Noncardiac Vascular Disease Research Articles

Relation of the pattern of diastolic augmentation during a course of enhanced external counterpulsation (EECP) to clinical benefit (from the International EECP Patient Registry [IEPR

E external counterpulsation (EECP) is a noninvasive counterpulsation technique that reduces angina and extends time to exercise-induced ischemia in patients with symptomatic stable angina. In addition to relieving myocardial ischemia, EECP is associated with improved quality of life. It uses a sequential inflation of 3 sets of pneumatic cuffs wrapped around the lower extremities. The cuffs are inflated sequentially at the onset of diastole, producing aortic counterpulsation, diastolic augmentation (DA), and increased venous return. At the onset of systole, external pressure in the cuffs is released, producing a decrease in systolic pressure (systolic unloading). These hemodynamic effects are monitored noninvasively by assessing the finger plethysmographic waveforms. A typical course of EECP involves 1 to 2 hours/day for a total of 35 hours of therapy. It has been hypothesized that the sustained benefits of EECP result from effective DA, which promotes coronary collateral formation or recruitment. A previous study has demonstrated that patients who are younger, male, nonsmoking, and without multivessel coronary or noncardiac vascular disease are most likely to have higher DA at the end of an EECP treatment course. Patients with higher DA ratios at the end of EECP tended to have a greater reduction in angina class than those with lower DA ratios, suggesting that clinical benefit from EECP is associated with the magnitude of DA. That initial study was limited by assessing the DA ratios on the final day of EECP therapy. This present analysis further investigates the role of DA in EECP by assessing the impact of DA levels both at the first and last treatment session with EECP.

Does higher diastolic augmentation predict clinical benefit from enhanced external counterpulsation?: Data from the international EECP patient registry (IEPR)

Enhanced external counterpulsation (EECP) has been demonstrated to be an effective treatment for stable angina in patients with coronary disease. The hemodynamic effects of EECP are maximized when the ratio of diastolic to systolic pressure area is in the range of 1.5 to 2.0. It is hypothesized that patients undergoing EECP who are able to achieve higher diastolic augmentation (DA) ratios may derive greater clinical benefit. This study examines the relationship between the DA ratio and clinical outcomes in patients undergoing EECP. We analyzed demographic, noninvasive hemodynamic, and clinical outcome data on 1,004 patients enrolled in the International EECP Patient Registry (IEPR) for treatment of chronic angina between January 1998 and August 1999. Blood pressure waveforms were recorded from finger plethysmography. Six-month clinical outcomes were obtained by telephone interview. At the end of EECP treatment, 370 (37%) patients had a higher DA ratio (defined as > or = 1.5) and 634 (63%) had a lower DA ratio (defined as < 1.5). Factors associated with a lower DA ratio included age > or =65 years (p <0.001), female gender (p < 0.001), left ventricular ejection fraction < 35% (p < 0.05), hypertension (p < 0.01), prior coronary bypass surgery (p < 0.01), noncardiac vascular disease (p < 0.001), multivessel disease (p < 0.01), congestive heart failure (p < 0.01), current smoking (p < 0.01), unsuitability for further revascularization (p < 0.001), and higher baseline angina class (p < 0.001). There were no significant differences regarding diabetes mellitus, prior coronary angioplasty, prior myocardial infarction, or antianginal medication use between patients with higher or lower DA ratios. Based on a multiple logistic regression model, independent predictors of a DA ratio < 1.5 at the end of EECP included current smoking (odds ratio 3.3; 95% confidence intervals 2.0-5.4); multivessel disease (1.7; 1.3-2.3); female gender (2.2; 1.7-3.0); no prior EECP (1.9; 1.1-3.3); noncardiac vascular disease (2.3; 1.7-2.9); age > or = 65 years (1.7; 1.4-2.2), and patients not suitable for revascularization (1.6; 1.2-2.0). By the end of therapy, there were no significant differences in myocardial infarction, revascularization rates, or nitroglycerin use with respect to higher DA ratios. At 6-month follow-up, patients with higher DA had a trend toward a greater reduction in angina class compared with those with lower DA (p = 0.069). There was a significantly higher rate of unstable angina and congestive heart failure in the group not achieving higher augmentation (p < 0.05). Patients who are younger, male, nonsmoking, and without multivessel coronary or noncardiac vascular disease are most likely to have higher DA with EECP. Patients with higher DA tended to have a greater reduction in angina class at 6-month follow-up compared with those with lower DA ratios. There is evidence that higher DA ratios are associated with improved short- or long-term clinical outcomes, suggesting that clinical benefit from EECP is associated with the magnitude of DA.

Patients with non-cardiac vascular disease and chronic angina benefit from enhanced external counterpulsation Subash Bazaz, Elizabeth D. Kennard, Richard Holubkov, Nichole Dwyer, Lawrence Crawford. Cardiovascular Research Institute, UPMC, Pittsburgh, PA, University of Pittsburgh, Pittsburgh, PA

Patients with non-cardiac vascular disease and chronic angina benefit from enhanced external counterpulsation Subash Bazaz, Elizabeth D. Kennard, Richard Holubkov, Nichole Dwyer, Lawrence Crawford. Cardiovascular Research Institute, UPMC, Pittsburgh, PA, University of Pittsburgh, Pittsburgh, PA

Do Interventional Radiologists Pose a Significant Threat to the Practice of Vascular Surgery?

Vascular surgeons have become concerned recently about perceived threats to their practices posed by the growth of interventional radiology. The authors studied nationwide 1996 Medicare Part B procedure data to determine the seriousness of these threats. The national Health Care Financing Administration (HCFA) Physician/Supplier Procedure Summary Master File for 1996 was searched. Two hundred thirteen distinct Current Procedural Terminology (CPT-4) codes were identified for therapeutic surgical and percutaneous interventional procedures performed to treat noncardiac vascular diseases. For each code, determination was made of total volume, specialty of the physician providers, and Medicare Part B reimbursement dollars paid to the providers as professional fees. In view of the conflicts among various specialties over peripheral vascular interventions, the authors also determined the percentages of these procedures performed by radiologists, surgeons, cardiologists, and other physicians. A total of 759,548 noncardiac therapeutic vascular procedures (operations or percutaneous interventions) were performed during 1996 in patients receiving Medicare benefits. Radiologists performed 135,103 (17.8%) of these procedures but received only 10.4% of professional reimbursements. By contrast, surgeons performed 510,871 (67.3%) procedures, but received 78.0% of professional reimbursements. Cardiologists performed 4.7% of procedures and other specialists performed the remaining 10.3%. Radiologists performed 75.5% of percutaneous transluminal angioplasties, the majority of thrombolysis procedures, stent placements, and portal decompression procedures, and approximately half of inferior vena cava interruptions. Cardiologists performed 12.6% of percutaneous transluminal angioplasties, surgeons performed 6.3%, and other specialists performed 5.6%. In terms of overall physician workload and professional reimbursements paid for invasive treatment of all types of noncardiac vascular disease, surgeons predominate and do not appear to be seriously threatened by interventional radiologists. Radiologists perform three-fourths of noncardiac percutaneous transluminal angioplasties and a majority of other percutaneous interventional therapies for vascular disease, but some inroads have been made by cardiologists and surgeons, particularly the former.

The New Living Heart

The end of this millennium will be remembered for many things. Chief among them will be that this was the era of the consumer, whose needs helped to ignite and continue to fuel an explosive information age. Slogans such as “An educated consumer is our best customer” epitomize the paradigm shift from gullery to tutelage in contemporary marketing, although some may view the latter as simply a more sophisticated form of mendacity. In part, the new strategy is a response to advances in communication technology coupled with the compulsions of discerning consumers. Parallel transitions have occurred in medicine, now known as the healthcare industry, in which the term client has become synonymous with patient, the concept of population served has been replaced by the number of lives covered, and in which a practice may not survive without an elaborate Web site or home page. The patient is now the commodity. The buyer’s market in medicine has stimulated efforts at outreach and information transfer at unprecedented levels. Medical consumers have become efficient search engines. They can access the latest medical information on-line, they are intrigued by watching live operations on the Nova channel, and they are able to read the results of research studies in the New York Times, often long before medical journals ever hit our “in” boxes. With …

Intensity of Testing and Invasive Procedures-Reply

In Reply. —Whether patients with known or suspected noncardiac vascular disease should have evaluation for coronary artery disease is an important clinical question. Patients with peripheral vascular disease are at a high risk for fatal and nonfatal cardiac events. 1 While significant work has been done concerning the preoperative cardiac evaluation in patients undergoing noncardiac vascular surgery, 2 debate continues about how to manage these patients even after the extent of their disease is known. 3 Finally, there is no consensus about whether case finding and risk stratification is either appropriate or costeffective in the population being evaluated in a vascular laboratory. Thus, the question of the use of exercise testing raised by Dr Crouse and colleagues is relevant. Unfortunately, our data could not allow us to discern between those undergoing testing for symptoms and those undergoing testing for case finding and stratification. However, the use of exercise testing in the setting