CT coronary angiography is a relatively new modality for identifying coronary artery disease. What is its place in ED chest pain assessment. See the evidence -and the evidence gaps- and judge for yourself where it might fit!
CT coronary angiography in ED chest pain patientskellyam18
CT coronary angiography is the new kid on the block for assessing emergency department patients with chest pain. How accurate is it? What are the down sides? How useful is it? Which patients is it suitable for? This presentation attempts to answer these questions in light of current evidence.
CT coronary angiography in ED chest pain patientskellyam18
CT coronary angiography is the new kid on the block for assessing emergency department patients with chest pain. How accurate is it? What are the down sides? How useful is it? Which patients is it suitable for? This presentation attempts to answer these questions in light of current evidence.
DANISH is a major breakthrough trial published in NEJM on 29/09/2016 regarding Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. All content of this slide is Copy right of NEJM.
A Registry-Based Randomized Trial Comparing Radial and Femoral Approaches In Women Undergoing Percutaneous Coronary Intervention: The Study of Access Enhancement of PCI for Women (SAFE-PCI for Women) Trial
Sydney Sexual Health Centre Journal Club presentation by Cherie Desreaux on the British Medical Journal and the Medical Journal of Australia editions published between November 2015 and March 2016.
The Sydney Sexual Health Centre Journal Club allows our team to stay up-to-date with what is being published in the field of sexual health. Staff members take turns to read, review and share the contents of an allocated journal. Journal Club encourages knowledge sharing and discussion about topics raised.
DANISH is a major breakthrough trial published in NEJM on 29/09/2016 regarding Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. All content of this slide is Copy right of NEJM.
A Registry-Based Randomized Trial Comparing Radial and Femoral Approaches In Women Undergoing Percutaneous Coronary Intervention: The Study of Access Enhancement of PCI for Women (SAFE-PCI for Women) Trial
Sydney Sexual Health Centre Journal Club presentation by Cherie Desreaux on the British Medical Journal and the Medical Journal of Australia editions published between November 2015 and March 2016.
The Sydney Sexual Health Centre Journal Club allows our team to stay up-to-date with what is being published in the field of sexual health. Staff members take turns to read, review and share the contents of an allocated journal. Journal Club encourages knowledge sharing and discussion about topics raised.
How to review a journal paper and prepare oral presentationSeppo Karrila
The slides are for an about 2-hour lecture to students who each have to review one scientific journal article.
There are guidelines on key content, as well as planning, preparing, and delivering an oral presentation.
This should be useful to any student preparing for an oral presentation with slides.
Cancer screening may discover many dormant, regressing, or slowly progressing tumors that would not have affected the screened individuals. Such findings with there therapies are obviously harmful. This lecture is highly based on the book "over diagnosed" by H. Gilbert Welch and was presented in 2013 to KFSH-Dammam physicians
As presented at EUSEM 2015, this presentation discusses how venous blood gas analysis fits into clinical care in emergency departments. The evidence is correct as of Sept 2015
How to cultivate a research culture in the emergency departmentkellyam18
Getting research going in emergency departments can be hard but it is vitally important for improving healthcare. This presentation gives tips and strategies for building a research culture. Taking the first step is often the hardest part!
Arterial blood gases in ED: Rest in Peace?kellyam18
This presentation, the keynote address at CEM 2014 (UK), tests the theory that arterial blood gases are no longer needed in emergency department decision-making for many patients. Though cases, it explores the risks and benefits of a venous blood gas approach.
Is clinician gestalt undervalued in chest pain assessment in EDkellyam18
This presentation discusses the role of clinician gestalt in assessment of emergency department chest pain patients. Is it accurate? How does it compare with risk scores? What are its weaknesses? Can we teach it?
Are venous and arterial blood gas analysis interchangeable in ED assessment o...kellyam18
Ever wondered if you can use a venous blood gas instead on an arterial analysis to guide management of patients with acute respiratory disease in the eemergency department? This presentation will try to answer the key questions including does my patient have acute respiratory failure, is my patient a CO2 retainer, do I need to provide additional ventilatory support and is my treatment working.
Arteriovenous blood gas agreement: A research journeykellyam18
This presentation discusses the state of evidence for arteriovenous blood gas agreement for pH, pCO2, bicarbonate and base excess and how that fits into clinical decision-making. It also describes the resaerch journey of a smal clinical team to answer important clinical questions and address an issue of concern to patients.
Survival after cardiac arrest is poor but some therapies can make a difference. This presentation discusses the evidence for therpauetic hypothermia, normoxia, management of blood pressure and early cardiac catherterisation. It also makes the case that these might be elements of a bundle of care.
Thinking and error in emergency departmentskellyam18
Errors in clinical decision making in the emergency department can be fatal! Through case studies, this presentation explores the factors contributing to error and strategies to overcome them.
Pain assessment in ED an evidence-based updatekellyam18
This presentation delivered at the International Conference on Emergency Medicine in Dublin describes different approaches to assessing pain in emergency department patients. It summarises the evidence supporting the various approaches and makes recommendations for practice.
Venous and arterial blood gas analysis in the ED: What we know and what we don'tkellyam18
This presentation delivered at the International Conference on Emergency Medicine in Dublin summarises agreement between venous and arterial blood gas parameters and utility of venous blood gas analysis in emergency department clinical practice. It also highlights important gaps in our knowledge on this topic.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
2. No relationships with cardiac diagnostic or imaging companies
Co-author of National Heart Foundation (Australia) guidelines for the
management of ACS (and addenda)
Supervisor of PhDs in CTCA’s role in chest pain
Editorial boards of:
◦ Annals of Emergency Medicine
◦ Emergency Medicine Australasia
◦ Hong Kong Journal of Emergency Medicine
3. To explore the role of CTCA in ED chest pain patients,
with a focus on those that ‘rule out’ for ACS in ED
To explore the cost-benefit of a CTCA compared to
alternatives
To provoke debate about the rational place of CTCA in
ED chest pain work-up!
4. From Schussler JM. Cardiac computed tomography:Emergeing
cardiac devices and technology. Asian Hospital and Healthcare
Management.
http://www.asianhhm.com/diagnostics/cardiac_computed_tomograp
hy.htm
• Non-invasive
• Nice pictures
• Can ‘see’ if there are lesions
or not
5. Three major studies have suggested that CTCA for ED chest pain
patients:
• Reduces ED length of stay
• Reduces admissions
• That negative scans have good prognostic performance
• That CTCA may be more ‘accurate’ in identification of CAD
than alternatives
ROMICAT II
ACRIN-PA
CT-STAT
6. ACRIN-PA ROMICAT II
50% reduction in
admissions (23% vs. 50%)
25% reduction in LOS (18
hours vs. 25 hours)
67% reduction in median
LOS (9 hours vs. 27 hours)
19% reduction in ED costs
Litt HI et al. N Engl J Med 2012; 366:1393-403. Hoffmann U et al. NEJM 2012; 367:299-308
7. CT-STAT
54% reduction in time to
diagnosis (3 hours vs. 6
hours)
38% reduction in costs
No difference in events
Goldstein et al. J Am Coll Cardiol 2011;58:1414-22
8. In Victoria, estimated 40,000 patients
undergo ACS rule out in ED annually
The ‘rule in’ rate for ACS is ~15-20%
◦ Depends how you count
About 32,000 have ACS ruled out and
(according to ACS guidelines) need a
further assessment strategy to rule
out clinically significant CAD
Based on Dept Health Victoria data and
estimates of chest pain presentations by
Goodacre (UK): Goodacre et al. Heart. 2005;
91: 229–230.
Victoria, Australia
Population 5.6 million
9. Highly variable
Options
◦ Exercise test
◦ Nuclear medicine studies
◦ CTCA
◦ GP or cardiologist can decide!
◦ Nothing (active choice)
10. TIMI score Demographics
0 33%
1 18%
2 18%
3 11%
4 11%
5+ ~9%
Male =60%
Average age=62
Known CAD = 33%
Based on data from cohort study @ WH
2009
11. Is CTCA sensitive for the detection of CAD?
Is CTCA suitable for the ED chest pain patient cohort?
Does a negative CTCA have good prognostic performance for
future ACS events?
Does CTCA improve outcomes for patients?
How does CTCA perform in comparison to alternative
investigation strategies?
Which patients should have this test rather than an
alternative?
12. Depends on whether analysis is at patient level or segment level
◦ Patient level is of prime importance in the ED context
Simple answer is ‘YES’
In a recent systematic review/ meta-analysis, CTCA had 94% (61-99%)
sensitivity and 87% (16-100%) specificity for CAD.
Another meta-analysis of 64-slice +, reports sensitivity of 99% (95% CI 97-
99%)
BUT about 9% of tests are non-diagnostic/ inconclusive
•Goodacre et al. Health Technol Assess 2013;17:1-188
•Mowatt et al. Technol Assess. 2008; 12:iii-iv, ix-143.
13. Remember, the question being asked is “Is there CAD”?
Just over 50% of the patient cohort is suitable for CTCA
About 30-40% of patients already have known CAD
◦ Other investigation pathways are more suitable in most of these
Other ‘contra-indications’: 10-15%
◦ Metformin
◦ Inability to control rate adequately
◦ Renal failure/ impairment
◦ Thyroid disease
◦ Irregular rhythms
Hamid S et al. Am J Emerg Med. 2010;28:494-8
14. Safety
◦ Short term adverse events related to the scan are very rare
◦ Contrast allergy at expected rate (1/2,500-1/25,000)
◦ Adverse effects due to rate control-usually minor
◦ Radiation risk
Feasibility
◦ Limited by access to scanner and availability of experienced readers
◦ ‘In hours’ only availability does not match ED 24/7 patient flow
◦ ‘Competition’ with other patients needing CT scan
15. In meta-analysis:
I death from 1334 patients
No PCI, MI etc
Rate = 0.07% (95% CI
0.01% to 0.4%)
Goodacre et al. Health Technol Assess 2013;17:1-188
In cohort study:
No PCI, MI, deaths in 508
patients at median 47
month follow-up
Rate = 0% (95% CI 0% to
0.07%)
Simple answer is ‘YES’
Nasis et al. Radiol 2014; April 14
16. In meta-analysis:
39 events in 332 cases
12 MI
Two thirds of events were revascularisations
Rate 12% (95% CI 9-16%)
Only one study was blinded to CTCA results:
◦ Showed CTCA result (presence of stenosis) was independently
associated with MACE (HR 17)
Goodacre et al. Health Technol Assess 2013;17:1-188. S
Schlett CA et al. JACC Cardiovasc Imaging. 2011;4: 481–491.
17. A growing literature with several points of view
Focus is the sub-population without known CAD
◦ 65-70% of cohort (about 25,000 patients annually in Victoria)
Available data suggests background rate of asymptomatic
CAD ~5-8%.
18. Cost benefit depends on:
◦ Sensitivity of the tests being compared
◦ Prevalence of clinically relevant CAD, especially in low risk
subgroups
◦ Relative costs in the healthcare system in question
◦ Patterns of investigation/ intervention especially for
intermediate or indeterminate tests
◦ The risk of adverse events associated with CAD
◦ The time period of follow-up
◦ The community’s willingness to pay (e.g. $ per QALY)
◦ Any negative impact of CT delay for other patients e.g. acute
stroke, head injury, etc.
19. CTCA asks “Is there plaque”?
I am not sure that is the right question
20. What is the risk of MACE in patients without known
CAD, with non-diagnostic ECG and normal serial
biomarkers in ED?
◦ This prognostic information is still evolving
◦ Complicated (and simplified) by new higher sensitivity
biomarkers
At what MACE risk level is ‘routine’ testing
indicated?
21. What is the risk of MACE in patients without
known CAD, with non-diagnostic ECG and normal
serial biomarkers in ED?
A. 5%
B. 2%
C. 1%
D. 0.5%
Fitzgerald P et al. Acad Emerg Med 2011;18:488–95.
22. Test Sensitivity NPV (MACE)
CTCA 94-99% >99%
MPS 87% 97.2%
Exercise ECG (EST) 20-30% As low as 86%
Conti et al. Nucl Med Commun 2011 32;1223
23. Varying study design, populations and outcomes
studied
In meta-analysis
Rate of MACE for negative EST 0.7% (95% CI 0.5-
1.2%)
But sensitivity questionable
◦ Some studies around 30% sensitivity for occlusive CAD
Goodacre et al. Health Technol Assess 2013;17:1-188. S
Schlett CA et al. JACC Cardiovasc Imaging. 2011;4:481–491.
24. Not enough data in the specific population of interest
to draw conclusions
25. Positive predictive value for CAD at segment level is
only moderate (78%)
◦ False positives: over-estimation of lesion severity in presence
of calcified plaques
Scanning 15,000 patients in Victoria/year will pose
access issues for CT scanners!
26. An ‘elephant in the room’
Retrospectively gated protocols, risk estimated at:
◦ 0.11 to 0.13% for men
◦ 0.27-0.37% for women
Prospectively gated protocols, risk estimated at:
◦ 0.014-0.017% for men
◦ 0.035-0.06% for women
Risk is inversely related to age
Significant ethnic variation
Huang et al. Br J Radiol. 2010;83(986):152-8.
27. ACRIN-PA
50% reduction in
admissions (23% vs. 50%)
25% reduction in LOS (18
hours vs. 25 hours)
No patient with negative
CTCA had death, MI within
30 days
Only 2/1357 (0.15%) of
patients not diagnosed with
MI at index visit had MI
within 30 days
Trial conditions re CT
availability
TIMI 0-2
◦ >85% TIMI 0 or 1
Litt HI et al. N Engl J Med 2012; 366:1393-403.
28. CT-STAT
54% reduction in time to
diagnosis (3 hours vs. 6
hours)
38% reduction in costs
Only included ED costs
Trial conditions re CT availability
Highly selected cohort
In CTCA cohort, 6 times greater
rate of additional non-invasive
tests after ED discharge
◦ Cost
◦ Radiation, etc
Goldstein et al. J Am Coll Cardiol 2011;58:1414-22
29. ROMICAT II
67% reduction in median
LOS (9 hours vs. 27 hours)
19% reduction in ED costs
Eventual hospital costs actually
50% higher in CTCA group
Higher rate of additional testing
(27% vs.12%)
No difference in events
Trial conditions re CT availability
Selected population
◦ 40-74
◦ No AF or renal disease or BMI<40Hoffmann U et al. NEJM 2012; 367:299-308
30. Data from administrative dataset
◦ Age 66+
◦ Non-emergent, non-invasive test for ?CAD
◦ No known CAD
Compared CTCA vs. stress myocardial perfusion scan
Results:
Outcome CTCA MPS
Cardiac catheter 23% 12%
PCI 7.8% 3.4%
CABG 3.7% 1.3%
All cause mortality 180
days
1.05% 1.28%
Hospitalization for MI 180
days
0.19% 0.43%
Schreibati et al. JAMA 2011; 306:2128-36
31. 1. That a test to rule out CAD before discharge is needed in
ED chest pain patients
◦ This is unproven!
◦ The rationale for any test (compared to no test) is that it improves
outcome
◦ Event rates are so low (<1%) in all arms that it is impossible to tell if
CTCA provided benefit
2. All lesions found were cause of symptoms
◦ 5% rate of occlusive lesions found in screening of asymptomatic
patients
With risk of dye, radiation, extra tests etc. harm
is likely to seriously compete with any benefit!
32. In Australasia:
◦ ~75% of patients are discharged from ED/SSU
◦ Most do not have additional testing before discharge
◦ Median LOS of the order of 6-10 hours, depending on
centre and protocol (some much shorter)
◦ LOS likely to reduce as accelerated diagnostic biomarker
pathways are implemented
33. SCCT/AHA/ACC:
◦ Symptomatic patients without known CAD with ‘intermediate’
pre-test probability
◦ Symptomatic patients without known CAD with ‘low’ pre-test
probability who cannot perform a functional test or with
equivocal functional test results
◦ Not suitable for high pre-test probability patients due to:
High likelihood of plaques
Limited spatial and temporal resolution
These should have CA or functional test
Taylor AJ et al. J Am Coll Cardiol 2010:56:1864-94.
34. CTCA is not indicated as a ‘routine’ test in ED patients
with chest pain without known CAD and with normal
biomarkers and ECG
It may be useful in a subgroup based on risk, but how
this risk might be defined in unclear
There is a reasonable case for no further testing in
significant proportion of ED chest pain patients who
have had ACS ruled out by clinical evaluation, ECG and
biomarkers
35. Comparison of DM, ‘metabolic syndrome’ and other (MPS
study)
Metabolic syndrome defined as at least 3 of:
◦ Fasting glucose >110mg/dl
◦ High BP
◦ Low HDL
◦ High triglicerides
◦ High waist circumference
Rate of MACE at 1 year
◦ DM 30%
◦ Metabolic syndrome 26%
◦ Others 15%
Conti et al. Nucl Med Commun 2008; 29:1106-12.
Could similar parameters identify a
subgroup of patients who might
benefit from CTCA?
36. CTCA is a test looking for its role in the ED chest pain
population
More data regarding patient selection and patient-
centred outcomes is needed before its place can be
better defined