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Background Transcatheter aortic valve replacement (TAVR) computed tomography (CTA) images can be used to evaluate coronary artery disease (CAD). Methods We conducted a prospective cohort study of consecutive TAVR patients from November 2019 to February 2021 to evaluate TAVR CTA assessment of CAD on the rate of pre-TAVR invasive angiography. Patients had CTA first or invasive angiography first at the discretion of their treating physician. TAVR CTA scans were categorized as normal/mild CAD, single vessel disease, high risk (multi-vessel or left main disease), or non-diagnostic in patients without prior coronary artery bypass grafting (CABG) and as low risk or high risk in patients with prior CABG. Invasive angiography was recommended pre-TAVR for high risk or non-diagnostic CTA findings. Results TAVR was performed on 354 patients and CTA first was performed in 273 patients and invasive angiography first in 81 patients. Among 231 patients without prior CABG who had CTA first, 22.1% (51/231) had pre-TAVR invasive angiography and 1.3% (3/231) had pre-TAVR revascularization. Normal/mild CAD or single vessel disease was found on CTA in 174 patients of whom, 0.5% (1/174) had high risk disease on invasive angiography. Among 42 patients with prior CABG who had CTA first, 14.3% (6/42) had pre-TAVR invasive angiography and 2.4% (1/42) had pre-TAVR revascularization. Conclusion TAVR CTA CAD evaluation can avoid pre-TAVR invasive angiography in over 70 % of patients while rarely missing high-risk findings. A CTA first strategy to assess CAD should be considered, especially among patients where conservative management of CAD is preferred.

In the COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial, angiography-guided percutaneous coronary intervention (PCI) of nonculprit lesions with the aim of complete revascularization reduced major cardiovascular (CV) events in patients with ST-segment elevation myocardial infarction (MI) and multivessel coronary artery disease.The purpose of this study was to determine the effect of nonculprit-lesion stenosis severity measured by quantitative coronary angiography (QCA) on the benefit of complete revascularization.Among 4,041 patients randomized in the COMPLETE trial, nonculprit lesion stenosis severity was measured using QCA in the angiographic core laboratory in 3,851 patients with 5,355 nonculprit lesions. In pre-specified analyses, the treatment effect in patients with QCA stenosis ≥60% versus 60% on the first coprimary outcome of CV death or new MI and the second co-primary outcome of CV death, new MI, or ischemia-driven revascularization was determined.The first coprimary outcome was reduced with complete revascularization in the 2,479 patients with QCA stenosis ≥60% (2.5%/year vs. 4.2%/year; hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.47 to 0.79), but not in the 1,372 patients with QCA stenosis 60% (3.0%/year vs. 2.9%/year; HR: 1.04; 95% CI: 0.72 to 1.50; interaction p = 0.02). The second coprimary outcome was reduced in patients with QCA stenosis ≥60% (2.9%/year vs. 6.9%/year; HR: 0.43; 95% CI: 0.34 to 0.54) to a greater extent than patients with QCA stenosis 60% (3.3%/year vs. 5.2%/year; HR: 0.65; 95% CI: 0.47 to 0.89; interaction p = 0.04).Among patients with ST-segment elevation MI and multivessel coronary artery disease, complete revascularization reduced major CV outcomes to a greater extent in patients with stenosis severity of ≥60% compared with 60%, as determined by quantitative coronary angiography.

Objectives The authors sought to prospectively determine the safety and efficacy of next-day discharge using the Vancouver 3M (Multidisciplinary, Multimodality, but Minimalist) Clinical Pathway. Background Transfemoral transcatheter aortic valve replacement (TAVR) is an alternative to surgery in high- and intermediate-risk patients; however, hospital stays average at least 6 days in most trials. The Vancouver 3M Clinical Pathway is focused on next-day discharge, made possible by the use of objective screening criteria as well as streamlined peri- and post-procedural management guidelines. Methods Patients were enrolled from 6 low-volume ( 200 TAVR/year) centers in Canada and the United States. The primary outcomes were a composite of all-cause death or stroke by 30 days and the proportion of patients successfully discharged home the day following TAVR. Results Of 1,400 screened patients, 411 were enrolled at 13 centers and received a SAPIEN XT (58.2%) or SAPIEN 3 (41.8%) valve (Edwards Lifesciences, Irvine, California). In centers enrolling exclusively in the study, 55% of screened patients were enrolled. The median age was 84 years (interquartile range: 78 to 87 years) with a median STS score of 4.9% (interquartile range: 3.3% to 6.8%). Next-day discharge home was achieved in 80.1% of patients, and within 48 h in 89.5%. The composite of all-cause mortality or stroke by 30 days occurred in 2.9% (95% confidence interval: 1.7% to 5.1%), with neither component of the primary outcome affected by hospital TAVR volume (p = 0.51). Secondary outcomes at 30 days included major vascular complication 2.4% (n = 10), readmission 9.2% (n = 36), cardiac readmission 5.7% (n = 22), new permanent pacemaker 5.7% (n = 23), and >mild paravalvular regurgitation 3.8% (n = 15). Conclusions Adherence to the Vancouver 3M Clinical Pathway at low-, medium-, and high-volume TAVR centers allows next-day discharge home with excellent safety and efficacy outcomes.

Background Routine thrombus aspiration in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) does not improve clinical outcomes. However, there is remaining uncertainty about the potential benefit in those patients with high thrombus burden, where there is a biological rationale for greater benefit. Objectives The purpose of this study was to evaluate the benefit of thrombus aspiration among STEMI patients with high thrombus burden. Methods TOTAL (ThrOmbecTomy with PCI vs. PCI ALone in patients with STEMI) was a randomized trial of routine manual thrombectomy versus PCI alone in patients with STEMI (n = 10,732). High thrombus burden (Thrombolysis In Myocardial Infarction thrombus grade ≥3) was a pre-specified subgroup. Results The primary outcome of cardiovascular (CV) death, MI, cardiogenic shock, or heart failure was not different at 1 year with thrombus aspiration in patients with high thrombus burden (8.1% vs. 8.3% thrombus aspiration; hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.84 to 1.13) or low thrombus burden (6.0% vs. 5.0% thrombus aspiration; HR: 1.22; 95% CI: 0.73 to 2.05; interaction p = 0.41). However, among patients with high thrombus burden, stroke at 30 days was more frequent with thrombus aspiration (31 [0.7%] thrombus aspiration vs. 16 [0.4%] PCI alone, HR: 1.90; 95% CI: 1.04 to 3.48). In the high thrombus burden group, thrombus aspiration did not significantly improve CV mortality at 30 days (HR: 0.78; 95% CI: 0.61 to 1.01; p = 0.06) and at 1 year (HR: 0.88; 95% CI: 0.72 to 1.09; p = 0.25). Irrespective of treatment assignment, high thrombus burden was an independent predictor of death (HR: 1.78; 95% CI: 1.05 to 3.01). Conclusions In patients with high thrombus burden, routine thrombus aspiration did not improve outcomes at 1 year and was associated with an increased rate of stroke. High thrombus burden is still an important predictor of outcome in STEMI. (A Trial of routine aspiration ThrOmbecTomy with PCI vs. PCI ALone in patients with STEMI [TOTAL]; NCT01149044)

In patients with a ST-segment elevation myocardial infarction (STEMI), the prevalence of chronic total occlusion (CTO) in a non–infarct-related artery (non-IRA) is 8% to 15% [(1)][1] with 2-fold greater morbidity and mortality than in those with single-vessel disease (SVD) [(2)][2]. The TOTAL (

Objectives The purpose of this study was to determine the efficacy and safety of radial versus femoral access in women undergoing coronary angiography/intervention. Background The risk of bleeding and vascular access site complications are higher in women than in men. Methods In a pre-specified RIVAL (RadIal Vs femorAL access for coronary intervention) subgroup analysis, we compared outcomes in women (n = 1,861) and men (n = 5,160) randomized to radial versus femoral access. Results Overall, women were at higher risk of major vascular complications compared with men (4.7% vs. 1.7%; p Conclusions Women undergoing coronary angiography and PCI have a higher risk of vascular access site complications compared with men, and radial access is an effective method to reduce these complications.

Objectives This study sought to evaluate the main baseline and procedural characteristics, management, and clinical outcomes of patients from a large cohort of patients undergoing transcatheter aortic valve implantation (TAVI) who suffered coronary obstruction (CO). Background Very little data exist on CO following TAVI. Methods This multicenter registry included 44 patients who suffered symptomatic CO following TAVI of 6,688 patients (0.66%). Pre-TAVI computed tomography data was available in 28 CO patients and in a control group of 345 patients (comparisons were performed including all patients and a cohort matched 1:1 by age, sex, previous coronary artery bypass graft, transcatheter valve type, and size). Results Baseline and procedural variables associated with CO were older age (p Conclusions Symptomatic CO following TAVI was a rare but life-threatening complication that occurred more frequently in women, in patients receiving a balloon-expandable valve, and in those with a previous surgical bioprosthesis. Lower-lying coronary ostium and shallow sinus of Valsalva were associated anatomic factors, and despite successful treatment, acute and late mortality remained very high, highlighting the importance of anticipating and preventing the occurrence of this complication.

Objectives This study sought to evaluate the long-term outcomes after transcatheter aortic valve implantation (TAVI) in the Multicenter Canadian Experience study, with special focus on the causes and predictors of late mortality and valve durability. Background Very few data exist on the long-term outcomes associated with TAVI. Methods This was a multicenter study including 339 patients considered to be nonoperable or at very high surgical risk (mean age: 81 ± 8 years; Society of Thoracic Surgeons score: 9.8 ± 6.4%) who underwent TAVI with a balloon-expandable Edwards valve (transfemoral: 48%, transapical: 52%). Follow-up was available in 99% of the patients, and serial echocardiographic exams were evaluated in a central echocardiography core laboratory. Results At a mean follow-up of 42 ± 15 months 188 patients (55.5%) had died. The causes of late death (152 patients) were noncardiac (59.2%), cardiac (23.0%), and unknown (17.8%). The predictors of late mortality were chronic obstructive pulmonary disease (hazard ratio [HR]: 2.18, 95% confidence interval [CI]: 1.53 to 3.11), chronic kidney disease (HR: 1.08 for each decrease of 10 ml/min in estimated glomerular filtration rate, 95% CI: 1.01 to 1.19), chronic atrial fibrillation (HR: 1.44, 95% CI: 1.02 to 2.03), and frailty (HR: 1.52, 95% CI: 1.07 to 2.17). A mild nonclinically significant decrease in valve area occurred at 2-year follow-up (p Conclusions Approximately one-half of the patients who underwent TAVI because of a high or prohibitive surgical risk profile had died at a mean follow-up of 3.5 years. Late mortality was due to noncardiac comorbidities in more than one-half of patients. No clinically significant deterioration in valve function was observed throughout the follow-up period.

ObjectivesThe aim of this study was to compare the incidence and predictive factors of complete atrioventricular block (AVB) and permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR).BackgroundNo data exist on the need for PPI after TAVI versus SAVR in patients with similar baseline electrocardiographic (ECG) findings.MethodsA total of 411 patients with severe aortic stenosis (AS) and no prior pacemaker who underwent TAVI with the balloon-expandable Edwards valve (Edwards Lifesciences, Irvine, California) were matched (1:1) with 411 elderly patients with severe AS who underwent isolated SAVR on the basis of baseline ECG findings. The incidence, reasons, and predictive factors for PPI within 30 days after the procedure were compared between groups.ResultsMean age was similar in both groups (p = 0.11), and the TAVI group had a higher Society of Thoracic Surgeons score (p < 0.001). The rate of new PPI was higher after TAVI (7.3%) compared with SAVR (3.4%), p = 0.014. Complete AVB and severe symptomatic bradycardia, respectively, were the reasons for PPI in the TAVI (5.6% and 1.7%, respectively) and SAVR (2.7% and 0.7%, respectively) groups (p = 0.039 for complete AVB, p = NS for symptomatic bradycardia). The presence of baseline right bundle branch block was the only variable associated with PPI in the TAVI group (odds ratio: 8.61, 95% confidence interval: 3.14 to 23.67, p < 0.0001), whereas no variable was found in the SAVR group.ConclusionsTranscatheter aortic valve implantation was associated with a higher rate of complete AVB and PPI compared with SAVR in elderly patients with severe AS and similar baseline ECG findings. The presence of baseline right bundle branch block correlated with the need for PPI in the TAVI group.

ObjectivesWe sought to determine whether radial artery access is associated with increased radiation exposure during cardiac catheterization and whether this relationship differs between operators, after adjustment for clinical and patient characteristics associated with greater radiation exposure.BackgroundAlthough previous studies have demonstrated a relationship between radial access and increased radiation exposure to the patient during fluoroscopy-guided cardiac procedures, such studies did not account for differences in operator technique or clustering of patients, procedure complexity, or patient size. Those studies included data from few operators.MethodsData were collected prospectively on 5,954 diagnostic cardiac catheterizations performed at a tertiary cardiac center. A multilevel regression analysis was used to determine the relationship between radial artery access and radiation exposure.ResultsAfter adjustment for multiple factors, radial access was associated with increased exposure (beta = 0.22, p < 0.0001) when compared with the use of femoral access, as measured using the logarithmically transformed air kerma (LogAK). On average, radial access accounted for a 23% increase in measured AK. This was consistent between operators. There were observed differences in the mean LogAK between operators (p = 0.0158), as well as substantial variation in measured LogAK between patients within each operator's practice (p < 0.001).ConclusionsRadial artery access cardiac catheterization was associated with increased radiation exposure to the patient when compared with femoral access. The measured AK was still far below the threshold for deterministic effects in most patients studied. Observed variations in AK between and within operators may point to better opportunities to reduce exposure.

Objectives We evaluated transcatheter aortic valve implantation (TAVI) in high-risk patients with bicuspid aortic valve (BAV) stenosis. Background TAVI shows promise in the treatment of severe stenosis of triscupid aortic valves, especially in high-risk patients. However, BAV stenosis has been considered a contraindication to TAVI. Methods Eleven patients (age 52 to 90 years) with symptomatic severe BAV stenosis underwent TAVI at 3 Canadian tertiary hospitals between May 2006 and April 2010. All patients were considered high risk for surgical aortic valve replacement. Edwards-SAPIEN transcatheter heart valves (Edwards Lifesciences, Inc., Irvine, California) were used. Transfemoral or transapical access was selected, depending on the adequacy of femoral access. Results Access was transfemoral in 7 patients and transapical in 4 patients. There were no intraprocedural complications. Significant symptomatic and hemodynamic improvement was observed in 10 of 11 patients. Baseline aortic valve area of 0.65 ± 0.17 cm 2 and mean transaortic pressure gradient of 41 ± 22.4 mm Hg were improved to 1.45 ± 0.3 cm 2 and 13.4 ± 5.7 mm Hg, respectively. Two patients had moderate perivalvular leaks. At the 30-day follow-up there were 2 deaths due to multisystem failure in 2 transapical patients. In 1 patient an undersized, suboptimally positioned, unstable valve required late conversion to open surgery. Conclusions TAVI in selected high-risk patients with severe BAV stenosis can be successfully performed with acceptable clinical outcomes but will require further evaluation.

A ‘minimalist’ approach to transcatheter aortic valve replacement (TAVR) usually advocates avoidance of general anaesthesia; however, there is currently no consensus on the optimal degree of procedural sedation. We assessed the impact of the level of anaesthesia on procedural variables and early

A minimalist approach for transcatheter aortic valve replacement (TAVR) may be advantageous in frail patients undergoing TAVR. We assessed the impact of frailty, as measured with a 5-meter walk test, on early discharge and clinical outcomes using the Vancouver Clinical Pathway in the 3M (

The objectives of this study were to investigate the incidence, predictors, and clinical significance of isolated postprocedural troponin-I elevations in a consecutive series of patients who underwent percutaneous coronary intervention. We observed, in a series of 1,128 patients, that isolated troponin-I elevations without concomitant creatine kinase elevations occurred in 17% of patients after percutaneous coronary intervention, and that even troponin-I elevations 5 times above the upper limit of normal did not predict events after hospital discharge.

OBJECTIVES We sought to compare survival after coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA) in high-risk anatomic subsets. BACKGROUND Compared with medical therapy, CABG decreases mortality in patients with three-vessel disease and two-vessel disease involving the proximal left anterior descending artery (LAD), particularly if left ventricular (LV) dysfunction is present. How survival after PTCA and CABG compares in these high-risk anatomic subsets is unknown. METHODS In the Bypass Angioplasty Revascularization Investigation (BARI), 1,829 patients with multivessel disease were randomized to an initial strategy of PTCA or CABG between 1988 and 1991. Stents and IIb/IIIa inhibitors were not utilized. Since patients in BARI with diabetes mellitus had greater survival with CABG, separate analyses of patients without diabetes were performed. RESULTS Seven-year survival among patients with three-vessel disease undergoing PTCA and CABG (n = 754) was 79% versus 84% (p = 0.06), respectively, and 85% versus 87% (p = 0.36) when only non-diabetics (n = 592) were analyzed. In patients with three-vessel disease and reduced LV function (ejection fraction

Among 214 patients treated with abciximab within 24 hours of full-dose thrombolytic therapy, major bleeding occurred in 50 patients (23%; 95% confidence interval [CI] 18% to 30%) and intracranial hemorrhage occurred in 3 patients (1.4%; 95% CI 0.3% to 4%). The independent multivariate predictors of major bleeding were age (odds ratio [OR] 1.53/10 years, 95% CI 1.05 to 2.21, p = 0.03), time from thrombolytic to abciximab (OR 0.91/hour, 95% CI 0.83 to 0.99, p = 0.03), and intra-aortic balloon pump insertion (OR 4.42, 95% CI 2.00 to 9.72, p = 0.0002).

Percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM) is associated with higher rates of adverse cardiac events. Recent data suggest that adverse events are reduced in DM after PCI using stents with abciximab. We performed a retrospective analysis of a prospective PCI registry for all patients with DM who underwent stent placement at the Mayo Clinic from 1995 to 1997 (n = 570), and divided them into 2 groups based on whether abciximab was administered. Characterization and comparison of the clinical and angiographic variables, procedural outcomes, and short- and long-term event rates between groups was performed. The baseline clinical characteristics of the groups were similar, but patients treated with abciximab were more likely to be men with a lower left ventricular ejection fraction. Patients treated with abciximab had more multivessel intervention, saphenous vein graft intervention, and thrombus before intervention. The 30-day mortality rate (0.6% vs 3.0%, p = 0.03) and repeat PCI (0% vs 1.1%, p = 0.03) was lower in patients treated with abciximab. The 30-day rates of bypass surgery, myocardial infarction (MI), and a composite of death, MI, and revascularization were similar. The 1-year event rates did not differ significantly between patients taking and not taking abciximab for the end points of death (8.9% vs 8.8%, p = 0.97), MI (13.3% vs 11.4%, p = 0.57), bypass surgery (10.3% vs 6.2%, p = 0.20), repeat PCI (14.7% vs 15.9%, p = 0.76), and a composite of death, MI, and revascularization (30.4% vs 26.7%, p = 0.43). After adjusting for baseline variables, abciximab did not influence the occurrence of late adverse events.

To characterize and determine the overall impact of changes in primary percutaneous coronary intervention (PCI) on the clinical outcome of patients presenting within 24 hours of acute myocardial infarction (AMI).We retrospectively analyzed a prospective PCI registry for 1073 consecutive patients undergoing primary PCI for AMI at the Mayo Clinic in Rochester, Minn, from 1991 through 1997. The primary outcome measure was mortality from any cause within 30 days and 1 year.The number of patients treated for AMI by primary PCI per year increased from 119 in 1991 to 193 in 1997. Intracoronary stent use increased from 1.7% in 1991 to 64.8% in 1997 (P.001). This coincided with an increase in ticlopidine use from 3.6% in 1994 to 62.1% in 1997 (P.001) and in abciximab use from 2.7% in 1995 to 63.2% in 1997 (P.001). An increase in beta-blocker (58.3% to 75.3%; P.001), angiotensin-converting enzyme inhibitor (0.9% to 40.0%; P.001), and 3-hydroxy-3-methylglutaryl coenzyme A reductase use (1.9% to 40.5%; P.001) as well as a decrease in calcium channel antagonist (34.3% to 8.4%; P.001) use occurred on discharge. From 1991 through 1997, there was a significant decrease in the 30-day mortality rate (10.1% to 5.2%; P = .05). The 1-year mortality rate also decreased (13.4% in 1991 to 10.4% in 1997) (P = .09). After adjustment for other confounding variables, treatment in more recent years was associated with a significant decrease in death at 30 days (odds ratio, 0.89; 95% confidence interval, 0.79-1.00; P = .05) and during long-term follow-up (odds ratio, 0.93; 95% confidence interval, 0.87-1.00; P = .04).Percutaneous coronary intervention methods of reperfusion for AMI, along with adjuvant pharmacotherapy, have changed over recent years and have been associated with improved short- and long-term survival.

In patients receiving coronary stents treated with aspirin and coumadin, the peak incidence of stent thrombosis occurs on the fifth and sixth days following the implantation procedure. Little is known about the timing of stent thrombosis in patients treated with aspirin and ticlopidine. We compared the timing of coronary stent thrombosis in patients treated with ticlopidine and aspirin with the timing in those receiving coumadin and aspirin. A retrospective databank analysis was performed and 39 patients were identified who experienced stent thrombosis after successful coronary stent implantation. Of these, 21 had been treated with ticlopidine and aspirin and 18 with coumadin and aspirin therapy. The median time from stent implantation to stent thrombosis in the ticlopidine and aspirin group was 12 hours (interquartile range 6 to 72 hours) compared with 4 days in the coumadin and aspirin group (interquartile range 21 to 68 hours) (p

s S21 dose-adjusted and full-dose TNK compared to primary PCI were evaluated in an elderly STEMI cohort. METHODS: Within the Vital Heart Response (VHR) registry, data on consecutive elderly STEMI was evaluated from Jan 2013 to Mar 2014. In this STEMI network of care (VHR), the reperfusion modality (pharmacoinvasive or primary PCI) is based on individual patient characteristics and site of presentation. VHR covers a catchment area of 440, 000km2, serving 1.8 million inhabitants, with two PCI-capable facilities located in Edmonton, Canada. Within the pharmacoinvasive strategy, the pre-hospital treated group received half-dose TNK while patients presenting to a non-cath lab facility emergency room received full-dose TNK. All patients within the three treatment groups received evidence based protocolized parenteral anticoagulation and evidence based dual antiplatelet therapy. RESULTS: The baseline characteristics of STEMI patients 75 years in the three treatment groups {(half-dose TNK, n1⁄426), (full-dose TNK, n1⁄427), (primary PCI, n1⁄4125)} are depicted in table 1. Variances in patient age and gender were present with the full dose TNK group being younger and more likely male. The cardiac risk factor profiles, demonstrate comparable demographics at presentation, ischemic and treatment times. In the pharmacoinvasive strategy, 46.1% (n1⁄412/26) and 63% (n1⁄417/27) within the half-dose and fulldose TNK group, respectively required rescue PCI. In hospital clinical events in the half-dose TNK, full dose-TNK and primary PCI were: in-hospital all cause mortality {(11.5%, n1⁄43/26), (7.4%, n1⁄42/27) and (8.0%, n1⁄410/125)}, cardiogenic shock {(15.4%, n1⁄44/26), (7.4%, n1⁄42/27) and (10.4%, n1⁄413/125)}, and major bleed (excluding intracranial bleed) {(3.8%, n1⁄41/26), (7.4%, n1⁄42/27) and (7.2%, n1⁄49/125)} respectively. Intracranial hemorrhage occurred in two patients one in the half dose TNK group (1/26) and one receiving primary PCI group (1/125). CONCLUSION: This preliminary ‘real-world’ all-comer STEMI dataset supports the emerging evidence on both safety and efficacy of a half-dose TNK strategy compared to full-dose TNK and primary PCI in the elderly; limited by the small numbers, these observations currently remain hypothesis generating and require validation in adequately power trials. 042 OUTCOMES FOLLOWING TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) IN ONTARIO (2007-2013) EA Cohen, DT Ko, GH Oakes, M Koh, H Guo, MK Natarajan, HC Wijeysundera, JL Velianou, KJ Kingsbury

Patients with prosthetic valves are at high risk for complications in pregnancy. 29-year-old female at 12 weeks gestation presented with dyspnea and exertional chest pain. Her medical history included congenital bicuspid aortic valve stenosis, at the age of 24 she underwent aortic valve replacement

BACKGROUND: Coronary artery disease (CAD) a leading cause of mortality among women and despite this, there is a perception that “CAD is a man’s disease”. Little is known about the perceptions that influence patients and how it affects the process to seek medical care. The study objectives include 1) to understand from a gender-centered patient perspective the underlying process that urge women and men to seek medical attention when experiencing chest-pain and 2) to determine the association of factors which influence a patient’s decision to seek medical care. METHODS: Using a mixed Methods approach, the study was conducted in two parts: first, angina symptoms and perceptions influencing the decision to seek medical care were qualitatively explored using in-depth semi-structured interviews and analyzed using modified grounded theory approach. A new cohort of patients was enrolled into the second phase of study, which sought to quantify the reasons why patients decided to seek care according to gender. The entry criteria for both studies were the same: patients with suspected CAD and at least one prior abnormal test, referred for theirfirst coronary angiogram.Logistic regression was used to estimate the association of gender with factors that influence seeking medical care, adjusted for age. RESULTS: The qualitative analysis of 31 men and women revealed that symptoms alone did not prompt medical care. We developed the term, “symptomatic tipping point” to capture the transitional period between experiencing the symptom and seeking medical attention. We identified 6 stages before patients seek medical attention and the stages were similar between men and women varying only in duration between and within the stages, as women wouldwait for amore severe confirmatory event to occurbefore they would qualify their symptoms as “possibly cardiac”. In our quantitative study of 237 patients we found that men would seek medical attention when they perceived that their symptoms were “severe” (OR1⁄42.1 95%CI 1.2-3.7) and if the symptoms occurred “more frequently” (OR1⁄41.9, 95%CI 1.1-3.3) compared to women. CONCLUSION: We captured the process in which patients seek medical attention, as the symptomatic tipping point. Women and men went through a similar series of stages, however women would often delay seeking care for more severe or frequent symptoms to occur. The reasons for this are unclear. This has important public health implications to improve timely cardiac care among women.