Dyspnea has a broad differential diagnosis and early identification of reversible causes can optimize patient care. A 45 year-old woman with hypertension, hyperlipidemia, and prediabetes presented with progressive dyspnea and chest tightness over 4 weeks, worse with exertional activity and relieved

Ischemia-reperfusion (IR) was surgically performed in murine hearts which were then subjected to repeated imaging to monitor temporal changes in functional parameters of key clinical significance. Two-dimensional movies were acquired at high frame rate (8 kHz) and were utilized to estimate high-quality myocardial strain. Two-dimensional elastograms (strain images), as well as strain profiles, were visualized. Results were powerful in quantitatively assessing IR-induced changes in cardiac events including left-ventricular (LV) contraction, LV relaxation and isovolumetric phases of both pre-IR and post-IR beating hearts in intact mice. In addition, compromised sector-wise wall motion and anatomical deformation in the infarcted myocardium were visualized. The elastograms were uniquely able to provide information on the following parameters in addition to standard physiological indices that are known to be affected by myocardial infarction in the mouse: internal diameters of mitral valve orifice and aorta, effective regurgitant orifice, myocardial strain (circumferential as well as radial), turbulence in blood flow pattern as revealed by the color Doppler movies and velocity profiles, asynchrony in LV sector, and changes in the length and direction of vectors demonstrating slower and asymmetrical wall movement. This work emphasizes on the visual demonstration of how such analyses are performed.

Background: Many reported studies of medical trainees and physicians have demonstrated major deficiencies in correctly identifying heart sounds and murmurs, but cardiologists had not been tested. We previously confirmed these deficiencies using a 50-question multimedia cardiac examination (CE) test featuring video vignettes of patients with auscultatory and visible manifestations of cardiovascular pathology (virtual cardiac patients). Previous testing of 62 internal medical faculty yielded scores no better than those of medical students and residents.Hypothesis: In this study, we tested whether cardiologists outperformed other physicians in cardiac examination skills, and whether years in practice correlated with test performance.Methods: To obviate cardiologists' reluctance to be tested, the CE test was installed at 19 US teaching centers for confidential testing. Test scores and demographic data (training level, subspecialty, and years in practice) were uploaded to a secure database.Results: The 520 tests revealed mean scores (out of 100 +/- 95% confidence interval) in descending order: 10 cardiology volunteer faculty (86.3 +/- 8.0), 57 full-time cardiologists (82.0 +/- 3.3), 4 private-practice cardiologists (77.0 +/- 6.8), and 19 noncardiology faculty (67.3 +/- 8.8). Trainees' scores in descending order: 150 cardiology fellows (77.3 +/- 2.1), 78 medical students (63.7 +/- 3.5), 95 internal medicine residents (62.7 +/- 3.2), and 107 family medicine residents (59.2 +/- 3.2). Faculty scores were higher in those trained earlier with longer practice experience.Conclusions: Academic and volunteer cardiologists outperformed other medical faculty, as did cardiology fellows. Lower scores were observed in more recently trained faculty. Remote testing yielded scores similar to proctored tests in comparable groups previously studied. No significant improvement was seen after medical school with residency training.

We used polarized light microscopy and thin-layer chromatography to determine whether embolization of atherosclerotic material occurs after transluminal angioplasty. The experimental model consisted of an in vivo perfusion system of the atherosclerotic rabbit left iliac artery. Of eight rabbits that underwent successful angioplasty, four had angiographic evidence of dissection and three showed aneurysm formation. Histologic studies demonstrated fracture of the intimal plaque, dissection, and stretching of the noninvolved portion of the vessel. Perfusate analysis revealed no detectable cholesterol by thin-layer chromatography in six of eight rabbits. In two rabbits, a very small amount of cholesterol was measured, which was totally accounted for by hemorrhage into the perfusate rather than from cholesterol in the plaque. No evidence of arterial wall embolic debris could be detected by polarized light microscopy in seven rabbits, but lipid debris from the plaque was found in the perfusate of one rabbit that had excessive arterial trauma. We conclude that the major mechanism of successful transluminal angioplasty in this experimental model is intimal fracture combined with stretching of a noninvolved portion of the vessel. Furthermore, embolization of atheromatous lipid debris was an uncommn event related to arterial trauma during catheter placement rather than transluminal angioplasty itself.

Over the past several years leadership in general, and corporate leadership in particular, has come under warranted scrutiny by the American public not only for unethical but, in many instances, fraudulent practices. The professions, and particularly the medical and scientific professions, have also been placed under increased scrutiny by government officials and the public. To be sure, these stains on the moral fabric of American leadership are spotty and hardly reflect the norm that characterizes the leadership of the totality of American enterprise. Notwithstanding, it seems both timely and important to examine and codify, if possible, the behavioral patterns that should be operative within the leadership of organized cardiology as reflected in its two principal institutions, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA). The goal of this Task Force is to highlight those high moral and ethical standards that will serve to convey the integrity and professionalism of our organizations. It is the obligation of leadership and staff to reflect values by acting in a morally responsible and professional manner. The ACCF and the AHA are both uniquely intertwined with the dual obligation that the health care professional (HCP) has to both the patient and to society. The primary obligation of the HCP is to the patient and to do that which is best for his or her well-being. This is the principle of beneficence (the obligation to protect persons from harm by maximizing anticipated benefits and minimizing possible risks of harm). In addition to supporting members in caring for individual patients, the ACCF and the AHA must also address societal concerns and adhere to the principle of distributive justice (which requires that the benefits and burdens of research and other health care resources be distributed fairly). Another tension is the dual obligation of …

It is generally agreed that one of the most important contributions made in medicine during the past century was the establishment of the coronary care unit in the early 1960s. Although Herrick ([1][1]) had clearly defined the clinical entity of acute myocardial infarction (MI) some 50 years earlier

The recently published American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Acute Myocardial Infarction stress 3 major points: (1) the prehospital phase from the onset of symptoms to definitive therapy in the emergency department must be shortened by 50% in order to reduce further the estimated 30% mortality rate for all patients in the community who suffer an acute myocardial infarction; (2) a more widespread use of thrombolytic agents is warranted because of the demonstrated, extremely time-dependent benefit to survivorship: the sooner it is given, the better the outcome; and (3) the administration of aspirin (160-325 mg) daily for an indefinite period is perhaps the most important therapy for a patient with acute myocardial infarction. Long-term therapy with lipid-lowering Statin drugs and angiotensin-converting enzyme inhibitor agents are gaining increasing evidence-based data to support their perpetual use as well.

BACKGROUND:Underuse of coronary angiography is common among patients with acute myocardial infarction (AMI) and the magnitude of underuse varies across geographic areas. OBJECTIVES:To examine the influence of patient demographic, clinical and hospital characteristics on underuse of coronary angiography, and the contribution of these factors to variation in underuse across geographic regions. RESEARCH DESIGN:Cohort study using data from the Cooperative Cardiovascular Project. SUBJECTS:Nine thousand four hundred fifty-eight patients in 95 hospital referral regions (HRRs) hospitalized for AMI in 1994 to 1995 and for whom angiography was rated necessary. MEASURES:Odds ratios (95% confidence intervals) associated with underuse of angiography according to patient and hospital characteristics. The difference between low and high rates of underuse of angiography across regions after controlling for regional differences in patient and hospital characteristics. RESULTS:Of those for whom angiography was rated necessary, 42% did not undergo the procedure. Underuse of angiography was associated with several patient demographic and hospital attributes (eg, female gender, black race, treatment in a hospital without angiography, treatment by a general practitioner) as well as with prevalent clinical characteristics, such as renal insufficiency, congestive heart failure, prior coronary artery bypass surgery, and chronic obstructive pulmonary disease. Across HRRs, variation in underuse ranged from 24.0% to 58.3%. The difference between low and high rates did not decline significantly after controlling for regional differences in patient or hospital characteristics. CONCLUSIONS:At the patient-level, rates of necessary angiography may be improved if we address disparities in care related to sociodemographic characteristics and to the technological capabilities of hospitals. In addition, practice guidelines should be updated to reflect clinical concerns about the risks and benefits of angiography and subsequent revascularization in certain patient sub-groups, both to provide appropriate guidance to physicians and to facilitate better estimates of underuse. The causes of regional variation in underuse do not appear to be related to regional differences in patient or hospital characteristics, and therefore, require further study.

BACKGROUND:Geographic variation in the use of medical procedures has been well documented. However, it is not known whether this variation is due to differences in use when procedures are indicated, discretionary, or contraindicated.OBJECTIVES:To examine whether use of coronary angiography after acute myocardial infarction (AMI) according to appropriateness criteria varied across geographic regions and whether underuse, overuse, or discretionary use accounted for variation in overall use.DESIGN:Retrospective cohort study using data from the Cooperative Cardiovascular Project.SETTING:Ninety-five hospital referral regions.PATIENTS:There were 44,294 Medicare patients hospitalized with AMI during 1994 or 1995, classified according to appropriateness for angiography.MAIN OUTCOME MEASURE:Variation in use of angiography, as measured by the difference between high and low rates of use across regions.RESULTS:Across regions, variation in the use of angiography was similar for indications judged necessary; appropriate, but not necessary; or uncertain. Variation was lowest for indications judged unsuitable (difference between high rate and low rate across regions = 16.3%; 95% CI = 12.6%; 20.6%). The primary cause of variation in the overall rate of angiography was due to use for indications judged appropriate, but not necessary or uncertain. When variation associated with these indications was accounted for, the difference between the resulting high and low overall rates was 10.8% (9.4%, 12.4%). In contrast, variation in the overall rate remained high when underuse in necessary situations or overuse in unsuitable situations was accounted for.CONCLUSIONS:Across regions, practice was more similar for patients categorized unsuitable for angiography than for patients with other indications. Variation in overall use of angiography appeared to be driven by utilization for discretionary indications rather than by underuse or overuse. If equivalent rates across geographic areas are judged desirable, then greater effort must be directed toward defining care for patients with discretionary indications.

We determined whether adherence to recommendations for coronary angiography more than 12 h after symptom onset but prior to hospital discharge after acute myocardial infarction (AMI) resulted in better survival. Using propensity scores, we created a matched retrospective sample of 19,568 Medicare patients hospitalized with AMI during 1994–1995 in the United States. Twenty-nine percent, 36%, and 34% of patients were judged necessary, appropriate, or uncertain, respectively, for angiography while 60% of those judged necessary received the procedure during the hospitalization. The 3-year survival benefit was largest for patients rated necessary [mean survival difference (95% CI): 17.6% (15.1, 20.1)] and smallest for those rated uncertain [8.8% (6.8, 10.7)]. Angiography recommendations appear to select patients who are likely to benefit from the procedure and the consequent interventions. Because of the magnitude of the benefit and of the number of patients involved, steps should be taken to replicate these findings.

BACKGROUND:Previous studies have documented that cardiac procedures are performed less frequently in patients enrolled in managed-care plans than in those with fee-for-service coverage. However, it is not known whether this difference is due to less frequent use of cardiac procedures when they are indicated or to less frequent use when they are not indicated.METHODS:We compared the use of coronary angiography after acute myocardial infarction among Medicare beneficiaries who had traditional fee-for-service coverage with the use among Medicare beneficiaries enrolled in managed-care plans. The analysis was adjusted for differences in demographic and clinical characteristics of the patients and for characteristics of the hospitals to which they were admitted. We studied more than 50,000 beneficiaries in seven states and evaluated their care according to guidelines proposed by the American College of Cardiology and the American Heart Association (ACC-AHA).RESULTS:Among the 44 percent of patients in both groups who had ACC-AHA class I indications (those for which angiography is useful and effective), more fee-for-service beneficiaries than managed-care enrollees underwent angiography (46 percent vs. 37 percent, P<0.001). The rate of angiography was very low among patients with class I indications who were admitted to hospitals without angiography facilities (31 percent in the fee-for-service group and 15 percent in the managed-care group, P<0.001). Among patients with class III indications (those for which angiography is not effective), the rate of use was low in both groups (approximately 13 percent).CONCLUSIONS:In situations in which angiography is thought to be useful, it is used less often among Medicare beneficiaries enrolled in managed-care plans than among those with fee-for-service coverage. Moreover, rates of use among patients with class I indications are fairly low in both groups, suggesting that there is room for improving the care of elderly patients with myocardial infarction, especially those admitted to hospitals without angiography facilities.

Coronary heart disease (CHD) remains the leading cause of death in the United States for those older than 65 years of age, despite a substantial reduction in CHD death rates during the last 30 years. CHD is the leading overall cause of death for women because the CHD death rate in older women (particularly >75 years) is so high, exceeding that of older men. Life expectancy in men is less, and the incidence of CHD is strikingly higher in younger men (see the article by Batchelor et al elsewhere in this issue). 47,51,161 The epidemiologic characteristics for the United States are similar to those of the rest of the Western world. Cardiovascular disease (including hypertension) is becoming the leading cause of death throughout the entire world. The implications of aging for cardiovascular disease, especially CHD, are profound. Standard cardiology textbooks and many specialty texts cover CHD syndromes extensively, so this article emphasizes those features that are of particular importance in the older population. Although it is often stated that care of elderly CHD patients does not differ from the care of younger CHD patients but requires only greater individualization, such a generalization underestimates the importance of the major differences that aging produces in the presentation, diagnosis, prognosis, and response to therapy. In addition, the extent of coronary atherosclerosis is greater in the elderly, and comorbid conditions, both cardiac (left ventricular hypertrophy, systolic hypertension, and aortic stenosis) and noncardiac (diabetes, pulmonary and renal disease), are frequently present. Thus, the elderly CHD patient requires a highly individualized approach to management. This article describes the prudent approach to such management. CHD in the elderly emphasizes the difference between coronary atherosclerosis (CAS) and CHD. CAS is a pathologic process that is regularly present in the elderly but often unassociated with any symptoms or objective evidence of cardiac dysfunction resulting from ischemia (e.g., exercise testing or other estimates of coronary blood flow and cardiac performance are normal). CHD produces symptomatic or asymptomatic functional abnormalities and clinical events secondary to CAS through a variety of syndromes. Hence the precise relationship between CHD, CAS, and aging is complicated. At necropsy, greater than 50% of patients older than 50 years of age have been found to have significant stenosis in at least one coronary artery, 1,137,163 and the severity and number of stenoses increase with each decade. The presentation and response of the older patient to CHD, however, are modified by age-related alterations in endothelial function, modification of smooth muscle cell activity, diastolic dysfunction, and altered responses to circulating catecholamines, as discussed in the articles by Schwartz and Shulman.

Background Some deaths after percutaneous coronary angioplasty (PTCA) occur in high-risk situations (eg, shock), whereas others are unexpected and related to procedural complications. To better describe the epidemiologic causes of death after PTCA, we undertook a systematic review of all in-hospital PTCA deaths in Northern New England from 1990 to 1993. Methods The medical records of 121 patients who died during their acute hospitalization for PTCA were reviewed with a standardized data extraction tool to determine a mode of death (eg, low output failure, arrhythmia, respiratory failure) and a circumstance of death (eg, death attributable to a procedural complication, preexisting acute cardiac disease). Any death not classified as a procedural complication was reviewed by a committee and the circumstance of death assigned by a majority rule. Results Low-output failure was the most common mode of death occurring in 80 (66.1%) of 121 patients. Other modes of death included ventricular arrhythmias (10.7%), stroke (4.1%), preexisting renal failure (4.1%), bleeding (2.5%), ventricular rupture (2.5%), respiratory failure (2.5%), pulmonary embolism (1.7%), and infection (1.7%). The circumstance of death was a procedural complication in 65 patients (53.7%) and a preexisting acute cardiac condition in 41 patients (33.9%). Women were more likely to die of a procedural complication than were men. Conclusion Procedural complications account for half of all post-PTCA deaths and are a particular problem for women. Other deaths are more directly related to patient acuity or noncardiac, comorbid conditions. Understanding why women face an increased risk of procedural complications may lead to improved outcomes for all patients. (Am Heart J 1999;137:632-8.)