29 Aug 07
Posted in Heart failure/Cardiogenic shock, Pacemaker - ICD at 17:12 by Laci
By JA Ezekowitz, BH Rowe, DM Dryden, N Hooton, B Vandermeer, C Spooner and FA McAlister
Ann Intern Med. 2007;147:251-262
Patients with left ventricular (LV) systolic dysfunction have an increased risk for ventricular arrhythmias.
Purpose
To summarize the evidence about benefits and harms of implantable cardioverter defibrillators (ICDs) in adult patients with LV systolic dysfunction.
Data Sources
A search of electronic databases (including MEDLINE, EMBASE, Cochrane Central, and U.S. Food and Drug Administration reports) from 1980 through April 2007, not limited by language of publication, was supplemented by hand searches and contact with study authors and device manufacturers.
Study Selection
Two reviewers independently selected studies on the basis of prespecified criteria. They selected 12 randomized, controlled trials (RCTs) (8516 patients) that reported on mortality and 76 observational studies (96 951 patients) that examined safety or effectiveness.
Data Extraction
Data were extracted in duplicate and independently by 2 reviewers.
Data Synthesis
In adult patients with LV systolic dysfunction, 86% of whom had New York Heart Association class II or III symptoms, ICDs reduced all-cause mortality by 20% (95% CI, 10% to 29%) in the RCTs and by 46% (CI, 32% to 57%) in the observational studies. Death associated with implantation of ICDs occurred during 1.2% (CI, 0.9% to 1.5%) of procedures. The frequency of postimplantation complications per 100 patient-years included 1.4 (CI, 1.2 to 1.6) device malfunctions, 1.5 (CI, 1.3 to 1.8) lead problems, and 0.6 (CI, 0.5 to 0.8) site infection. Rates of inappropriate discharges per 100 patient-years ranged from 19.1 (CI, 16.5 to 22.0) in RCTs to 4.9 (CI, 4.5 to 5.3) in observational studies.
Limitations
Studies were of short duration and infrequently reported nonfatal outcomes. Few studies evaluated dual-chamber ICDs. Lack of individual-patient data prevents identification of subgroup-specific effects.
Conclusions
Implantable cardioverter defibrillators are efficacious in reducing mortality for adult patients with LV systolic dysfunction, and this benefit extends to nontrial populations. Improved risk stratification tools to identify patients who are most likely to benefit from ICD are needed.
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Posted in Echocardiography, General at 12:14 by Laci
By ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR
J Am Coll Cardiol, 2007; 50:187-204
The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE), together with key specialty and subspecialty societies, conducted an appropriateness review for transthoracic and transesophageal echocardiography (TTE/TEE). This review assesses the risks and benefits of TTE and/or TEE for several indications or clinical scenarios and scored them based on a scale of 1 to 9. The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for an echocardiogram is uncertain.
The indications for this review were drawn from common applications or anticipated uses as well as current clinical practice guidelines. Use of TTE/TEE for initial evaluation of structure and function was viewed favorably, while routine repeat testing and general screening uses in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision-making and performance, reimbursement policy, and will help guide future research.
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28 Aug 07
Posted in Anesthesia, BNP, Pre-operatie evaluation at 19:01 by Laci
By BH Cuthbertson, G Card, BL Croal, J McNeilly, GS Hillis
Anaesthesia 2007;62:875–881
B-type natriuretic peptide (BNP) levels predict cardiovascular risk in several settings. We hypothesised that they would identify individuals at increased risk of complications and mortality following major emergency non-cardiac surgery. Forty patients were studied with a primary end-point of a new postoperative cardiac event, and/or development of significant ECG changes, and/or cardiac death. The main secondary outcome was all-cause mortality at 6 months. Pre-operative BNP levels were higher in 11 patients who suffered a new postoperative cardiac event (p = 0.001) and predicted this outcome with an area under the receiver operating characteristic curve of 0.85 (CI = 0.72–0.98, p = 0.001). A pre-operative BNP value > 170 pg.ml-1 has a sensitivity of 82% and a specificity of 79% for the primary end-point. In this small study, pre-operative BNP levels identify patients undergoing major emergency non-cardiac surgery who are at increased risk of early postoperative cardiac events. Larger studies are required to confirm these data.
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21 Aug 07
Posted in Adrenal insufficiency, Sepsis at 18:02 by Laci
By M Mullen, T Ellis, J Marcelin, V Mangolds, K Przyklenk
Acad Emerg Med 2007;14:S187-S188
Introduction
Recent literature suggests that etomidate use in severe sepsis/septic shock patients leads to relative adrenal insufficiency. We hypothesize that etomidate does not contribute to adrenal insufficiency or mortality in this opulation.
Conclusions
Etomidate use may lead to an increase incidence of adrenal insufficiency in intubated severe sepsis/septic shock patients. However, this risk of adrenal insufficiency was not associated with increased mortality.
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