28 Feb 09
Posted in Coronary artery disease, Pre-operatie evaluation at 22:40 by Laci
By W E Boden, R A O’Rourke, K K Teo, P M Hartigan, D J Maron, W J Kostuk et al for the COURAGE Trial Research Group
N Engl J Med 2007;356:1503-1516
In patients with stable coronary artery disease, it remains unclear whether an initial management strategy of percutaneous coronary intervention (PCI) with intensive pharmacologic therapy and lifestyle intervention (optimal medical therapy) is superior to optimal medical therapy alone in reducing the risk of cardiovascular events.
Methods
We conducted a randomized trial involving 2287 patients who had objective evidence of myocardial ischemia and significant coronary artery disease at 50 U.S. and Canadian centers. Between 1999 and 2004, we assigned 1149 patients to undergo PCI with optimal medical therapy (PCI group) and 1138 to receive optimal medical therapy alone (medical-therapy group). The primary outcome was death from any cause and nonfatal myocardial infarction during a follow-up period of 2.5 to 7.0 years (median, 4.6).
Results
There were 211 primary events in the PCI group and 202 events in the medical-therapy group. The 4.6-year cumulative primary-event rates were 19.0% in the PCI group and 18.5% in the medical-therapy group (hazard ratio for the PCI group, 1.05; 95% confidence interval [CI], 0.87 to 1.27; P=0.62). There were no significant differences between the PCI group and the medical-therapy group in the composite of death, myocardial infarction, and stroke (20.0% vs. 19.5%; hazard ratio, 1.05; 95% CI, 0.87 to 1.27; P=0.62); hospitalization for acute coronary syndrome (12.4% vs. 11.8%; hazard ratio, 1.07; 95% CI, 0.84 to 1.37; P=0.56); or myocardial infarction (13.2% vs. 12.3%; hazard ratio, 1.13; 95% CI, 0.89 to 1.43; P=0.33).
Conclusions
As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy.
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20 Feb 09
Posted in Regional blocks at 5:58 by Laci
By T M Cook, D Counsell, J A W Wildsmith on behalf of The Royal College of Anaesthetists Third National Audit Project
BJA 2009;102:179-190
Serious complications of central neuraxial block (CNB) are rare. Limited information on their incidence and impact impedes clinical decision-making and patient consent. The Royal College of Anaesthetists Third National Audit Project was designed to inform this situation.
Methods
A 2 week national census estimated the number of CNB procedures performed annually in the UK National Health Service. All major complications of CNBs performed over 1 yr (vertebral canal abscess or haematoma, meningitis, nerve injury, spinal cord ischaemia, fatal cardiovascular collapse, and wrong route errors) were reported. Each case was reviewed by an expert panel to assess causation, severity, and outcome. ‘Permanent’ injury was defined as symptoms persisting for more than 6 months. Efforts were made to validate denominator (procedures performed) and numerator (complications) data through national databases.
Results
The census phase produced a denominator of 707 455 CNB. Eighty-four major complications were reported, of which 52 met the inclusion criteria at the time they were reported. Data were interpreted ‘pessimistically’ and ‘optimistically’. ‘Pessimistically’ there were 30 permanent injuries and ‘optimistically’ 14. The incidence of permanent injury due to CNB (expressed per 100 000 cases) was ‘pessimistically’ 4.2 (95% confidence interval 2.9–6.1) and ‘optimistically’ 2.0 (1.1–3.3). ‘Pessimistically’ there were 13 deaths or paraplegias, ‘optimistically’ five. The incidence of paraplegia or death was ‘pessimistically’ 1.8 per 100 000 (1.0–3.1) and ‘optimistically’ 0.7 (0–1.6). Two-thirds of initially disabling injuries resolved fully.
Conclusions
The data are reassuring and suggest that CNB has a low incidence of major complications, many of which resolve within 6 months.
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16 Feb 09
Posted in Echocardiography, Heart failure/Cardiogenic shock at 0:43 by Laci
By J Grewal, R B McCully, G C Kane, C Lam, P A Pellikka
JAMA. 2009;301:286-294
Limited information exists regarding the role of left ventricular function in predicting exercise capacity and impact on age- and sex-related differences.
Objectives
To determine the impact of measures of cardiac function assessed by echocardiography on exercise capacity and to determine if these associations are modified by sex or advancing age.
Design
Cross-sectional study of patients undergoing exercise echocardiography with routine measurements of left ventricular systolic and diastolic function by 2-dimensional and Doppler techniques. Analyses were conducted to determine the strongest correlates of exercise capacity and the age and sex interactions of these variables with exercise capacity.
Setting
Large tertiary referral center in Rochester, Minnesota, in 2006.
Participants
Patients undergoing exercise echocardiography using the Bruce protocol (N = 2867). Patients with echocardiographic evidence of exercise-induced ischemia, ejection fractions lower than 50%, or significant valvular heart disease were excluded.
Main outcome measure
Exercise capacity in metabolic equivalents (METs).
Results
Diastolic dysfunction was strongly and inversely associated with exercise capacity. Compared with normal function, after multivariate adjustment, those with moderate/severe resting diastolic dysfunction (–1.30 METs; 95% confidence interval [CI], –1.52 to –0.99; P < .001) and mild resting diastolic dysfunction (–0.70 METs; 95% CI, –0.88 to –0.46; P < .001) had substantially lower exercise capacity. Variation of left ventricular systolic function within the normal range was not associated with exercise capacity. Left ventricular filling pressures measured by resting E/e’ of 15 or greater (–0.41 METs; 95% CI, –0.70 to –0.11; P = .007) or postexercise E/e’ of 15 or greater (–0.41 METs; 95% CI, –0.71 to –0.11; P = .007) were similarly associated with a reduction in exercise capacity, each in separate multivariate analyses. Individuals with impaired relaxation (mild dysfunction) or resting E/e’ of 15 or greater had a progressive increase in the magnitude of reduction in exercise capacity with advancing age (P < .001 and P = .02, respectively). Other independent correlates of exercise capacity were age (unstandardized β coefficient, –0.85 METs; 95% CI, –0.92 to –0.77, per 10-year increment; P < .001), female sex (–1.98 METs; 95% CI, –2.15 to –1.84; P < .001), and body mass index greater than 30 (–1.24 METs; 95% CI, –1.41 to –1.10; P < .001).
Conclusion
In this large cross-sectional study of those referred for exercise echocardiography and not limited by ischemia, abnormalities of left ventricular diastolic function were independently associated with exercise capacity.
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14 Feb 09
Posted in Inotropic support at 6:55 by Laci
BY L Tritapepe, V De Santis, D Vitale, F Guarracino, F Pellegrini, P Pietropaoli and M. Singer
BJA 2009;102:198-204
The calcium sensitizer levosimendan has anti-ischaemic effects mediated via the opening of sarcolemmal and mitochondrial ATP-sensitive potassium channels. These properties suggest potential application in clinical situations where cardioprotection would be beneficial, such as cardiac surgery. We thus decided to investigate whether pharmacological pre-treatment with levosimendan reduces intensive care unit (ICU) length of stay in patients undergoing elective myocardial revascularization under cardiopulmonary bypass.
Methods
One hundred and six patients undergoing elective coronary artery bypass grafting were randomly assigned in a double-blind manner to receive levosimendan or placebo. Levosimendan (24 µg kg–1) or placebo was administered as a slow i.v. bolus over a 10 min period before the initiation of bypass.
Results
Tracheal intubation time and the length of ICU stay were significantly reduced in the levosimendan group (P<0.01). The number of patients needing inotropic support for >12 h was significantly higher in the control group (18.0% vs 3.8%; P=0.021). Compared with control patients, levosimendan-treated patients had lower postoperative troponin I concentrations (P<0.0001) and a higher cardiac power index (P<0.0001).
Conclusions
Pre-treatment with levosimendan in patients undergoing surgical myocardial revascularization resulted in less myocardial injury, a reduction in tracheal intubation time, less requirement for inotropic support, and a shorter length of ICU stay.
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