Triaging Primary Care Patients Referred for Chest Pain to Specialist Cardiology Centres: Efficacy of an Optimised Protocol

INTRODUCTION@#Patients referred for chest pain from primary care have increased, along with demand for outpatient cardiology consultations. We evaluated 'Triage Protocol' that implements standardised diagnostic testing prior to patients' first cardiology consultation.@*MATERIALS AND METHODS@#Under the 'Triage Protocol', patients referred for chest pain were pretriaged using a standardised algorithm and subsequently referred for relevant functional diagnostic cardiology tests before their initial cardiology consultation. At the initial cardiology consultation scheduled by the primary care provider, test results were reviewed. A total of 522 triage patients (mean age 55 ± 13, male 53%) were frequency-matched by age, gender and risk cohort to 289 control patients (mean age: 56 ± 11, male: 52%). Pretest risk of coronary artery disease was defined according to a Modified Duke Clinical Score (MDCS) as low (20). The primary outcome was time from referral to diagnosis (days). Secondary outcomes were total visits, discharge rate at first consultation, patient cost and adverse cardiac outcomes.@*RESULTS@#The 'Triage Protocol' resulted in shorter times from referral to diagnosis (46 vs 131 days; <0.0001) and fewer total visits (2.4 vs 3.0; <0.0001). However, triage patients in low-risk groups experienced higher costs due to increased testing (S$421 vs S$357, = 0.003). Adverse cardiac event rates under the 'Triage Protocol' indicated no compromise to patient safety (triage vs control: 0.57% vs 0.35%; = 1.000).@*CONCLUSION@#By implementing diagnostic cardiac testing prior to patients' first specialist consultation, the 'Triage Protocol' expedited diagnosis and reduced subsequent visits across all risk groups in ambulatory chest pain patients.

Percutaneous transcatheter aortic valve implantation for degenerated surgical bioprostheses: the first case series in Asia with one-year follow-up

<p><b>INTRODUCTION</b>Percutaneous transcatheter aortic valve implantation (TAVI) has become an established therapy for inoperable and high-surgical-risk patients with severe aortic stenosis. Although TAVI in patients with degenerated surgical aortic bioprostheses (i.e. valve-in-valve TAVI) is increasingly reported in Western studies, such data is lacking in Asian patients. We describe the initial experience of valve-in-valve TAVI in Asia.</p><p><b>METHODS</b>Eight patients who underwent valve-in-valve TAVI due to degenerated aortic bioprostheses were enrolled. The mechanism of bioprosthetic valve failure was stenotic, regurgitation or mixed. All procedures were performed via transfemoral arterial access, using the self-expanding CoreValve prosthesis or balloon-expandable SAPIEN XT prosthesis.</p><p><b>RESULTS</b>The mean age of the patients was 71.6 ± 13.2 years and five were male. Mean duration to surgical bioprosthesis degeneration was 10.2 ± 4.1 years. Valve-in-valve TAVI was successfully performed in all patients. CoreValve and SAPIEN XT prostheses were used in six and two patients, respectively. There were no deaths, strokes or permanent pacemaker requirement at 30 days, with one noncardiac mortality at one year. All patients experienced New York Heart Association functional class improvement. Post-procedure mean pressure gradients were 20 ± 11 mmHg and 22 ± 8 mmHg at 30 days and one year, respectively. Residual aortic regurgitation (AR) of more than mild severity occurred in one patient at 30 days. At one year, only one patient had mild residual AR.</p><p><b>CONCLUSION</b>In our experience of valve-in-valve TAVI, procedural success was achieved in all patients without adverse events at 30 days. Good clinical and haemodynamic outcomes were sustained at one year.</p>