of the cardiac disease in pregnancy. In non-Western countries rheumatic valvular disease causes 55–89% of cardiovascular disease in pregnancy.Of patients with congenital heart disease, 96% will live for at least 15 years if they survive infancy. It is therefore essential to have a good knowledge of these cardiac conditions and a good understanding of the stresses on the cardiovascular physiology caused by pregnancy. These patients can turn up on any delivery suite in any hospital at any time.PhysiologyImportant physiological changes in the cardiovascular system need to occur during pregnancy in order to facilitate the increased demand for oxygen and nutrients by the uteroplacental unit, and that of the growing fetus. Blood flow to the uterus increases from 50 mL/min at 10 weeks’ gestation to 850 mL/min at term. This is accomplished by a 50% rise in cardiac output (CO) and blood volume. There is an increase in heart rate from 6 weeks. There is a reduction in systemic and pulmonary vascular resistance due to vasoactive prostaglandins and nitric oxide production, thus preventing a rise in pulmonary artery pressure from the increased circulating volume. The systolic and diastolic pressures decrease, reaching their lowest values during the second trimester, before increasing as term approaches, although never reaching prepregnancy values. Therefore, there is a risk of cardiac decompensation as pregnancy progresses

A case report of recurrent takotsubo cardiomyopathy including the rare ‘inverted’ form

Abstract Background Takotsubo cardiomyopathy (TC) is a disease that causes transient left ventricular (LV) dysfunction in multiple vascular territories in the absence of coronary artery disease. Takotsubo cardiomyopathy is typically associated with dilation and dyskinesia of the apical and mid-LV segments induced by acute emotional and/or physical stress. Here, we present a case of recurrent TC including one episode of inverted TC, which is a rare form where dyskinesia occurs in the basal segments with sparing of the apical segments. Case summary A 53-year-old female patient with a background history of chronic stress and anxiety was admitted with three episodes of recurrent TC over 4 years. The first episode in 2017 was triggered by an acute stressful event, but no major triggers were identified for the subsequent episodes. Although the first and third episodes displayed the signs of classical TC, the second episode was an inverted TC. Full cardiac function was restored after each episode. She now takes prognostic heart failure medications long term and mental health teams are trying to support her emotional wellbeing. Discussion This patient displayed a rare disease course involving three recurrent episodes of TC, including one instance of its inverted form. Although psychiatric conditions and emotional stress are acknowledged as risk factors for TC, further research is needed to assess whether mental health treatment following TC can prevent disease recurrence. </jats:sec