Search

Background: Little is known about how best to support both patients and their partners in the reengagement of sexual activity (SA) after acute coronary syndrome (ACS), with sparse direct data from the partner on their needs and concerns in the area of SA support., Objectives: We undertook a qualitative study to address this gap in the literature through 3 objectives from a patient and partner perspective: (1) to characterize the experience of reengaging in SA post ACS, (2) to identify needs and priorities in the area of SA support post ACS, and (3) to determine whether cardiac rehabilitation (CR) could be an acceptable point of intervention for SA support., Methods: Semistructured qualitative interviews were conducted with 6 male patients who were post ACS and their partners (age range, 47-81 years). Patients were criterion sampled from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease database. Inductive thematic data analysis was conducted., Results: Four themes were identified: "importance," "support received," "on their own," and "wanting support." Couples reaffirmed the importance of SA pre and post ACS, reported SA support as currently insufficient but articulated ways it could be improved, and reported CR as a current source of SA support but thought there could be room for improvement on the content and delivery of such information., Conclusions: This study illustrates the potential value of promoting SA support for both patients who are post ACS and their partners and reports that SA support provided at CR would be viewed as important, needed, and acceptable., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc.)

Background: Patients with chronic kidney disease (CKD) and heart disease face challenging treatment decisions. We sought to explore the perceptions of patients and physicians about shared decision-making for coronary procedures for people with CKD, as well as opinions about strategies and tools to improve these decisions., Methods: We partnered with 4 patients with CKD and 1 caregiver to design and conduct a qualitative descriptive study using semi-structured interviews and content analysis. Patient participants with CKD and either acute coronary syndrome or cardiac catheterization in the preceding year were recruited from a provincial cardiac registry, cardiology wards and clinics in Calgary between March and September 2018. Cardiologists from the region also participated in the study. Data analysis emphasized identifying, organizing and describing themes found within the data., Results: Twenty patients with CKD and 10 cardiologists identified several complexities related to bidirectional information exchange needed for shared decision-making. Themes identified by both patients and physicians included challenges synthesizing best evidence, variable patient knowledge seeking, timeliness in the acute care setting and influence of roles on decision-making. Themes identified by physicians related to processes and tools to help support shared decision-making in this setting included personalization to reflect the variability of risks and heterogeneity of patient preferences as well as allowing for physicians to share their clinical judgment., Interpretation: There are complexities related to bidirectional information exchange between patients with CKD and their physicians for shared decision-making about coronary procedures. Processes and tools to facilitate shared decision-making in this setting require personalization and need to be time sensitive., Competing Interests: Competing interests: Matthew James has received investigator-initiated research grant funding for unrelated work from Amgen Canada. No other competing interests were declared., (Copyright 2020, Joule Inc. or its licensors.)

Purpose: Perceived social support is known to be an important predictor of health outcomes in patients with acute coronary syndrome (ACS). This study investigates patterns of longitudinal trajectories of patient-reported perceived social support in individuals with ACS., Methods: Data are from 3013 patients from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry who had their first cardiac catheterization between 2004 and 2011. Perceived social support was assessed using the 19-item Medical Outcomes Study Social Support Survey (MOS) 2 weeks, 1 year, and 3 years post catheterization. Group-based trajectory analysis based on longitudinal multiple imputation model was used to identify distinct subgroups of trajectories of perceived social support over a 3-year follow-up period., Results: Three distinct social support trajectory subgroups were identified, namely: "High" social support group (60%), "Intermediate" social support group (30%), and "Low" social support subgroup (10%). Being female (OR = 1.67; 95% CI = [1.18-2.36]), depression (OR = 8.10; 95% CI = [4.27-15.36]) and smoking (OR = 1.70; 95% CI = [1.23-2.35]) were predictors of the differences among these trajectory subgroups., Conclusion: Although the majority of ACS patients showed increased or fairly stable trajectories of social support, about 10% of the cohort reported declining social support. These findings can inform targeted psycho-social interventions to improve their perceived social support and health outcomes.

Background: Surveys of patients suggest many want to be actively involved in treatment decisions for acute coronary syndromes. However, patient experiences of their engagement and participation in early phase decision-making have not been well described., Methods: We performed a patient led qualitative study to explore patient experiences with decision-making processes when admitted to hospital with non-ST elevation acute coronary syndrome. Trained patient-researchers conducted the study via a three-phase approach using focus groups and semi-structured interviews and employing grounded theory methodology., Results: Twenty patients discharged within one year of a non-ST elevation acute coronary syndrome participated in the study. Several common themes emerged. First, patients characterized the admission and early treatment of ACS as a rapidly unfolding process where they had little control. Participants felt they played a passive role in early phase decision-making. Furthermore, participants described feeling reduced capacity for decision-making owing to fear and mental stress from acute illness, and therefore most but not all participants were relieved that expert clinicians made decisions for them. Finally, once past the emergent phase of care, participants wanted to retake a more active role in their treatment and follow-up plans., Conclusions: Patients admitted with ACS often do not take an active role in initial clinical decisions, and are satisfied to allow the medical team to direct early phase care. These results provide important insight relevant to designing patient-centered interventions in ACS and other urgent care situations.

Background: We examined variation in hospital treatment and its relationship to clinical outcome in a large population-based cohort of ACS patients within a single payer-government funded health care system., Methods: Patients hospitalized in 106 hospitals in Alberta, Canada with a primary diagnosis of ACS were included (July 1, 2010-March 31, 2013) with comparisons made across the three cardiac catheterization-capable hospitals (Sites A-C). Cox proportional-hazard regression models were used to examine the multivariable-adjusted association between site and 1-year death or repeat cardiovascular (CV) hospitalization (primary endpoint)., Results: Of 14,155 patients, 1938 (13.7%) were admitted to a community hospital without transfer to an invasive hospital (10.7% in-hospital death). The remaining were admitted (n=4514, 36.9%) or transferred (n=7703, 63.1%) to an invasive hospital (A:5480; B:3621; C:3116) where 11,247 (92.1%) underwent catheterization. Comorbidities and angiographic disease burden differed across sites. Variation in 30-day revascularization (PCI: 71.3%, 72.0%, 68.7%, p<0.001; CABG: 6.2%, 6.4%, 9.3%, p<0.001) and drug-eluting stent use for PCI (24.3%, 54.6%, 50.5%, p<0.001) were observed. After adjustment for patient demographics and comorbidities, variation in rates of 1-year death or CV hospitalization was observed among those with 30-day revascularization (p(interaction)<0.001; B versus A: HR 0.78, 95%CI 0.66-0.91; C versus A: HR 0.77, 95%CI 0.65-0.91; B versus C: HR 1.01, 95%CI 0.84-1.21)., Conclusions: Despite a government funded health system, we have shown variation in hospital treatment exists. Following adjustment hospital site was associated with differences in clinical outcome within 1year. Hence, further efforts may be warranted to help address potential disparities in ACS care., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Studies suggest that young women are at highest risk for failing to recognise early symptoms of acute coronary syndrome (ACS)., Objectives: To examine sex differences in prodromal symptoms occurring days and weeks prior to the acute presentation of ACS. We also examined health-seeking behaviours and prehospital management in young patients., Methods: Prospective cross-sectional analysis of 1145 patients (368 women) hospitalised for ACS, aged ≤55 years, from the GENdEr and Sex DetermInantS of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary SYndrome cohort study (January 2009-April 2013). Prodromal symptoms were determined using the McSweeney Acute and Prodromal Myocardial Infarction Symptom questionnaire. Health-seeking behaviour and prehospital care were determined by questionnaires., Results: The median age was 49 years. The prevalence of prodromal symptoms was high and more women reported symptoms than men (85% vs 72%, p<0.0001). Symptoms were similar between sexes and included unusual fatigue, sleep disturbances, anxiety and arm weakness/discomfort. Chest pain was less common in both sexes (24%). Women were more likely to seek care (49% vs 42%, p=0.04). Among those who sought care, women were more likely to use an ambulance for their ACS compared with men (52% vs 39%). Cardiovascular risk-reduction therapy use was low (≤40%) in all patients and less than half perceived their care provider suspected a cardiac source., Conclusions: Prior to ACS, women were more likely to experience prodromal symptoms and seek medical attention than men. Prehospital care was generally similar between sexes but demonstrated underutilisation of risk-reduction therapies in at-risk young adults., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Specialized cardiology services have contributed to reduced mortality in acute coronary syndromes (ACS).  We sought to evaluate the outcomes of ACS patients admitted to non-cardiology services in Southern Alberta., Methods: Retrospective chart review performed on all troponin-positive patients in the Calgary Health Region identified those diagnosed with ACS by their attending team. Patients admitted to non-cardiology and cardiology services were compared, using linked data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry and the Strategic Clinical Network for Cardiovascular Health and Stroke., Results: From January 1, 2007 to December 31, 2008, 2105 ACS patients were identified, with 1636 (77.7%) admitted to cardiology and 469 (22.3%) to non-cardiology services. Patients admitted to non-cardiology services were older, had more comorbidities, and rarely received cardiology consultation (5.1%). Cardiac catheterization was underutilized (5.1% vs 86.4% in cardiology patients (p < 0.0001)), as was evidence-based pharmacotherapy (p < 0.0001). Following adjustment for baseline comorbidities, 30-day through 4-year mortality was significantly higher on non-cardiology vs. cardiology services (49.1% vs. 11.0% respectively at 4-years, p < 0.0001)., Conclusion: In a large ACS population in the Calgary Health Region, 25% were admitted to non-cardiology services. These patients had worse outcomes, despite adjustment for baseline risk factor differences. Although many patients were appropriately admitted to non-cardiology services, the low use of investigations and secondary prevention medications may contribute to poorer patient outcome. Further research is required to identify process of care strategies to improve outcomes and lessen the burden of illness for patients and the health care system.

Background: "Gender" reflects social norms for women and men, whereas "sex" defines biological characteristics. Gender-related characteristics explain some differences in access to care for premature acute coronary syndrome (ACS); whether they are associated with cardiovascular outcomes is unknown., Objectives: This study estimated associations between gender and sex with recurrent ACS and major adverse cardiac events (MACE) (e.g., ACS, cardiac mortality, revascularization) over 12 months in patients with ACS., Methods: We studied 273 women and 636 men age 18 to 55 years from GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: from bench to beyond-Premature Acute Coronary SYndrome), a prospective observational cohort study, who were hospitalized for ACS between January 2009 and April 2013. Gender-related characteristics (e.g., social roles) were assessed using a self-administered questionnaire, and a composite measure of gender was derived. Outcomes included recurrent ACS and MACE over 12 months., Results: Feminine roles and personality traits were associated with higher rates of recurrent ACS and MACE compared with masculine characteristics. This difference persisted for recurrent ACS, after multivariable adjustment (hazard ratio from score 0 to 100: 4.50; 95% confidence interval: 1.05 to 19.27), and was a nonstatistically significant trend for MACE (hazard ratio: 1.54; 95% confidence interval: 0.90 to 2.66). A possible explanation is increased anxiety, the only condition that was more prevalent in patients with feminine characteristics and that rendered the association between gender and recurrent ACS nonstatistically significant (hazard ratio: 3.56; 95% confidence interval: 0.81 to 15.61). Female sex was not associated with outcomes post-ACS., Conclusions: Younger adults with ACS with feminine gender are at an increased risk of recurrent ACS over 12 months, independent of female sex., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

People of South Asian (SA) descent are particularly susceptible to acute coronary syndromes (ACS). Yet, little information exists regarding their overall prognosis. The purpose of this study was to compare short- and long-term clinical outcomes of SA and European Canadians admitted with an ACS. Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease registry, 63,393 patients with ACS were reviewed (January 1999 to March 2012). After excluding Chinese patients, 1,825 SAs were compared with 60,791 European Canadians. Both groups were propensity matched, and outcomes were compared. Adjustment was performed using a 3:1 propensity matching technique. Adjusted 30-day and 1-year mortality rates were similar between SA and European patients with ACS (2.6% vs 2.7%, p = 0.93; 5.0% vs 4.8%, respectively, p = 0.75). Repeat angiography did not differ (9.9% vs 9.2%, p = 0.35), yet repeat revascularization within 1 year was greater in SA patients (9.8% vs 7.6%, p <0.01). Improved long-term survival (median 64 months, interquartile range 66 months) was noted with SA patients (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.71 to 0.95). In particular, long-term survival was observed in SA patients receiving coronary artery bypass grafting (HR 0.75, 95% CI 0.52 to 1.08) and percutaneous coronary intervention (HR 0.75, 95% CI 0.59 to 0.96). In conclusion, SA patients treated with revascularization appear to have improved long-term survival after ACS, compared with European Canadians. As such, clinicians should be cognitive of ethnic-based outcomes when determining therapeutic strategies in patient management., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Limited data exist as to the relative contribution of sex and gender on health-related quality of life (HRQL) among patients with acute coronary syndrome (ACS). This study aims to evaluate the effect of sex and gender-related variables on long-term HRQL among young adults with ACS., Methods and Results: GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: from bench to beyond-Premature Acute Coronary SYndrome) is a multicenter, prospective cohort study (January 2009 to August 2013) of adults aged 18 to 55 years, hospitalized with ACS. HRQL was measured at baseline, 1, 6, and 12 months using the Short Form-12 and Seattle Angina Questionnaire (SAQ) among 1213 patients. Median age was 49 years. Women reported worse HRQL than men over time post-ACS, both in terms of physical and mental functioning. Gender-related factors were more likely to be predictors of HRQL than sex. Femininity score, social support, and housework responsibility were the most common gender-related predictors of HRQL at 12 months. We observed an interaction between female sex and social support (β=0.44 [95% confidence interval, 0.01, 0.88]; P=0.047) for the physical limitation subscale of the SAQ., Conclusions: Young women with ACS report significantly poorer HRQL than young men. Gender appears to be more important than sex in predicting long-term HRQL post-ACS. Specific gender-related factors, such as social support, may be amenable to interventions and could improve the HRQL of patients with premature ACS., (© 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Frailty is superior to chronological age as a predictor of outcome. The Edmonton Frail Scale (EFS) is a simple valid measure of frailty, covering multiple important domains, with scores ranging from 0 (not frail) to 17 (very frail). The purpose of this pilot study was to assess the EFS in a group of elderly patients with acute coronary syndrome (ACS)., Methods: The EFS was administered to 183 consecutive patients with ACS aged ≥ 65 years admitted to a single centre in Edmonton, Alberta, Canada., Results: Scores ranged from 0-13. Patients with higher EFS scores were older, with more comorbidities, longer lengths of stay (EFS 0-3: mean, 7.0 days; EFS 4-6: mean, 9.7 days; and EFS ≥ 7: mean, 12.7 days; P = 0.03), and decreased procedure use. Crude mortality rates at 1 year were 1.6% for EFS 0-3, 7.7% for EFS 4-6, and 12.7% for EFS ≥ 7 (P = 0.05). After adjusting for baseline risk differences using a "burden of illness" score, the hazard ratio for mortality for EFS ≥ 7 compared with EFS 0-3 was 3.49 (95% confidence interval [CI], 1.08-7.61; P = 0.002)., Conclusions: The EFS is associated with increased comorbidity, longer lengths of stay, and decreased procedure use. After adjustment for burden of illness, the highest frailty category is independently associated with mortality in elderly patients with ACS. Further work is needed to determine whether the use of a validated frailty instrument would better delineate medical decision making in this important, often disadvantaged population., (Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Importance: Little is known about whether sex differences in acute coronary syndrome (ACS) presentation exist in young patients and what factors determine absence of chest pain in ACS presentation., Objectives: To evaluate sex differences in ACS presentation and to estimate associations between sex, sociodemographic, gender identity, psychosocial and clinical factors, markers of coronary disease severity, and absence of chest pain in young patients with ACS., Design, Setting, Participants: We conducted a prospective cohort study of 1015 patients (30% women) 55 years or younger, hospitalized for ACS and enrolled in the GENESIS PRAXY (Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary Syndrome) study (January 2009-September 2012)., Main Outcomes and Measures: The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey was administered during hospitalization., Results: The median age for both sexes was 49 years. Women were more likely to have non-ST-segment elevation myocardial infarction (37.5 vs 30.7; P = .03) and present without chest pain compared with men (19.0% vs 13.7%; P = .03). Patients without chest pain reported fewer symptoms overall and no discernable pattern of non-chest pain symptoms was found. In the multivariate model, being a woman (odds ratio [OR], 1.95 [95% CI, 1.23-3.11]; P = .005) and tachycardia (OR, 2.07 [95% CI, 1.20-3.56]; P = .009) were independently associated with ACS presentation without chest pain. Patients without chest pain did not differ significantly from those with chest pain in terms of ACS type, troponin level elevation, or coronary stenosis., Conclusions and Relevance: Chest pain was the most common ACS symptom in both sexes. Although women were more likely to present without chest pain than men, absence of chest pain was not associated with markers of coronary disease severity. Strategies that explicitly incorporate assessment of common non-chest pain symptoms need to be evaluated.

Background: Although ACC/AHA guidelines recommend a low threshold for catheterization after coronary artery bypass surgery (CABG), in clinical practice repeat revascularization often appears unfeasible and data on outcomes are scarce., Methods: Using APPROACH, a clinical data collection and outcome monitoring initiative in Alberta, Canada, we analyzed nonemergency repeat catheterization, revascularization, and mortality rates of all patients with previous CABG, grouped by indication (acute coronary syndromes [ACS], stable angina [SA]) and compared to those of the cohort without previous CABG., Results: Of 7,127 patients, 31.5%, and 11% received percutaneous revascularization (PCI), or reoperation, respectively. Significantly more post-CABG patients were managed medically as compared with the overall APPROACH cohort of coronary disease patients (57.5% vs. 41.5%-P < 0.001). Post CABG patients with ACS received PCI more often than those with SA (36.4% vs. 24.8%). PCI was associated with improved both non-adjusted and adjusted mortality by 22 and 19%, respectively (P < 0.001) during a follow-up of up to 14 years. Patients with diabetes had a higher mortality rate than those without at 1-, 5-, and 10-year follow-up in every treatment group. However PCI was associated with a similar improvement in mortality (HR: 0.76 [95% SD: 0.65-0.90]) in diabetic patients (HR: 0.85 [95% SD: 0.75-0.96]) when compared to medical management., Conclusion: Significantly fewer post-CABG patients received repeat revascularization than all-comers however; PCI was associated with improved mortality in both the diabetic and the nondiabetic patient population. These findings support the practice of attempting revascularization in post-CABG patients, particularly in those with an ACS., (Copyright © 2012 Wiley Periodicals, Inc.)

At least implicitly, most clinical decisions represent an integration of disease and treatment-based risk assessments. Often, as is the case with acute coronary syndrome (ACS), these decisions need to be made quickly at a time when data elements are limited, and published risk models are very useful in clarifying time-dependent determinants of risk. The present review emphasizes the value of explicit risk assessment and reinforces the fact that patients at highest risk are often those most likely to benefit from newer and more invasive therapies. Suggested ways to incorporate published ACS risk models into clinical practice are included. In addition, the need to adopt a longer-term view of risk in ACS patients is stressed, with particular regard to the important role of heart failure prediction and treatment.

Increasing evidence suggests that there are sex/gender differences in the presentation and prodromal symptoms of acute coronary syndrome (ACS). The purpose of this pilot study was to identify sex differences in the prodromal symptoms of ACS using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS). Telephone surveys using the MAPMISS were conducted between 4 and 6 months after the ACS event. Seventy-six patients (24 women) participated in the study. The women generally reported higher prodromal scores. Moreover, scores demonstrated differences in prodromal symptoms based on menopausal status. The premenopausal and perimenopausal women reported a greater number and higher frequency of symptoms compared with the men and menopausal women. The results of this study suggest that both men and women report nontraditional prodromal symptoms of ACS. In addition, there appears to be a difference in the frequency and number of symptoms reported based on menopausal status.

Purpose: The Seattle Angina Questionnaire (SAQ) is a widely used patient-reported measure of health status in patients with coronary artery disease. Comparisons of SAQ scores amongst population groups and over time rely on the assumption that its factorial structure is invariant. This study evaluates the measurement invariance of the SAQ across different demographic and clinical groups and over time. Methods: Data were obtained from the Alberta Provincial Project on Outcome Assessment in Coronary Heart Disease registry, a registry of patients who received coronary angiogram in Alberta, Canada. The study cohort consists of adult patients who completed the paper-based version of the 16-item Canadian version of the SAQ (SAQ-CAN) 2 weeks and 1-year post-coronary angiogram between 2009 and 2016. Multi-group confirmatory factor analysis was used to assess configural, weak, strong, and strict measurement invariance across age groups, sex, angina type, treatment, and over time. Model fit was assessed using the comparative fit index and root mean square error of approximation. Results: Of the 8101 patients included in these analysis, 1300 (16.1%) were at least 75 years old, while 1755 (21.7%) were female, 5154 (63.6%) were diagnosed with acute coronary syndrome, 1177 (14.5%) received coronary artery bypass graft treatment, and 3279 had complete data on the SAQ-CAN at both occasions. There was evidence of strict invariance across age, sex, and angina type, and treatment groups, but partial strict invariance was established over time. Conclusion: SAQ-CAN can be used to compare the health status of coronary artery disease patients across population groups and over time. [ABSTRACT FROM AUTHOR]

A plethora of research has focused on the importance of seeking timely treatment in the event of an acute coronary syndrome. However, little attention has been given to symptom presentation in acute coronary syndromes, specifically among persons of South Asian descent. South Asians are of particular importance, as they have the highest burden of cardiovascular disease among any other ethnic group. A detailed analysis of typical versus atypical, location, characteristics, and intensity of symptoms in acute coronary syndromes is provided. The literature suggests that persons of South Asian descent are more likely to present with atypical symptoms, whereas Caucasian males typically present with classical symptoms. Further research is required and critical to creating awareness among health practitioners when considering differentials and timely treatment in acute coronary syndromes among South Asians. [ABSTRACT FROM AUTHOR]

Abstract: Objective: In-stent restenosis (ISR) remains an important problem following percutaneous coronary intervention (PCI). Although it is generally believed that patients with ISR present with stable angina, this has not been well characterized. The aim of this study was to define the incidence, predictors, timing and clinical presentation of patients with ISR requiring repeat catheterization. Design: Using a multiregion prospective database which captures all patients undergoing cardiac catheterization and revascularization in the Province of Alberta, Canada, consecutive bare metal stent (BMS) implantations from January 1, 1998 to December 31, 2002 were analyzed. All patients with a repeat angiogram within one year of the index PCI were reviewed for evidence of clinical-ISR (CISR), defined as ISR as the cause for clinical presentation at angiography. Results: Of the 12,492 consecutive PCI patients reviewed, 2521 had repeat angiography and 744 patients (6.0%) had CISR by study definition. The mean time to repeat angiography in CISR patients was 5.4±2.7 months and multivariate analysis identified female gender, diabetes mellitus, and prior PCI as predictors. The majority of patients presented with an acute coronary syndrome: 52.2% unstable angina/non-ST elevation myocardial infarction and 18.5% ST elevation myocardial infarction. Only 25.3% presented with stable exertional angina. Conclusion: Although the incidence of CISR within one year after BMS was relatively low, the recurrent clinical event in the majority of cases was a high-risk coronary syndrome. Thus, careful consideration of the risks of ISR to a specific patient against the cost implications of novel and expensive means to decrease its occurrence is required. [Copyright &y& Elsevier]