Accuracy of Physicians in Differentiating Type 1 and Type 2 Myocardial Infarction Based on Clinical Information.

BACKGROUND: Physicians commonly judge whether a myocardial infarction (MI) is type 1 (thrombotic) vs type 2 (supply/demand mismatch) based on clinical information. Little is known about the accuracy of physicians' clinical judgement in this regard. We aimed to determine the accuracy of physicians' judgement in the classification of type 1 vs type 2 MI in perioperative and nonoperative settings. METHODS: We performed an online survey using cases from the Optical Coherence Tomographic Imaging of Thrombus (OPTIMUS) Study, which investigated the prevalence of a culprit lesion thrombus based on intracoronary optical coherence tomography (OCT) in patients experiencing MI. Four MI cases, 2 perioperative and 2 nonoperative, were selected randomly, stratified by etiology. Physicians were provided with the patient's medical history, laboratory parameters, and electrocardiograms. Physicians did not have access to intracoronary OCT results. The primary outcome was the accuracy of physicians' judgement of MI etiology, measured as raw agreement between physicians and intracoronary OCT findings. Fleiss' kappa and Gwet's AC1 were calculated to correct for chance. RESULTS: The response rate was 57% (308 of 536). Respondents were 62% male; median age was 45 years (standard deviation ± 11); 45% had been in practice for > 15 years. Respondents' overall accuracy for MI etiology was 60% (95% confidence interval [CI] 57%-63%), including 63% (95% CI 60%-68%) for nonoperative cases, and 56% (95% CI 52%-60%) for perioperative cases. Overall chance-corrected agreement was poor (kappa = 0.05), consistent across specialties and clinical scenarios. CONCLUSIONS: Physician accuracy in determining MI etiology based on clinical information is poor. Physicians should consider results from other testing, such as invasive coronary angiography, when determining MI etiology.

CONTEXTE: Les médecins déterminent généralement s'ils sont en présence d'un infarctus du myocarde (IM) de type 1 (thrombotique) ou de type 2 (demande accrue ou apport réduit en oxygène) sur la base des renseignements cliniques. On en sait cependant très peu au sujet de la justesse du jugement clinique des médecins à cet égard. Nous avons donc cherché à déterminer si les médecins réussissent à distinguer correctement les IM de type 1 et de type 2 dans les contextes périopératoire et non opératoire. MÉTHODOLOGIE: Nous avons mené une enquête en ligne en utilisant les cas de l'étude OPTIMUS ( Op tical Coherence T omographic Im aging of Thromb us ), qui avait évalué la prévalence des lésions causant un thrombus au moyen de la tomographie par cohérence optique (TCO) endocoronaire chez les patients subissant un IM. Nous avons choisi au hasard quatre cas d'IM stratifiés en fonction de leur cause : deux cas en contexte périopératoire et deux cas en contexte non opératoire. Les médecins avaient accès aux antécédents médicaux, aux résultats des analyses de laboratoire et aux électrocardiogrammes des patients, mais pas aux résultats de la TCO endocoronaire. Le principal paramètre d'évaluation était la justesse du jugement du médecin concernant la cause de l'IM, mesurée en fonction de la concordance approximative entre le jugement du médecin et les observations à la TCO endocoronaire. Les coefficients de concordance kappa de Fleiss et AC1 de Gwet ont servi à corriger pour le hasard. RÉSULTATS: Le taux de réponse était de 57 % (308 sur 536). Des participants, 62 % étaient des hommes et 45 % exerçaient depuis plus de 15 ans; l'âge médian était de 45 ans (écart-type : ± 11). La justesse globale avec laquelle les répondants ont déterminé la cause des IM était de 60 % (intervalle de confiance [IC] à 95 % : 57-63 %) : 63 % (IC à 95 % : 60-68 %) dans le cas des IM en contexte non opératoire et 56 % (IC à 95 % : 52-60 %) dans le cas des IM en contexte périopératoire. La concordance globale corrigée pour le hasard était faible (kappa = 0,05) et demeurait constante, sans égard au domaine de spécialité ou au scénario clinique. CONCLUSIONS: La justesse du jugement des médecins évaluant la cause d'un IM en fonction des renseignements cliniques est faible. Les médecins devraient envisager de recourir à des tests additionnels, y compris la coronarographie invasive, avant de déterminer la cause d'un IM.

The Burden of Atherosclerotic Cardiovascular Disease in South Asians Residing in Canada: A Reflection From the South Asian Heart Alliance.

South Asians (SAs), originating from the Indian subcontinent (India, Pakistan, Sri Lanka, Bangladesh, Nepal, and Bhutan), represent one quarter of the global population and are the largest visible minority in Canada. SAs experience the highest rates of coronary artery disease in Canada. Although conventional cardiovascular risk factors remain predictive in SA, the excess risk is not fully explained by these risk factors alone. Abdominal obesity, metabolic syndrome, and insulin resistance likely contribute a greater risk in SAs than in other populations. The South Asian Heart Alliance has been recently formed to investigate and recommend the best strategies for the prevention of cardiometabolic disease in SAs in Canada. This topic review represents a comprehensive overview of the magnitude of cardiovascular disease in SAs in Canada, with a review of conventional and novel risk markers in the SA population. Both primary and secondary prevention strategies are suggested and when possible, adapted specifically for the SA population. The need for SAs and their healthcare professionals to be more aware of the problem and potential solutions, along with the need for population-specific research, is highlighted.

Les Asiatiques du sud originaires du sous-continent indien (Inde, Pakistan, Sri Lanka, Bangladesh, Népal et Bhoutan) représentent le quart de la population mondiale et constituent la plus importante minorité visible au Canada. C'est aussi au sein de cette population qu'on observe les taux de coronaropathie les plus élevés au Canada. Bien que les facteurs de risque cardiovasculaire classiques conservent leur valeur prédictive chez les Asiatiques du sud, ils n'expliquent pas à eux seuls le risque excédentaire observé. L'obésité abdominale, le syndrome métabolique et l'insulinorésistance constituent vraisemblablement des facteurs de risque plus importants chez les Asiatiques du sud que dans les autres populations. La South Asian Heart Alliance a récemment été mise sur pied afin d'explorer les stratégies exemplaires pour la prévention des maladies cardiométaboliques chez les Asiatiques du sud au Canada et de formuler des recommandations à cet égard. Cette revue thématique présente un aperçu de l'importance des maladies cardiovasculaires au sein de la population des Asiatiques du sud du Canada, ainsi qu'un résumé des marqueurs de risque classiques et nouveaux dans cette population. Les auteurs proposent des stratégies de prévention primaire et secondaire adaptées, dans la mesure du possible, à la population des Asiatiques du sud. Ils font également ressortir l'importance de sensibiliser davantage les Asiatiques du sud et les professionnels de la santé aux risques et aux solutions possibles, ainsi que la nécessité de mener des recherches axées sur cette population particulière.

Focused Cardiac Ultrasonography: Current Applications and Future Directions.

Focused cardiac ultrasonography is performed by clinicians at the bedside and is used in time-sensitive scenarios to evaluate a patient's cardiovascular status when comprehensive echocardiography is not immediately available. This simplified cardiac ultrasonography is often performed by noncardiologists using small, portable devices to augment the physical examination, triage patients, and direct management in both critical care and outpatient settings. However, as the use of focused cardiac ultrasonography continues to expand, careful consideration is required regarding training, scope of practice, impact on patient outcomes, and medicolegal implications. In this review, we examine some of the challenges with rapid uptake of this technique and explore the benefits and potential risk of focused cardiac ultrasonography. We propose possible mechanisms for cross-specialty collaboration, quality improvement, and oversight.

Long-term survival with revascularization in South Asians admitted with an acute coronary syndrome (from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease Registry).

People of South Asian (SA) descent are particularly susceptible to acute coronary syndromes (ACS). Yet, little information exists regarding their overall prognosis. The purpose of this study was to compare short- and long-term clinical outcomes of SA and European Canadians admitted with an ACS. Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease registry, 63,393 patients with ACS were reviewed (January 1999 to March 2012). After excluding Chinese patients, 1,825 SAs were compared with 60,791 European Canadians. Both groups were propensity matched, and outcomes were compared. Adjustment was performed using a 3:1 propensity matching technique. Adjusted 30-day and 1-year mortality rates were similar between SA and European patients with ACS (2.6% vs 2.7%, p = 0.93; 5.0% vs 4.8%, respectively, p = 0.75). Repeat angiography did not differ (9.9% vs 9.2%, p = 0.35), yet repeat revascularization within 1 year was greater in SA patients (9.8% vs 7.6%, p <0.01). Improved long-term survival (median 64 months, interquartile range 66 months) was noted with SA patients (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.71 to 0.95). In particular, long-term survival was observed in SA patients receiving coronary artery bypass grafting (HR 0.75, 95% CI 0.52 to 1.08) and percutaneous coronary intervention (HR 0.75, 95% CI 0.59 to 0.96). In conclusion, SA patients treated with revascularization appear to have improved long-term survival after ACS, compared with European Canadians. As such, clinicians should be cognitive of ethnic-based outcomes when determining therapeutic strategies in patient management.

Reperfusion times for ST elevation myocardial infarction: a prospective audit.

BACKGROUND: New published guidelines recommend treatment of ST elevation myocardial infarction (STEMI) within 30 minutes of first medical contact to thrombolysis and 90 minutes to primary percutaneous coronary intervention (PCI). OBJECTIVES: To determine how a tertiary care center compares to these new guidelines and to evaluate the success of measures directed to shorten delays. METHODS: This was a prospectively designed audit loop using retrospective chart review. Specific time intervals were evaluated: 1) T2 (ER presentation to diagnostic EKG; 2) T ER (ER presentation to reperfusion); and 3) T AHA (first medical contact to reperfusion). Results of the initial 12-month data were conveyed to Emergency Room staff and a dedicated EKG machine was placed in the ER for the subsequent 12 months, and the results were then re-analyzed. RESULTS: In 2003-4, 58 patients with STEMI were identified, with 41 (70.7%) receiving reperfusion. Of those receiving thrombolysis, median T AHA was 54 [37-72] minutes, with 12.0%<30 minutes, while those receiving PCI, median T AHA was 58 [43-78] minutes, with 25.0%<90 minutes. In 2004-5, 52 patients had STEMI, with 40 (76.9%) receiving reperfusion. The percentage of patients meeting the guidelines was 14.3% for the thrombolysis group and 11.1% for the PCI group. Introduction of a dedicated EKG machine led to a strong trend towards improvement in median T2 (22 vs 10 minutes; P=0.07), but other treatment times remained unchanged. CONCLUSIONS: Treatment times are longer than recommended guidelines. More comprehensive strategies and improved coordination of medical services are required to shorten pre-contact and post-contact response times.