In a chest pain population risk stratified with HEART, exercise testing has only a modest contribution to clinical decision making. 50 % of all tests are non-conclusive, with high rates of false positive tests in all three risk groups. In intermediate-risk patients, negative exercise tests may contribute to the exclusion of disease. Clinicians should rather go for sensitive tests, in particular in patients with low HEART scores.
ObjectiveCardiac guidelines recommend that the decision to perform coronary angiography (CA) in patients with Non-ST-Elevation Acute Coronary Syndrome (NST-ACS) is based on multiple factors. It is, however, unknown how cardiologists weigh these factors in their decision-making. The aim was to investigate the importance of different clinical characteristics, including information derived from risk scores, in the decision-making of Dutch cardiologists regarding performing CA in patients with suspected NST-ACS.DesignA web-based survey containing clinical vignettes.Setting and participantsRegistered Dutch cardiologists were approached to complete the survey, in which they were asked to indicate whether they would perform CA for 8 vignettes describing 7 clinical factors: age, renal function, known coronary artery disease, persistent chest pain, presence of risk factors, ECG findings and troponin levels. Cardiologists were divided into two groups: group 1 received vignettes ‘without’ a risk score present, while group 2 completed vignettes ‘with’ a risk score present.Results129 (of 946) cardiologists responded. In both groups, elevated troponin levels and typical ischaemic changes (p<0.001) made cardiologists decide more often to perform CA. Severe renal dysfunction (p<0.001) made cardiologists more hesitant to decide on CA. Age and risk score could not be assessed independently, as these factors were strongly associated. Inspecting the factors together showed, for example, that cardiologists were more hesitant to perform CA in elderly patients with high-risk scores than in younger patients with intermediate risk scores.ConclusionsWhen deciding to perform in-hospital CA (≤72 hours after patient admission) in patients with suspected NST-ACS, cardiologists tend to rely mostly on troponin levels, ECG changes and renal function. Future research should focus on why CA is less often recommended in patients with severe renal dysfunction, and in elderly patients with high-risk scores. In addition, the impact of age and risk score on decision-making should be further investigated.
Background Asymptomatic severe mitral valve (MV) regurgitation with preserved left ventricular function is a challenging clinical entity as data on the recommended treatment strategy for these patients are scarce and conflicting. For asymptomatic patients, no randomised trial has been performed for objectivising the best treatment strategy. Methods The Dutch AMR (Asymptomatic Mitral Regurgitation) trial is a multicenter, prospective, randomised trial comparing early MV repair versus watchful waiting in asymptomatic patients with severe organic MV regurgitation. A total of 250 asymptomatic patients (18-70 years) with preserved left ventricular function will be included. Intervention will be either watchful waiting or MV surgery. Follow-up will be 5 years. Primary outcome measures are all-cause mortality and a composite endpoint of cardiovascular mortality, congestive heart failure, and hospitalisation for non-fatal cardiovascular and cerebrovascular events. Secondary outcome measures are total costs, cost-effectiveness, quality of life, echocardiographic and cardiac magnetic resonance parameters, exercise tests, asymptomatic atrial fibrillation and brain natriuretic peptide levels. Additionally, the complication rate in the surgery group and rate of surgery in the watchful waiting group will be determined. Implications The Dutch AMR trial will be the first multicenter randomised trial on this topic. We anticipate that the results of this study are highly needed to elucidate the best treatment strategy and that this may prove to be an international landmark study.
PurposeExercise echocardiography can assess the dynamic component of mitral valve (MV) disease and may therefore be helpful for the clinical decision-making by the heart team. The purpose of this study is to determine the role of exercise echocardiography in the management of disproportionately symptomatic or otherwise atypical patients with mitral regurgitation (MR) and stenosis (MS) in clinical practice.MethodsData of 14 MR and 14 MS patients, including echocardiograms at rest, were presented retrospectively to an experienced heart team to determine treatment strategy. Subsequently, exercise echo data were provided whereupon once again the treatment strategy was determined. This resulted in: value of exercise echo by means of 1) alteration or 2) confirmation of treatment strategy or 3) no additional value.ResultsDuring exercise the echocardiographic severity of MV disease increased in 9 (64 %) MR and 8 (57 %) MS patients. Based upon alteration or confirmation of the treatment strategy, the value of exercise echocardiography in the management of MR and MS was 86 % and 57 %, respectively.ConclusionThis study showed that physical exercise echo can have an important role in the clinical decision-making of challenging patients with MV disease. Exercise echocardiography had additional value to the treatment strategy in 71 % of these patients.
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