more_vertEstablishing timely coronary revascularisation (eg, percutaneous coronary intervention [PCI]) in acute coronary syndrome has become a distinctive performance measure worldwide. Clinical guidelines recommend a door-to-balloon time of 90 min or less for patients with ST-elevation myocardial infarction (STEMI).1 In light of these guideline recommendations, the Japanese Ministry of Health, Labour and Welfare introduced a new reimbursement policy in April, 2014, providing an additional hospital incentive of approximately US$3500 when patients with positive cardiac biomarkers (eg, troponins) achieved a door-to-balloon time of 90 min or less.
Preference: Cardiology and Cardiac Surgery
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[Correspondence] Daytime variations in perioperative myocardial injury
With great interest, we read the Article by David Montaigne and colleagues (Jan 6, p 59)1 on daytime variations of perioperative myocardial injury. Data from our group regarding the circadian influence on myocardial ischaemia fully support the findings that decreased cardiac Rev-Erbα signalling is cardioprotective in the afternoon.2 However, we found it quite puzzling that in this publication the circadian expression levels in human beings are in opposition to those found in mice, and that the Per2 gene is in phase with the Rev-Erbα gene.
[Correspondence] Daytime variations in perioperative myocardial injury
We read with interest the Article by David Montaigne and colleagues1 reporting that among patients having on-pump cardiac surgery for aortic valve replacement, the time of day that surgery is done might affect their tolerance to ischaemia–reperfusion injury. The results are intriguing and we commend the researchers for their comprehensive translational study.
[Perspectives] A neurologist’s detective stories
Western medicine is organised into silos. Faced with a patient requiring specialist advice, a general practitioner or emergency doctor has to make a call about where to direct them. Sometimes, the right clinical destination is obvious: a compound thigh fracture will always need an orthopaedic surgeon. But many patients fall foul of this rigid system. An individual complaining of dizziness might get bounced from ENT, to cardiology, to neurology, to psychiatry before achieving a diagnosis.
Photoplethysmography using a smartphone application for assessment of ulnar artery patency: a randomized clinical trial [Research]
BACKGROUND:
Radial artery access is commonly performed for coronary angiography and invasive hemodynamic monitoring. Despite limitations in diagnostic accuracy, the modified Allen test (manual occlusion of radial and ulnar arteries followed by release of the latter and assessment of palmar blush) is used routinely to evaluate the collateral circulation to the hand and, therefore, to determine patient eligibility for radial artery access. We sought to evaluate whether a smartphone application may provide a superior alternative to the modified Allen test.
METHODS:
We compared the modified Allen test with a smartphone heart rate–monitoring application (photoplethysmography readings detected using a smartphone camera lens placed on the patient’s index finger) in patients undergoing a planned cardiac catheterization. Test order was randomly assigned in a 1:1 fashion. All patients then underwent conventional plethysmography of the index finger, followed by Doppler ultrasonography of the radial and ulnar arteries (the diagnostic standard). The primary outcome was diagnostic accuracy of the heart rate–monitoring application.
RESULTS:
Among 438 patients who were included in the study, we found that the heart rate–monitoring application had a superior diagnostic accuracy compared with the modified Allen test (91.8% v. 81.7%, p = 0.002), attributable to its greater specificity (93.0% v. 82.8%, p = 0.001). We also found that this application had greater diagnostic accuracy for assessment of radial or ulnar artery patency in the ipsilateral and contralateral wrist (94.0% v. 84.0%, p < 0.001).
INTERPRETATION:
A smartphone application used at the bedside was diagnostically superior to traditional physical examination for confirming ulnar patency before radial artery access. This study highlights the potential for smartphone-based diagnostics to aid in clinical decision-making at the patient’s bedside. Trial registration: Clinicaltrials.gov, no. NCT02519491.
The diet that reduces cardiovascular risk
The 5:2 diet championed by TV journalist Dr Michael Mosley appears to be better at reducing certain cardiovascular risks, compared with a more conventional calorie reduction diet, a new study has found.
The research published in the British Journal of Nutrition randomised 27 obese people, with an average BMI of 30 , to either a fasting diet – in which intake is limited to just 600 calories on two days a week – to a more standard weight-loss diet in which participants were advised to reduce their daily intake by 600 calories.
Previous research has focused on blood risk markers taken during fasting periods, whereas this study, undertaken by researchers from the University of Surrey, looked at lipid and glucose metabolism in the postprandial period.
Participants on the 5:2 diet achieved a 5% weight loss more quickly than those on a conventional diet (59 versus 73 days), and they also cleared triglycerides from their bloodstream more efficiently. Although there appeared to be no difference in the way the two diets handled glucose, there were significant variations between the diets in postprandial c-peptide, which is a marker for insulin secretion. This surprising finding needs further investigation, the researchers said.
The researchers also found a significant reduction in systolic blood pressure in those on the 5:2 diet. It was down by 9% in that cohort, and up by 2% in those on the daily calorie reduction diet.
“These preliminary findings highlight underlying differences between intermittent energy restriction and continuous energy restriction, including a superiority of intermittent energy restriction in reducing postprandial lipaemia,” the authors concluded.
But co-author Dr Rona Antoni of the University of Surrey said that although their research found benefits in the 5:2 diet compared with the more conventional alternative, the problem was compliance.
“Some of our participants struggled to tolerate the 5:2 diet, which suggests this approach is not suited to everybody; ultimately the key to dieting success is finding an approach you can sustain long term. But for those who do well and are able to stick to the 5:2 diet, i could potentially have a beneficial impact on some important risk markers for cardiovascular disease, in some cases more than daily dieting.”
You can access the study here.
[Series] Out-of-hospital cardiac arrest: prehospital management
Sudden out-of-hospital cardiac arrest is the most time-critical medical emergency. In the second paper of this Series on out-of-hospital cardiac arrest, we considered important issues in the prehospital management of cardiac arrest. Successful resuscitation relies on a strong chain of survival with the community, dispatch centre, ambulance, and hospital working together. Early cardiopulmonary resuscitation and defibrillation has the greatest impact on survival. If the community response does not restart the heart, resuscitation is continued by emergency medical services’ staff.
[Series] Out-of-hospital cardiac arrest: in-hospital intervention strategies
The prognosis after out-of-hospital cardiac arrest (OHCA) has improved in the past few decades because of advances in interventions used outside and in hospital. About half of patients who have OHCA with initial ventricular tachycardia or ventricular fibrillation and who are admitted to hospital in coma after return of spontaneous circulation will survive to discharge with a reasonable neurological status. In this Series paper we discuss in-hospital management of patients with post-cardiac-arrest syndrome.
[Articles] Outcome and undertreatment of mitral regurgitation: a community cohort study
In the community, isolated mitral regurgitation is common and is associated with excess mortality and frequent heart failure postdiagnosis in all patient subsets, even in those with normal left-ventricular ejection fraction and low comorbidity. Despite these poor outcomes, only a minority of affected patients undergo mitral (or any type of cardiac) surgery even in a community with all means of diagnosis and treatment readily available and accessible. This suggests that in a wider population there might be a substantial unmet need for treatment for this disorder.
[Series] Out-of-hospital cardiac arrest: current concepts
Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality. Regional variations in reporting frameworks and survival mean the exact burden of OHCA to public health is unknown. Nevertheless, overall prognosis and neurological outcome are relatively poor following OHCA and have remained almost static for the past three decades. In this Series paper, we explore the aetiology of OHCA. Coronary artery disease remains the predominant cause, but there is a diverse range of other potential cardiac and non-cardiac causes to be aware of.