Definition of the problem: In 1997, Percutaneous Transluminal Coronary Angioplasty (PTCA) was performed in 138.001 cases in Germany. The standard indications, single vessel disease and badly controlled angina, are more and more extended to multivessel disease with and without severe angina, unstable or preinfarction angina, and acute myocardial infarction (AMI) itself. Dilating asymptomatic stenoses of more than 70–80% is a widely used indication, intending prophylaxis of complete occlusion and AMI. Actually there is no generally accepted guideline (...) for the different new indications, conservative versus invasive treatment schedule. It is difficult for the patient to get appropriate information before his decision between mechanical procedures and conservative methods; authentic informed consent actually seems to be in a very bad position. In 1992 the working group called ”Arbeitsgemeinschaft leitender kardiologischer Krankenhausärzte (ALKK)” decided to start a registry of all PTCA procedures, in order to gain knowledge about the present status of PTCA in Germany. Up to March 1999, 198.608 PTCA are logged.Arguments: Each PTCA was included on an intention-to-treat basis. The registry succeeded in a nearly complete recording with 98,6% of all PTCA procedures complete on March 17th, 1999. 93,5% of stenosed and 72,2% of the total occluded vessels were successfully dilated. In 4.729 cases (2,63%) the PTCA caused severe complications. The overall in-hospital mortality was only 0,5%, if the procedures done for AMI were excluded (including AMI it was 1,1%). The calculation of complications should be an essential part of the patients informed consent.Conclusion: Complete recording of all PTCA procedures is feasible even on a nationwide basis. Some results of the registry, as the indication control and the complication rate may help to realize a better doctor-patient-conversation on risks and benefits of either concept. The trend of many CHD patients is ”modern”: It should be done what can be done (mechanically), with results at once. Although said somehow paternalistic, this point of view cannot be tolerated: Proper informed consent today includes the realistic alternative of modern medicaments, especially those with an aggressive cholesterol lowering potency. (shrink)

This study aimed to investigate the status and risk factors of post-traumatic stress disorder in patients with acute myocardial infarction after emergency percutaneous coronary intervention in acute and convalescence phases. A longitudinal study design was used. Two questionnaire surveys were conducted in the acute stage of hospitalization, and 3 months after onset in patients. Logistic regression was used to analyze the risk factors for PTSD in AMI patients. The incidence of PTSD was 33.1 and 20.4% in acute and (...) convalescent patients, respectively. The risk factors related to PTSD were door-to-balloon time, left ventricular ejection fraction, smoking, anxiety, and depression. AMI patients after PCI had PTSD in the acute and convalescent stage. The findings indicate that tailored measures should be developed and carried out to prevent PTSD and improve the mental health of patients with AMI after undergoing PCI. (shrink)

For medical interventions there is a gap between what clinical scientific research has established as likely to carry clinical benefit and what the National Institute for Clinical Excellence (NICE) has judged as cost-effective. This gap is the affordability gap. It is created by a value judgement made by NICE and affirmed by the Secretary of State for Health. This value judgement operates to affect other value judgements made in actual clinical situations where at least one choice of treatment falls into (...) the affordability gap. This paper considers how the creation of this affordability gap impacts upon actual clinical decisions. It explores these issues in the context of the choice between a drug-eluting stent and a bare metal stent for elective coronary angioplasty. It also argues that the option of an NHS procedure with a top-up fee to cover the cost of the affordability gap is a genuine one; that this option could improve clinical outcomes; that it is morally acceptable; and that the rules that prevent the utilization of this option should be relaxed. (shrink)

Interventional cardiologists are commonly faced with patients who prefer percutaneous coronary intervention (PCI) rather than coronary artery bypass surgery (CABG). Many prefer PCI even when CABG is recommended. Doctors may wonder whether (as the cardiac surgeons suspect) they consciously or unconsciously influence patients to choose PCI. We consider reasons why patient preferences in this context are not irrational.

Coronary by-pass surgery has been performed in hundreds of thousands of patients in the last 15 years with a high standard of technical and surgical perfection. The indications for this kind of surgery, however, are still controversial because in spite of many retrospective and several prospective studies it cannot be proven convincingly that in a given patient this surgical procedure will prolong life or prevent myocardial infarction. The present attempt to analyze the causes for this controversy shows that the (...) main reasons for this uncertainty lie: (a) in the enigma of the underlying (ischemic heart) disease itself, which is supposed to lend itself to surgical therapy; (b) in the inadequate methods available up until now for characterizing the state of the disease, its probable course, and its pathogenesis; and (c) in the professional group interests which have a momentum of their own. (shrink)

The purpose of this study was to explore the lived experiences of three couples in each of which one of the partners has undergone coronary artery bypass graft surgery . Previous research has been largely quantitative and focused on discrete dimensions of marital quality, spousal support, or patient and spouse distress. However, few studies explored the experiences of couples as a marital dyad. This study expanded upon previous research to explore couples' experiences of bypass surgery and to examine the (...) possibility of shared meanings about that event. Shared meaning refers to the congruent beliefs that a couple has about their CABG experience . Three couples from the Cardiac Wellness Institute of Calgary were interviewed and the transcribed interviews analyzed. The descriptive phenomenological psychological method was used to identify the underlying meaning structures of the couples' experiences. The analysis revealed a single structure consisting of seven interrelated constituents describing the psychological essence of the couples' experiences of bypass surgery. The study extended the understanding of what CABG is like for a marital dyad, particularly for medical and psychological practitioners who work with CABG patients and their spouses. (shrink)

The aim of this study was interpret the existential construct of family caring following Acute Coronary Syndrome. Family support is known to have a positive impact on recovery and adjustment after cardiac events. Few studies provide philosophically-based, interpretative explorations of carer experience following a spouse’s ischaemic event. As carer experiences, behaviours and meaning-making may impact on the quality of the support they provide to patients, further understanding could improve both patient outcomes and family experience. Fourteen spouses of people experiencing (...) Acute Coronary Syndrome in Sydney, Australia were engaged in a single, semi-structured interview. Interviews were audio-recorded and transcribed verbatim. Data were analysed using hermeneutic interpretation within a Heideggerian phenomenological framework. Acute Coronary Syndrome disrupts lived temporality, and the projected potential for carers’ being-alongside. Carers experienced an existential uncertainty that arose from difficulty in diagnosis, and situated fear as an attuned, being-towards-death. They constructed protective strategies to insulate their partner and themselves from further stress and risk, however, unclear boundaries for protection heightened carer anxiety. The existential structure of care included one of two possible Heideggerian modes: leaping-in care was a dominating mode that required a high level of carer vigilance; leaping-ahead care was a metaphorical walking alongside, as carers gave back control, freeing opportunities for the person to ‘own’ care. Supporting carers through the intensive phase of leaping-in care, and equipping them for informed leaping-ahead care should be a focus in both the acute and post-discharge care phases. (shrink)

La ciencia se sustenta en la veracidad de los datos de investigación, y por ende, en la confianza sobre la integridad moral y profesional de los investigadores. Sin embargo, diversos factores ocasionan que la conducta inapropiada en la investigación sea un problema vigente. Revisamos los problemas éticos en el ensayo _Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization_ (EXCEL), que comparó el intervencionismo coronario percutáneo frente a la cirugía de revascularización en la enfermedad (...) del tronco coronario izquierdo con un SYNTAX score ≤32. Preocupaciones sobre la metodología, actividades asociadas a la veracidad de los datos, y conducta inapropiada durante la investigación son advertidas en este estudio de caso. Se concluye sobre la necesidad de revisar y reconsiderar la vigencia e importancia de los aspectos bioéticos en la investigación clínica, aspectos que no pueden soslayarse. (shrink)

BackgroundHealth-related quality of life is known to be impaired in individuals with coronary artery disease, especially in those after a recent acute coronary syndrome. Heart failure is a common burden in this population that significantly contributes to worsening HRQoL. To accurately measure the level of HRQoL in individuals with CAD after ACS, disease-specific scales, such as the Minnesota living with heart failure questionnaire, are recommended. Nevertheless, to date, there has not been a study that would comprehensively evaluate the (...) psychometric properties of the MLHFQ in a large sample of individuals with CAD after ACS. The debate regarding the internal structure of MLHFQ is also still present. Hence, this study aimed to translate the MLHFQ and evaluate its internal structure, reliability/precision, and validity in individuals with CAD following ACS in Lithuania.MethodsIn the cross-sectional study, 1,083 participants were evaluated for sociodemographic and clinical characteristics. HRQoL was measured using the MLHFQ and the Short Form-36 health survey. In addition, exercise capacity was also evaluated in the study patients, using a standardized computer-driven bicycle ergometer.ResultsThe internal consistency of the MLHFQ subscales was found to be good. Confirmatory factor analysis provided the support for the three-factor model of the MLHFQ and showed acceptable fit [comparative fit indices = 0.894; goodness-of-fit = 0.898; non-normal fit index = 0.879, and root mean square error of approximation = 0.073]. Regarding convergent evidence, significant associations were found between the MLHFQ domains and the SF-36 domains and EC.ConclusionThe current study completed cultural validation and provided further information on the psychometric characteristics of the MLHFQ in Lithuania, suggesting MLHFQ as a valid and reliable instrument to measure HRQoL. The Lithuanian version of MLHFQ is best described by a three-factor solution, measuring physical, social, and emotional dimensions of HRQoL among individuals with CAD following ACS. (shrink)

Psychological distress, including depression and anxiety, and Type-D personality are prevalent in patients with coronary heart disease and associated with poor cardiovascular outcomes. Worry and rumination may be among the core features responsible for driving psychological distress in these patients. However, the nature of associations between these constructs remains to be delineated, yet they may have implications for the assessment and treatment of CHD patients. This study aimed to explore the factorial structure and potential overlap between measures of depression, (...) anxiety and the Type-D personality factors known as negative affectivity and social inhibition, and examine how these constructs relate to worry and rumination in a sample of 1,042 CHD outpatients who participated in the in the cross-sectional NORwegian CORonary Prevention study. We conducted confirmatory factor analyses and regression analyses within a structural equation modeling framework. Results showed all constructs to have acceptable factor structure and indicated an overlap between the constructs of depression and negative affectivity. Worry was most strongly associated with anxiety, whereas rumination was most strongly associated with depression and negative affectivity. The results suggest conceptual similarities across the measures of depression and negative affectivity. They further suggest that intervention efforts could benefit from targeting worry and/or rumination in the treatment of CHD outpatients presenting with symptoms of psychological distress. (shrink)

Members of the Student Clinical Ethics Committee discussed whether tube feeding should be instigated for a man who had indicated through his actions that he may be refusing it, although his family stated that he would have wanted to be kept alive in such a situation. The Committee considered the key issues of capacity and best interests, which in this case were confounded by lack of clarity about whether the patient’s actions amounted to a valid refusal of life sustaining treatment, (...) and if his previous views still pertained to his current, yet unforeseen, circumstances. As the discussion progressed, it became apparent that some members were reluctant to accept that non-insertion of clinically assisted feeding could ever be in a patient’s best interests. (shrink)

The relationship between law and a population’s health is complex and poorly understood. To the extent that scholarship exists on the subject, it has usually focused on epidemics that are concentrated in relatively vulnerable, marginalized communities. Often, individual behaviors are assumed to play a major role in the epidemiology of these diseases. Perhaps, as a result, these illnesses become stigmatized and the object of coercive laws, which in turn become the subject of litigation, legal debate, and ultimately scholarly analysis. Thus, (...) to the extent that U.S. legal scholars have thought about public health in the last 30 years, they have generally done so in the context of tuberculosis, intravenous drug abuse, and a handful of similar conditions. Likewise, Jonathan Mann’s own appreciation of the importance of human rights to public health emerged in the wake of his work with HIV, which is perhaps the prototypical stigmatized disease. (shrink)

BackgroundCoronary heart disease is closely associated with cognitive impairment, especially in severe cases of heart failure. However, it is unclear whether cardiac systolic function plays a role in the relationship between pre-existing CHD and cognitive impairment in subjects without clinical heart failure.MethodsIn total, 208 subjects from the First Affiliated Hospital of Xi’an Jiaotong University were recruited from June 2014 to January 2015, and were divided into CHD and non-CHD groups according to the inclusion and exclusion criteria. The global cognitive function (...) of all subjects was assessed by the Mini-Mental State Examination and cognitive impairment was defined as the score lower than the cutoff value. Left ventricular ejection fraction was measured using transthoracic echocardiograms. The relationship among pre-existing CHD, LVEF, and cognitive impairment was analyzed by multivariate logistic regression.ResultsIn total, 34 subjects met the criteria of cognitive impairment. Univariate analysis showed that the cognitive impairment prevalence in the CHD group was significantly higher than that in the non-CHD group. Multivariate logistic analysis revealed that CHD was significantly associated with a higher risk of cognitive impairment after adjusting for confounds except for LVEF. However, the OR of CHD decreased when LVEF was further corrected as a continuous variable, and LVEF was negatively associated with the risk of cognitive impairment.ConclusionPre-existing CHD is associated with a higher risk of cognitive impairment, and such an association can be considerably explained by reduced LVEF. An impaired cardiac systolic function may play a key role in the relationship between CHD and cognitive impairment among patients with pre-heart failure conditions. (shrink)

Coronary arteries were studied on 110 postmortem human hearts during January 2000 to December 2001 in the department of Anatomy and Microbiology, Bangladesh Medical College to observed. The pattern of coronary dominance and its relation with atherosclerosis was observed. Atherosclerosis was found in 49(44.5%) samples, among which 37(56.%) were from male and 12(26.7%) from female hearts. This difference was significant (P<0.01). Right dominance was observed in 72 (65.5%) cases while 17 (15.5%) had left dominance and 21 (19.1%) had (...) balanced type of circulation. Balanced type of circulation was observed more among females (14; 66.7%) while left dominance was more frequent among males (13; 76.5 %). This deference on the basis of sex was significant (P<0.05). Significant (P<0.001) relationship was also observed between atherosclerosis and dominance of coronary artery. It may be concluded that atherosclerosis was present in almost half of the studied subjects and was found more among males. Left dominance was more frequently present among males it was associated with atherosclerosis. (shrink)

Recently, the pandemic caused by COVID-19 is severe in the entire world. The prevention and control of crimes associated with COVID-19 are critical for controlling the pandemic. Therefore, to provide efficient and convenient intelligent legal knowledge services during the pandemic, we develop an intelligent system for legal information retrieval on the WeChat platform in this paper. The data source we used for training our system is “The typical cases of national procuratorial authorities handling crimes against the prevention and control of (...) the new coronary pneumonia pandemic following the law”, which is published online by the Supreme People’s Procuratorate of the People’s Republic of China. We base our system on convolutional neural network and use the semantic matching mechanism to capture inter-sentence relationship information and make a prediction. Moreover, we introduce an auxiliary learning process to help the network better distinguish the relation between two sentences. Finally, the system uses the trained model to identify the information entered by a user and responds to the user with a reference case similar to the query case and gives the reference legal gist applicable to the query case. (shrink)

It is a paradox that medical experimentation on individuals, whether patients or healthy volunteers, is now controlled by strict ethical guidelines, while no such protection exists for whole populations which are subjected to medical interventions in the name of preventive medicine or health promotion. As many such interventions are either of dubious benefit or of uncertain harm-benefit balance, such as mass screening for cancers or for risk factors associated with coronary heart disease, there is no justification for maintaining the (...) ethical vacuum in which preventive medicine finds itself at present. (shrink)