INTRODUCTION: Patients referred for chest pain from primary care have increased, along with demand for outpatient cardiology consultations. We evaluated 'Triage Protocol' that implements standardised diagnostic testing prior to patients' first cardiology consultation. MATERIALS AND METHODS: Under the 'Triage Protocol', patients referred for chest pain were pretriaged using a standardised algorithm and subsequently referred for relevant functional diagnostic cardiology tests before their initial cardiology consultation. At the initial cardiology consultation scheduled by the primary care provider, test results were reviewed. A total of 522 triage patients (mean age 55 ± 13, male 53%) were frequency-matched by age, gender and risk cohort to 289 control patients (mean age: 56 ± 11, male: 52%). Pretest risk of coronary artery disease was defined according to a Modified Duke Clinical Score (MDCS) as low (<10), intermediate (10-20) and high (>20). The primary outcome was time from referral to diagnosis (days). Secondary outcomes were total visits, discharge rate at first consultation, patient cost and adverse cardiac outcomes. RESULTS: The 'Triage Protocol' resulted in shorter times from referral to diagnosis (46 vs 131 days; <0.0001) and fewer total visits (2.4 vs 3.0; <0.0001). However, triage patients in low-risk groups experienced higher costs due to increased testing (S$421 vs S$357, = 0.003). Adverse cardiac event rates under the 'Triage Protocol' indicated no compromise to patient safety (triage vs control: 0.57% vs 0.35%; = 1.000). CONCLUSION By implementing diagnostic cardiac testing prior to patients' first specialist consultation, the 'Triage Protocol' expedited diagnosis and reduced subsequent visits across all risk groups in ambulatory chest pain patients.
Algorithms ; Cardiology Service, Hospital ; Chest Pain ; therapy ; Clinical Protocols ; Female ; Humans ; Male ; Middle Aged ; Primary Health Care ; Treatment Outcome ; Triage ; methods

BACKGROUND: The current indications of cardiac implantable electronic devices (CIEDs) have expanded to include young patients with serious cardiac risk factors, but CIED placement has the disadvantage of involving unsightly scarring and bulging of the chest wall. A collaborative team of cardiologists and plastic surgeons developed a technique for the subpectoral placement of CIEDs in young female patients via a transaxillary approach. METHODS: From July 2012 to December 2015, subpectoral CIED placement via an axillary incision was performed in 10 young female patients, with a mean age of 25.9 years and mean body mass index of 20.1 kg/m². In the supine position, with the patient's shoulder abducted, an approximately 5-cm linear incision was made along one of the deepest axillary creases. The submuscular plane was identified at the lateral border of the pectoralis major, and the dissection continued over the clavipectoral fascia until the subpectoral pocket could securely receive a pulse generator. Slight upward dissection also exposed an entrance to the subclavian vein, allowing the cardiology team to gain access to the vein. One patient with dilated cardiomyopathy underwent augmentation mammoplasty and CIED insertion simultaneously. RESULTS: One case of late-onset device infection occurred. All patients were highly satisfied with the results and reported that they would recommend the procedure to others. CONCLUSIONS: With superior aesthetic outcomes compared to conventional methods, the subpectoral placement of CIEDs via a transaxillary approach is an effective, single-incision method to hide operative scarring and minimize bulging of the device, and is particularly beneficial for young female or lean patients.
Body Mass Index ; Cardiac Resynchronization Therapy ; Cardiology ; Cardiomyopathy, Dilated ; Cicatrix ; Defibrillators, Implantable ; Fascia ; Female* ; Humans ; Mammaplasty ; Methods ; Pacemaker, Artificial ; Plastics ; Risk Factors ; Shoulder ; Subclavian Vein ; Supine Position ; Surgeons ; Thoracic Wall ; Veins

Asia, Southeastern ; Cardiology ; methods ; trends ; Cardiovascular Diseases ; diagnosis ; epidemiology ; therapy ; Heart Failure ; therapy ; Humans ; Myocardial Infarction ; therapy ; Percutaneous Coronary Intervention ; Risk Factors ; Singapore ; Stents

Magnetic resonance imaging (MRI) is increasingly becoming a standard of care and hence, an unmatched and irreplaceable diagnostic method. However, patients with implantable cardiac devices have not been guaranteed safety when exposed to the MRI environment. For this reason, Medtronic has taken the initiative and developed SureScan™ devices, which are MRI compatible devices for patients that would enable them to undergo MRI scans safely. The current technological developments in magnetic resonance (MR) and their clinical applications are discussed.
Cardiology ; Humans ; Magnetic Resonance Imaging* ; Methods ; Safety Management ; Standard of Care

Anticoagulation therapy is effective in preventing primary and secondary thromboembolic events due to atrial fibrillation. Warfarin, which was approved by the United States in 1954, was the only long-term oral anticoagulation therapy till the approval of dabigatran in 2010, and of rivaroxaban and other direct factor Xa inhibitors from 2011, forming a group known as novel oral anticoagulants (NOAC). NOAC have fewer food and drug interactions compared to warfarin; hence, the patient will require fewer clinic visits. However, the short half-life of NOAC means that twice-a-day dosing is needed and there is higher risk of a prothrombotic state when doses are missed. Other disadvantages are the lack of long-term data on NOAC, their high cost and the current lack of locally available antidotes.
Administration, Oral ; Anticoagulants ; administration & dosage ; Atrial Fibrillation ; drug therapy ; Cardiology ; methods ; Dabigatran ; administration & dosage ; Family ; Humans ; Professional-Patient Relations ; Rivaroxaban ; administration & dosage ; Stroke ; prevention & control ; Thromboembolism ; prevention & control ; Warfarin ; administration & dosage

With the increased use of cardiac implantable electronic devices (CIEDs), it is increasingly important to recognise the unique challenges involved in the management of patients with CIEDs who are undergoing surgery. Practice advisories and consensus statements have been issued by the American Society of Anesthesiologists and the Heart Rhythm Society, advocating a multidisciplinary approach. This review discusses and presents a practical approach to perioperative CIED management in the Singapore context.
Algorithms ; Bradycardia ; surgery ; Cardiac Surgical Procedures ; Cardiology ; methods ; Decision Making ; Defibrillators, Implantable ; Hemodynamics ; Humans ; Intraoperative Period ; Pacemaker, Artificial ; Preoperative Period ; Radiography, Thoracic ; methods ; Singapore

Despite continued improvement in risk factor recognition and aggressive medical management, heart disease remains the number one killer in the world. Medications for primary or secondary prevention of heart disease can cause unpleasant side effects leading to non-compliance. Novel therapies are needed to serve as a complement to or alternative for current medical management. Acupuncture and more specifically electroacupuncture may serve as a safe and viable option in the cardiology clinic. This review article focuses on both mechanistic and clinical studies evaluating acupuncture's effectiveness with symptomatic heart disease. Although continued research is needed, currently evidence warrants consideration of acupuncture's use with myocardial ischemia, hypertension, arrhythmias, heart failure as well as autonomic dysfunction.
Acupuncture Therapy ; Cardiology ; methods ; Electroacupuncture ; Humans

Pulse examination was probably the earliest attempt to distinguish between health and illnesses. Starting at the pre-Hippocratic era, Chinese medicine practitioners developed techniques for pulse examination and defined pulse images based on their perceptions of pulse waveforms at the radial artery. Pulse images were described using basic variables (frequency, rhythm, wideness, length, deepness, and qualities) developed under philosophical trends such as Taoism and Confucianism. Recent advances in biomedical instrumentation applied to cardiology opened possibilities to research on pulse examination based on ancient Chinese medical theories: the pulse wave analysis. Although strongly influenced by philosophy, some characteristics used to describe a pulse image are interpretable as parameters obtained by pulse waveform analysis such as pulse wave velocity and augmentation index. Those clinical parameters reflect concepts unique to Chinese medicine - such as yinyang - while are based on wave reflection and resonance theories of fluids mechanics. Major limitations for integration of Chinese and Western pulse examination are related to quantitative description of pulse images and pattern differentiation based on pulse examination. Recent evidence suggests that wave reflection and resonance phenomena may bridge Chinese medicine and cardiology to provide a more evidence-based medical practice.
Cardiology ; Humans ; Image Processing, Computer-Assisted ; Medicine, Chinese Traditional ; Pulse ; methods ; Radial Artery ; physiology ; Wavelet Analysis

A 67-year-old Chinese woman with comorbidities of chronic obstructive lung disease, hypertension and prior coronary artery bypass surgery presented with severe functional mitral regurgitation (MR) and severely depressed left ventricular function. She was in New York Heart Association (NYHA) Class II-III. Due to high surgical risk, she was referred for percutaneous treatment with the MitraClip valve repair system. This procedure is typically performed via the femoral venous system and involves a transseptal puncture. A clip is delivered to grasp the regurgitant mitral valve leaflets and reduce MR. This was performed uneventfully in our patient, with reduction of MR from 4+ to 1+. She was discharged on post-procedure Day 2 and her NYHA class improved to Class I. This was the first successful MitraClip procedure performed in Asia and represents a valuable treatment option in patients with severe MR, especially those with functional MR or those at high surgical risk.
Aged ; Cardiac Surgical Procedures ; methods ; Cardiology ; instrumentation ; methods ; Catheters ; Echocardiography ; methods ; Equipment and Supplies ; Female ; Heart Ventricles ; physiopathology ; Humans ; Mitral Valve ; surgery ; Mitral Valve Insufficiency ; surgery ; Pulmonary Disease, Chronic Obstructive ; complications ; Risk ; Ultrasonography, Doppler ; methods ; Ventricular Dysfunction, Left ; surgery

Although the treatment of aortic coarctation in adults with the use of stents has shown favourable results and reduced complications, there have been few studies involving elderly patients. We highlight the clinical challenges faced in the management of such patients, with attention to severe calcification at the coarctation site. The midterm results were good in our patient, showing an improvement in blood pressure control and maintenance of stent patency.
Aged ; Aortic Coarctation ; therapy ; Blood Pressure ; Calcinosis ; complications ; Cardiology ; methods ; Female ; Geriatrics ; methods ; Hemodynamics ; Humans ; Magnetic Resonance Angiography ; methods ; Myocardial Infarction ; therapy ; Stents ; Tomography, X-Ray Computed ; methods ; Treatment Outcome ; Troponin I ; blood