30-day Cardiovascular Events Research Articles

Perioperative β-blockade (Pobble) for patients undergoing infrarenal vascular surgery: Results of a randomized double-blind controlled trial

To assess whether a pragmatic policy of perioperative beta-blockade, with metoprolol, reduced the 30-day cardiovascular morbidity and mortality and reduced the length of hospital stay in average patients undergoing infrarenal vascular surgery. This was a double-blind randomized placebo-controlled trial that occurred in vascular surgical units in four UK hospitals. Participants were 103 patients without previous myocardial infarction who had infrarenal vascular surgery between July 2001 and March 2004. Interventions were oral metoprolol (50 mg twice daily, supplemented by intravenous doses when necessary) or placebo from admission until 7 days after surgery. Holter monitors were kept in place for 72 hours after surgery. Eighty men and 23 women (median age, 73 years) were randomized, 55 to metoprolol and 48 to placebo, and 97 (94%) underwent surgery during the trial. The most common operations were aortic aneurysm repair (38%) and distal bypass (29%). Intraoperative inotropic support was required in 64% and 92% of patients in the placebo and metoprolol groups, respectively. Within 30 days, cardiovascular events occurred in 32 patients, including myocardial infarction (8%), unstable angina (9%), ventricular tachycardia (19%), and stroke (1%). Four (4%) deaths were reported. Cardiovascular events occurred in 15 (34%) and 17 (32%) patients in the placebo and metoprolol groups, respectively (unadjusted relative risk, 0.94; 95% confidence interval, 0.53-1.66; adjusted [for age, sex, statin use, and aortic cross-clamping] relative risk, 0.87; 95% confidence interval, 0.48-1.55). Time from operation to discharge was reduced from a median of 12 days (95% confidence interval, 9-19 days) in the placebo group to 10 days (95% confidence interval, 8-12 days) in the metoprolol group (adjusted hazard ratio, 1.71; 95% confidence interval, 1.09-2.66; P < .02). Myocardial ischemia was evident in a high proportion (one third) of the patients after surgery. A pragmatic regimen of perioperative beta-blockade with metoprolol did not seem to reduce 30-day cardiovascular events, but it did decrease the time from surgery to discharge.

Evaluation of a Clinical Decision Rule for Young Adult Patients with Chest Pain

Objectives: The authors sought to validate a clinical decision rule that young adult (younger than 40 years) chest pain patients without known cardiac disease who had either no cardiac risk factors and/or a normal electrocardiogram (ECG) are at low risk (<1%) for acute coronary syndromes (ACS) and 30-day adverse cardiovascular (CV) events. Methods: A prospective cohort study of patients 24–39 years old who received an ECG for chest pain from July 1999 to March 2002 were included. Cocaine users were excluded. Data collection was structured at presentation, hospital course was followed daily, and 30-day follow-up was obtained by telephone. The main outcome was 30-day adverse CV events (death, acute myocardial infarction, percutaneous intervention, and coronary artery bypass graft). Descriptive statistics were used. Results: Of 4,492 visits for chest pain, 1,023 met criteria. Patients were most often female (61%) and African American (73%). Ninety-eight percent were available for 30-day follow-up. The overall risks of ACS and 30-day adverse CV events were 5.4% and 2.2%, respectively, in our entire cohort. For patients with no cardiac history and no cardiac risk factors, the risk of ACS and 30-day adverse CV events was 1.8%. The risk in patients with no cardiac history and a normal ECG was 1.3%. Patients with no cardiac history, no cardiac risk factors, and a normal ECG had a risk of 1.0%. A modified clinical decision rule found that in young adult patients without a known cardiac history, either no classic cardiac risk factors or a normal ECG, and initially normal cardiac marker studies, the risk of ACS was also extremely low (0.14%) and there were no adverse CV events at 30-day follow-up (95% confidence interval = 0.1% to 0.2%). Conclusions: A modified clinical decision rule described a group of patients with a 0.14% risk of ACS that was free from 30-day adverse CV events.

Impact of stress testing on 30-day cardiovascular outcomes for low-risk patients with chest pain admitted to floor telemetry beds

The role of immediate stress testing in low-risk patients with a potential acute coronary syndrome has not been rigorously evaluated with respect to impact on 30-day cardiovascular events. We evaluated the impact of inpatient, outpatient, or no stress testing (ETT) on 30-day cardiovascular outcomes. We performed a prospective cohort study in which consecutive patients with chest pain were admitted to a non-intensive-care telemetry bed over 16 months. Patients were identified in the ED, followed daily through hospitalization, and contacted by telephone at 30 days. Patients were excluded if they were admitted to the coronary care unit, died during hospitalization, sustained an acute myocardial infarction (AMI), or received cardiac catheterization before ETT. Patients were stratified according to whether they received an ETT as an inpatient, outpatient, or no ETT. Main outcomes were 30-day cardiac death, AMI, percutaneous interventions (PCI), and coronary artery bypass graft surgery (CABG). Data are presented as percentages with 95% confidence intervals (CI) for main outcomes. A total of 832 patients were admitted 962 times. A total of 205 patients (21%) received an in-house ETT. Seventy-four patients (10%) without an inpatient ETT received an outpatient ETT. At baseline, the groups were similar with respect to likelihood of ischemia based on mean ACI-TIPI score and Goldman risk score. A total of 98% of patients had 30-day follow-up. The cardiovascular outcomes (with 95% confidence interval) for patients with inpatient ETT versus outpatient ETT versus no ETT were as follows: death, 0% (0–1.5%) vs 0% (0–4.1%) vs1% (0.3–1.7%); AMI, 1% (0.1–2.4%) vs 1.4% (0.1–4.1%) vs 0.3% (0.1–0.7%); PCI, 0.5% (0.1–1.5%) vs 1.3% (0.1–4.1%) vs 0% (0–0.4%); and CABG, 0.5% (0.1–1.5%) vs 0% (0–4.1%) vs 0.2% (0.1–0.4%). There was no statistical difference in 30-day cardiovascular outcomes among patients who received inpatient, outpatient, or no ETT within 30 days. This suggests that patients with chest pain who are admitted to non-intensive-care telemetry (or observation unit) beds might not need stress testing before hospital release.

Treatment of coronary stent thrombosis with rheolytic thrombectomy: Results from a multicenter experience

The objective of this study was to assess the feasibility, efficacy, and safety of rheolytic thrombectomy (RT) for treatment of coronary stent thrombosis. Stent thrombosis is an infrequent but potentially devastating complication. Conventional treatment with balloon angioplasty and/or thrombolysis has yielded suboptimal results. RT was used to treat 18 patients (mean age, 62 +/- 8 years; 72% male) with in-stent thrombosis (mean time to stent thrombosis, 2.4 +/- 1.8 days). Device success, procedure success, in-hospital and 30-day major cardiovascular events (MACE) were assessed in the hospital and at 30 days. Device success was obtained in 94% and procedure success was achieved in 100% of patients. Following RT, 11 patients underwent balloon angioplasty and 7 patients received additional stents. TIMI 3 coronary flow was obtained in 94.4% and all (100%) patients achieved either TIMI 2 or 3 coronary flow. The angiographic thrombus area decreased from 113.7 +/- 79 to 5.5 +/- 5.7 mm(2) after RT, and to 0.9 +/- 2.1 mm(2) (P < 0.001) after final treatment. Procedural complications were limited to transient no-reflow in five patients. Only one patient evolved a Q-wave MI. At 30 days of follow-up, no patients suffered death, emergent bypass surgery, or stroke. Our data suggest that the adjunctive use of rheolytic thrombectomy offers improved outcomes compared to prior results of intervention after coronary stent thrombosis and should be strongly considered as a treatment option for this complication.

Young adults with chest pain.

Most studies of emergency department chest pain patients exclude patients&#x003C;30-40 years old. As a result, the clinical course of these patients is poorly described. This study's objective was to identify the clinical characteristics, hospital course, and 30-day outcomes of ED chest pain patients&#x003C;40 years old. The hypothesis was that patients&#x003C;40 years old without a cardiac history and with normal electro-cardiograms (ECGs) or no cardiac risk factors would be at a&#x003C;1 per cent risk for acute coronary syndromes (ACSs) and 30-day adverse cardiovascular (CV) events.

Characteristics and outcomes of young adults who present to the emergency department with chest pain.

Most studies of emergency department (ED) chest pain patients exclude patients <30-40 years old. As a result, the clinical course of these patients is poorly described. To study the clinical characteristics, hospital course, and 30-day outcomes of ED chest pain patients <40 years old. The hypothesis was that patients <40 years old without a cardiac history and with normal electro-cardiograms (ECGs) or no cardiac risk factors would be at a <1% risk for acute coronary syndromes (ACSs) and 30-day adverse cardiovascular (CV) events. This was a prospective cohort study of non-cocaine-using ED patients, 24-39 years old, who received an ECG for chest pain between July 9, 1999, and October 23, 2000. Structured data collection at presentation included demographics, chest pain description, history, laboratory, and ECG data. Hospital course was followed daily. Thirty-day follow-up was performed by telephone. The main outcomes were discharge diagnosis and 30-day adverse CV events [acute myocardial infarction (AMI), death, percutaneous intervention (PCI), or coronary artery bypass grafting (CABG)]. A total of 487 patients presented 527 times and comprised the study group. Patients were most often 30-39 years old (71%), female (60%), and African-American (73%). Thirty-two percent were admitted. Five hundred seven of 527 patient visits (96%) had 30-day follow-up. Patients had the following cardiac risk factors: tobacco, 37%; hypertension, 22%; family history, 19%; diabetes mellitus, 6%; cholesterol, 6%; prior angina, 3%; known coronary artery disease, 3%; and prior AMI, 2%. Patients usually had unremarkable ECGs (61% normal, 98% nonischemic). Overall, 11 of 527 patients had adverse CV events (2.1%; 95% CI = 0.9% to 3.3%): 8 AMIs (1.5%), 4 deaths (0.8%), 5 PCIs (0.9%), and no CABG. Twenty-five patients had a final diagnosis of ACS (4.7%; 95% CI = 2.9% to 6.5%). The incidence of ACS in the 210 patients without a cardiac history and without cardiac risk factors was 0.5% (95% CI = 0% to 1.4%). At 30 days, none of these 210 patients had AMI, PCI, CABG, or death (0%, 95% CI = 0% to 1.4%). The incidence of ACS in the 312 patients with normal ECGs and a negative cardiac history was 0.3% (95% CI = 0% to 0.9%). At 30 days, there was no AMI, PCI, or CABG in these 312 patients, and one patient with metastatic cancer died (adverse CV event 0.3%, 95% CI = 0% to 0.9%). Although young patients, as a whole, have a 4.7% risk of ACSs and a 2.1% risk of adverse CV events at 30 days, those without known cardiac disease or any cardiac risk factors had a <1% risk of ACSs and were free from adverse CV events over 30 days. Likewise, young patients without a cardiac history and with a normal ECG had a <1% risk of ACSs and adverse CV events at 30 days. It may be reasonable to expedite outpatient management and limit unnecessary admissions in these cohorts.