Recent Congestive Heart Failure Research Articles

Risk stratification for isolated tricuspid valve surgery assisted using the Model for End-Stage Liver Disease score

ObjectiveIsolated tricuspid valve surgery is perceived as high-risk. This perception is nurtured by patients who often present with substantial liver dysfunction, which is inappropriately reflected in current surgical risk scores (eg, the Society of Thoracic Surgeons [STS] score has no specific tricuspid model). The Model for End-Stage Liver Disease (MELD) has was developed as a measure for the severity of liver dysfunction. We report scores and outcomes for our patient population. MethodsWe calculated STS, European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (ESII), and MELD scores for all of our patients who received isolated tricuspid valve surgery between 2011 and 2020 (n = 157). We determined the MELD score, stratified patients into 3 groups (MELD <10: low, n = 53; 10 to <20: intermediate, n = 78; ≥20: high, n = 26) and describe associated outcomes. ResultsPatients were 72 ± 10 years old and 43% were male. Mean STS score was 4.9 ± 3.5% and ESII was 7.2 ± 6.6%. Mortality was 8.9% at 30 days and 65% at latest follow-up (95% CI, 51%-76%). Median follow-up was 4.4 years (range, 0-9.7 years). Although ESII and STS score accurately predicted 30-day mortality at low MELD scores (observed to expected [O/E] for ESII score = 0.8 and O/E for STS score = 1.0) and intermediate MELD (O/E for ESII score = 0.7, O/E for STS score = 1.0), mortality was underestimated at high MELD (O/E for ESII score = 3.0, O/E for STS score = 4.7). This subgroup also had higher incidence of new-onset hemodialysis. Besides MELD category, recent congestive heart failure, endocarditis, and hemodialysis were also associated with 30-day mortality. ConclusionsFor isolated tricuspid valve regurgitation, classic surgical risk stratification with STS or ESII scores failed to predict perioperative mortality if there was evidence of severe liver dysfunction. Preoperative MELD assessment might be useful to assist in proper risk assessment for isolated tricuspid valve surgery.

Effects of pimobendan in cats with hypertrophic cardiomyopathy and recent congestive heart failure: Results of a prospective, double-blind, randomized, nonpivotal, exploratory field study.

BackgroundThe benefits of pimobendan in the treatment of congestive heart failure (CHF) in cats with hypertrophic cardiomyopathy (HCM) have not been evaluated prospectively.Hypothesis/ObjectivesTo investigate the effects of pimobendan in cats with HCM and recent CHF and to identify possible endpoints for a pivotal study. We hypothesized that pimobendan would be well‐tolerated and associated with improved outcome.AnimalsEighty‐three cats with HCM and recently controlled CHF: 30 with and 53 without left ventricular outflow tract obstruction.MethodsProspective randomized placebo‐controlled double‐blind multicenter nonpivotal field study. Cats received either pimobendan (0.30 mg/kg q12h, n = 43), placebo (n = 39), or no medication (n = 1) together with furosemide (<10 mg/kg/d) with or without clopidogrel. The primary endpoint was a successful outcome (ie, completing the 180‐day study period without a dose escalation of furosemide).ResultsThe proportion of cats in the full analysis set population with a successful outcome was not different between treatment groups (P = .75). For nonobstructive cats, the success rate was 32% in pimobendan‐treated cats versus 18.2% in the placebo group (odds ratio [OR], 2.12; 95% confidence interval [CI], 0.54‐8.34). For obstructive cats, the success rate was 28.6% and 60% in the pimobendan and placebo groups, respectively (OR, 0.27; 95% CI, 0.06‐1.26). No difference was found between treatments for the secondary endpoints of time to furosemide dose escalation or death (P = .89). Results were similar in the per‐protocol sets. Adverse events in both treatment groups were similar.Conclusions and Clinical ImportanceIn this study of cats with HCM and recent CHF, no benefit of pimobendan on 180‐day outcome was identified.

What should the C ('congestive heart failure') represent in the CHA2 DS2 -VASc score?

What should the C ('congestive heart failure') represent in the CHA2 DS2 -VASc score?

Major Acute Cardiovascular Events After Transurethral Prostate Surgery: A Population-based Analysis

ObjectiveTo test the prevalence and predictors of major acute cardiovascular events (MACE) after transurethral prostate surgery (TPS). Material and methodsThe American College of Surgeons National Surgical Quality Improvement Program database (2011-2016) was queried for patients who underwent transurethral resection of the prostate, photoselective vaporization, or laser enucleation. MACE included: cerebrovascular events, cardiac arrest, myocardial infarction, deep venous thrombosis requiring therapy, and pulmonary embolism episodes occurred up to 30 days after discharge. Univariable and multivariable logistic regression models tested MACE predictors and effect of MACE on perioperative mortality. Within covariates significant at univariable analyses a stepwise selection, based on Akaike Information Criterion values, was performed to fit the most appropriate multivariable model. ResultsOverall 44,939 patients were included in our analyses. Of these 365 (0.8%) had MACE within 30 days after surgery. The strongest MACE predictors were recent congestive heart failure (odds ratio [OR]: 2.1, 95% confidence interval [CI]: 1.2-3.7, P = .007), transfusions (OR: 2.5, 95% CI: 1.5-4.1, P <.001) and preoperative Systemic Inflammatory Response Syndrome or sepsis (OR: 2.6, 95% CI: 1.6-4.2, P <.001). Similarly, inpatient (OR: 2.0, 95% CI: 1.6-2.5, P <.001) and nonelective (OR: 1.5, 95% CI: 1.1-2.1, P = .012) patients experienced higher MACE rates. Perioperative mortality rates were statistical significantly higher in MACE patients (OR: 13.1, 95% CI: 8.2-21.0, P <.001). ConclusionUp to 1% of patients undergoing transurethral prostate surgery experience MACE. MACE are burdened by high mortality rates (up to 14% in MACE patients). Proper patient selection and postoperative monitoring are necessary to reduce MACE incidence and mortality rates.

Preoperative Predictors of Discharge Destination after Endovascular Repair of Abdominal Aortic Aneurysms

There is a paucity of data guiding preoperative counseling on the need for discharge to a facility or nonhome discharge (NHD) following elective endovascular repair of abdominal aortic aneurysms (endovascular aneurysm repair [EVAR]). This study seeks to determine the preoperative predictors of NHD following EVAR in baseline home-dwelling patients and to determine whether NHD is associated with major postdischarge complications and readmission. This retrospective cohort study utilized the National Surgical Quality Improvement Program Vascular Procedure Targeted database to identify elective EVAR cases admitted from home (2011 to 2015). The primary end point was NHD. A multivariable logistic regression model was used to determine predictive preoperative factors for NHD and to determine whether NHD predicted major postdischarge complications and readmission. Overall 6,276 cases were included; 291 (4.6%) required NHD. NHD were more frequently female, anemic, functionally dependent, nonsmokers, had chronic obstructive pulmonary disease, recent congestive heart failure exacerbation, and open baseline wounds. NHD was associated with complex surgery, indicated by operative time more than the median, 2.5hr. Significant predictors for NHD on multivariable analysis included female sex (odds ratio [OR]: 2.2, confidence interval [CI]: 1.7-2.9, P<0.001), octogenarians (OR: 5.7 CI: 2.3-14.1; P<0.001) and nonagenarians (OR: 14.6, CI: 5.4-39.2; P<0.001), dependent functional status (OR: 5.4, CI: 3.3-8.8; P<0.001), preoperative open wound (OR: 3.5, CI: 1.4-8.9; P=0.006), high operative time (OR: 2.7, CI: 2.0-3.6; P<0.001), and hypogastric embolization (OR: 1.6, CI: 1.1-2.1 P=0.022), C-statistic=0.780. On adjusted analysis, NHD did not independently predict major postdischarge complication (OR: 1.0 CI: 0.6-1.9; P=0.875) or unplanned readmission (OR 1.0, CI: 0.6-1.5, P=0.842). Discharge to skilled facility following EVAR can be predicted using preoperative factors. Future studies should seek to validate these findings in a prospective manner. Identifying high-risk patients' NHD can help define expectations and facilitate early referral to skilled facilities that may reduce hospital length of stay, reducing health-care costs.

Sildenafil (ViagraTM): Synthesis Step by Step and its Pharmaceutical Importance in Diabetic Patients with Erectile Dysfunction

Objective: Sildenafil is a selective inhibitor of phosphodiesterase 5 (PDE5) and is the first agent with this mode of action for the treatment of male erectile dysfunction. There has recently been an explosion of interest in sexual dysfunction. Erectile dysfunction (ED) is defined as the persistent inability to achieve and/or maintain an erection sufficient for satisfactory sexual activity. This article aims to discuss in details the commercial synthesis of Sildenafil as published by the Pfizer research group and describe critically the role of Sildenafil in diabetic neuropathic patients with erectile dysfunction.Method: A computer as well as manual search was made to collect the relevant data published in various peer-reviewed journals on ViagraTM.Results: The synthesis of Sildenafil serves as an excellent example of the demands of commercial chemistry. Also, the serendipitous discovery of this drug's positive effect on sexual performance has revolutionized the management of erectile dysfunction. Although the literature is spare, Tadalafil has a longer half-life than Sildenafil and therefore may be recommended as the choice of preference. Contraindications for their use include the use of nitrates, unstable angina, recent myocardial infarction or complicated congestive heart failure (CHF). Other oral agents including apomorphine, Phentolamine and trazodone have also been proposed to treat ED with some adverse effects.Conclusion: Our data in this review portrays accurately using Sildenafil for restoring sexual functions in diabetic neuropathic population. Other limitations include a great potential for misuse and costly.

Mesenteric Vascular Ischemia

Elderly patients with underlying cardiovascular disease such as valvular heart disease, recent myocardial infarction, atrial fibrillation, and congestive heart failure are more likely to present with acute mesenteric vascular ischemia [1]. These disorders may lead to arterial macro embolization with sudden occlusion of mesenteric arteries [2]. Patients with chronic mesenteric vascular ischemia due to severe atherosclerotic obstruction of the mesenteric arteries may develop sudden thrombosis causing acute vascular ischemic symptoms [2].

Abstract 1: The Value of Adding Laboratory Data to Coronary Artery Bypass Graft Surgery Registry Data to Improve Models for Risk-Adjusting Provider Mortality Rates

Background: Clinical registry data for coronary artery bypass graft (CABG) surgery are currently being used in a few states and by the Society for Thoracic Surgeons to calculate provider risk-adjusted mortality rates. However, very little laboratory data are contained in these databases for purposes of risk-adjustment. The objective of this study was to examine whether adding laboratory data to New York’s CABG registry data will identify laboratory variables that are significant independent predictors of in-hospital/30-day mortality, and if so, whether the risk adjustment model containing these laboratory variables will significantly alter the quality assessments of New York hospitals where CABG surgeries are performed. Methods: New York hospitals that performed CABG surgery in 2008-2010 were recruited into a study that required submitting data for 32 laboratory tests which were combined with CABG registry data. Statistical models were developed, with and without laboratory data, to compare risk-adjusted mortality rates. Discrimination, calibration, correlation in hospital risk-adjusted mortality rates, and differences in hospital quality outlier status were examined for both registry and registry/laboratory models. Results: There were 9,958 patients who underwent isolated CABG surgery at 15 participating hospitals during the study period. Discrimination of statistical models was very similar (C = 0.783 for the registry model and 0.812 for the registry/laboratory model, P = 0.26). Most of the non-laboratory variables in the two models were identical, except that the registry model contained diabetes requiring medication and the registry/laboratory model included recent congestive heart failure and renal dialysis. The registry/laboratory model also included two laboratory variables: Aspartate Aminotransferase (AST) &gt; 50 U/L, and International Normalized Ratio (INR) &gt;1.5. The addition of laboratory data did not affect the quality outlier status of hospitals, and had minimal effect on the tertile of risk-adjusted mortality of New York hospitals. Conclusion: Clinical models with and without laboratory data had similar discrimination, hospital risk-adjusted mortality rates were essentially unchanged, and hospital outlier status was identical. Two laboratory variables, AST and INR, were significant independent predictors of mortality and might be valuable additions to CABG clinical registry data. The benefits and practical challenges of adding key laboratory variables to CABG registry data should be carefully considered.

Ischemic stroke associated with left cardiac catheterization: The importance of modifiable and non-modifiable risk factors

Stroke associated with left cardiac catheterization is a devastating complication, and its incidence has not changed over the decades. We investigated the incidence, in-hospital outcomes and the modifiable and non-modifiable risk factors for periprocedural ischemic stroke. Our retrospective cohort study included all patients experiencing periprocedural ischemic stroke among the 24,500 patients who underwent left cardiac catheterization between January 2003 and October 2010. The case group was compared with a group of control patients randomly selected among those who underwent the procedure during this period. Ischemic cerebrovascular events attested by brain imaging occurred in 37 patients (0.15% of procedures), transient ischemic attack occurred in 9 cases, and persistent neurological deficit occurred in 28 cases. Patients who developed strokes were more likely to be older and were more often female with a greater prevalence of comorbidities. Emergency and longer procedures were more frequent in patients in the case group who had more coronary complications. A multivariate analysis identified diabetes mellitus (adjusted odds ratio (OR) 4.2; 95% CI 1.8-9.9; P < .001), chronic renal dysfunction (OR 2.4; 95% CI 1.1-5.4; P < .001), known cerebrovascular disease (OR 5.1; 95% CI 2.3-11.5; P < .001), emergency procedure (OR 3.1; 95% CI 1.4-9.2; P < .01) and recent congestive heart failure (OR 6.1; 95% CI 2.9-13; P < .001) as independent predictors for stroke. The independent modifiable predictive factors were represented by left ventricular angiography (OR 7.5; 95% CI 2.7-21; P < .001), and low operator volume (OR 3.1; 95% CI 1.3-7.4; P < .01). Limiting the performance of left cardiac catheterization to high volume operators and avoiding unnecessary left ventricular angiography may reduce periprocedural ischemic stroke.

Infrainguinal bypass is associated with lower perioperative mortality than major amputation in high-risk surgical candidates

Major amputation is often selected over infrainguinal bypass in patients with severe systemic comorbidities because it is assumed to have lower perioperative risks, yet this assumption is unproven and largely unexamined. The 2005 to 2008 National Surgical Quality Improvement Project (NSQIP) database was used to identify all patients undergoing either infrainguinal bypass or major amputation using procedural codes. Patients with systemic or local infections were excluded. A subset of high-risk patients were then defined as American Society of Anesthesiologists (ASA) class 4 or 5, or ASA class 3 with renal failure, dyspnea at rest, ventilator dependence, recent congestive heart failure, or recent myocardial infarct. Propensity score matching was used to obtain two high-risk patient groups matched for preoperative characteristics. No significant differences in demographic, preoperative, or anesthetic variables were found between the matched, high-risk amputation or bypass groups (792 and 780 patients, respectively). Bypass was associated with a lower 30-day postoperative mortality than amputation (6.54% vs 9.97%; P = .0147). Amputation was associated with higher rates of pulmonary embolism (0.9% vs 0% for amputation vs bypass groups, respectively; P = .009) and urinary tract infection (5.2% vs 2.7%; P = .01), while bypass was associated with higher rates of return to the operating room (14.1% vs 27.6%; P < .001) and a trend toward higher postoperative transfusion requirements (0.9% vs 2.1%; P = .054). The postoperative time to discharge did not differ between the two groups. The decision to perform an infrainguinal bypass or amputation should depend on well-established predictors of graft patency and functional success rather than presumptions about different perioperative risks between the two procedures.

The CHADS2 score for stroke risk stratification in atrial fibrillation – friend or foe?

The risk of stroke in patients with non-valvular atrial fibrillation (NVAF) varies widely depending on patient age and the presence of other risk factors such as hypertension, diabetes mellitus, congestive heart failure or prior stroke or transient ischaemic attack (TIA) (1, 2). Warfarin reduces the risk of stroke by about twothirds when compared to placebo or no treatment, and by about two-fifths when compared to aspirin, but substantially increases major bleeding (2, 3). The most feared complication of warfarin is intracranial bleeding which occurs at the rate of 2–5 per 1,000 patients per year and often results in disability or death (3). Consequently, the decision to use warfarin must balance the benefits of warfarin for stroke prevention against the risk of major bleeding. The goal of stroke prediction models is to help clinicians and patients select the most appropriate antithrombotic therapy for stroke prevention. Because the absolute benefit of warfarin for stroke prevention increases with increasing baseline stroke risk whereas the absolute risk of major bleeding is more constant (3, 4), the balance between benefits and risks of warfarin in individual patients is determined primarily by their baseline untreated stroke risk. In this paper we critically examine the value of the CHADS2 (acronym for recent Congestive heart failure, history of Hypertension, Age≥75 years, Diabetes mellitus, and past history of Stroke or TIA) risk index to estimate stroke risk in patients with NVAF.

Clinical, economic, and quality of life impact of atrial fibrillation.

Atrial fibrillation (AF) is a common, age-related arrhythmia that disproportionately affects men, adversely affects quality of life, and causes considerable morbidity and mortality. To describe trends in the prevalence and incidence of AF in the United States; discuss the etiologies and complications of AF; characterize the economic burden of AF; and predict an individual's risk for developing AF and AF-related stroke. The prevalence and incidence of AF in the United States are expected to increase in the coming decades because of the aging of the population; improved survival rates associated with coronary heart disease, heart failure, and hypertension; and increased rate of performance of surgical procedures. The economic burden of AF is substantial because of high rates of hospitalization and other health resource utilization. Hypertension, coronary heart disease, and systolic heart failure are the most important risk factors for AF. Ischemic stroke is the most devastating complication of AF. Risk factors for stroke in patients with AF include recent congestive heart failure, hypertension, advanced age, diabetes mellitus, and a history of stroke or transient ischemic attack. Risk scoring systems have been developed to predict an individual's risk for developing AF and the risk for stroke in a patient with AF. The estimated lifetime risk for AF in men and women aged 40 years of age or older is 1 in 4, which is higher than the risk for other diseases that are a common cause for concern among elderly patients. The clinical and economic burden of AF in the United States is large and will continue to increase in the future. The use of scoring systems to predict the risk of AF and AF-related stroke affords clinicians the opportunity to intervene to minimize these risks and improve patient outcomes.

Atrial Fibrillation and Managed Care: Current Approaches and Future Directions for Long-Term Therapy

BACKGROUND: Atrial fibrillation (AF) is a common, age-related arrhythmia that disproportionately affects men, adversely affects quality of life, and causes considerable morbidity and mortality. OBJECTIVES: To describe trends in the prevalence and incidence of AF in the United States; discuss the etiologies and complications of AF; characterize the economic burden of AF; and predict an individual’s risk for developing AF and AF-related stroke. SUMMARY: The prevalence and incidence of AF in the United States are expected to increase in the coming decades because of the aging of the population; improved survival rates associated with coronary heart disease, heart failure, and hypertension; and increased rate of performance of surgical procedures. The economic burden of AF is substantial because of high rates of hospitalization and other health resource utilization. Hypertension, coronary heart disease, and systolic heart failure are the most important risk factors for AF. Ischemic stroke is the most devastating complication of AF. Risk factors for stroke in patients with AF include recent congestive heart failure, hypertension, advanced age, diabetes mellitus, and a history of stroke or transient ischemic attack. Risk scoring systems have been developed to predict an individual’s risk for developing AF and the risk for stroke in a patient with AF. The estimated lifetime risk for AF in men and women aged 40 years of age or older is 1 in 4, which is higher than the risk for other diseases that are a common cause for concern among elderly patients. CONCLUSIONS: The clinical and economic burden of AF in the United States is large and will continue to increase in the future. The use of scoring systems to predict the risk of AF and AF-related stroke affords clinicians the opportunity to intervene to minimize these risks and improve patient outcomes. J Manag Care Pharm. 2009;15(6-b)(Suppl):S4-S9 Copyright © 2009, Academy of Managed Care Pharmacy. All rights reserved. CYNTHIA A. SANOSKI, PharmD, FCCP, BCPS, is Associate Professor and Chair, Department of Pharmacy Practice, Jefferson School of Pharmacy, Thomas Jefferson University, Philadelphia, Pennsylvania. AUTHOR CORRESPONDENCE: Cynthia A. Sanoski, PharmD, FCCP, BCPS, Chair, Department of Pharmacy Practice, Jefferson School of Pharmacy, Thomas Jefferson University, 130 9th St., Ste. 1540, Philadelphia, PA 19107-5233. Tel.: 215.503.1722; Fax: 215.503.9052; E-mail: cynthia.sanoski@jefferson.edu Author Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting approximately 2.2 million Americans.1 The prevalence of AF increases with age, with 70% of cases occurring in patients between the ages of 65 years and 85 years (Figure 1).2 Atrial fibrillation is also more common in men than in women at all ages. For example, a cohort of 2,090 men and 2,641 women who participated in the Framingham Heart Study and did not have AF at the time of enrollment were followed for 38 years.3 After adjusting for age and other AF risk factors, the men were 50% more likely to develop AF than were the women. The higher risk of AF in men persisted in each decade between 55 and 94 years of age (Figure 2).

Bloodstream infections after invasive nonsurgical cardiologic procedures.

To define the incidence, risk factors, and characteristics of bloodstream infections (BSIs) after invasive nonsurgical cardiologic procedures (ICPs). Retrospective case-control study; multivariate analysis. Between January 1991 and December 1998, 22 006 ICPs were performed in our hospital and 25 BSIs were documented within 72 hours after ICP. Overall incidence of bacteremia was 0.11% (25 cases) (0.24% after percutaneous transluminal coronary angioplasty [14 cases of 5625 patients], 0.06% [corrected] after diagnostic cardiac catheterization [9 cases of 14 034 patients], and 0.08% [corrected] after electrophysiologic studies [2 cases of 2347 patients]). These 25 patients with bacteremia were compared with 50 controls randomly selected among patients who underwent an ICP but did not have BSIs. Patient-related risk factors for BSI were age older than 60 years (20 cases [80%] vs 28 controls [56%]), valvular disease (4 [16%] vs 1 [2%]), congestive heart failure (7 [28%] vs 1 [2%]), indwelling bladder catheter before the ICP (5 [20%] vs 1 [2%]), more than 1 puncture for the ICP (5 [20%] vs 3 [6%]), a prolonged procedure (83.7 vs 65.1 minutes); and/or more than 1 ICP performed (2 [8%] vs 0). Multivariate analysis identified the presence of congestive heart failure (odds ratio, 21; 95% confidence interval, 6.8-66.0) and age older than 60 years (odds ratio, 1.9; 95% confidence interval, 1.9-6.3) as independent risk factors for BSI after ICP. Bloodstream infection was detected a median of 1.7 days after the procedure. Gram-negative bacteremia accounted for 17 cases (68%) of the BSIs. Among the patients with BSI, the duration of hospital stay was significantly increased (21 vs 6 days). The overall mortality rate was 0.009% for patients who underwent an ICP (8.0% for the 25 patients with bacteremia documented within 72 hours after ICP). Bloodstream infection should be included among the potential complications of ICP. Elderly patients with recent congestive heart failure episodes constitute a subgroup with a higher risk of postprocedure bacteremia. Therapy with antimicrobial agents against gram-positive and gram-negative bacteremia should be initiated after performing blood cultures in patients with signs suggestive of infection.

Analysis of risk factors for myocardial infarction and cardiac mortality after major vascular surgery.

Patients undergoing vascular surgical procedures are at high risk for perioperative myocardial infarction (PMI). This study was undertaken to identify predictors of PMI and in-hospital death in major vascular surgical patients. From the Vascular Surgery Registry (6,948 operations from January 1989 through June 1997) the authors identified 107 patients in whom PMI developed during the same hospital stay. Case-control patients (patients without PMI) were matched at a 1x:x1 ratio with index cases according to the type of surgery, gender, patient age, and year of surgery. The authors analyzed data regarding preoperative cardiac disease and surgical and anesthetic factors to study association with PMI and cardiac death. By using univariable analysis the authors identified the following predictors of PMI: valvular disease (P = 0.007), previous congestive heart failure (P = 0.04), emergency surgery (P = 0.02), general anesthesia (P = 0.03), preoperative history of coronary artery disease (P = 0.001), preoperative treatment with beta-blockers (P = 0.003), lower preoperative (P = 0.03) and postoperative (P = 0.002) hemoglobin concentrations, increased bleeding rate (as assessed from increased cell salvage; P = 0.025), and lower ejection fraction (P = 0.02). Of the 107 patients with PMI, 20.6% died of cardiac cause during the same hospital stay. The following factors increased the odds ratios for cardiac death: age (P = 0.001), recent congestive heart failure (P = 0.01), type of surgery (P = 0.04), emergency surgery (P = 0.02), lower intraoperative diastolic blood pressure (P = 0.001), new intraoperative ST-T changes (P = 0.01), and increased intraoperative use of blood (P = 0.005). Patients who underwent coronary artery bypass grafting, even more than 12 months before index surgery, had a 79% reduction in risk of death if they had PMI (P = 0.01). Multivariable analysis revealed preoperative definitive diagnosis of coronary artery disease (P = 0.001) and significant valvular disease (P = 0.03) were associated with increased risk of PMI. Congestive heart failure less than 1 yr before index vascular surgery (P = 0. 0002) and increased intraoperative use of blood (P = 0.007) were associated with cardiac death. The history of coronary artery bypass grafting reduced the risk of cardiac death (P = 0.04) in patients with PMI. The in-hospital cardiac mortality rate is high for patients who undergo vascular surgery and experience clinically significant PMI. Stress of surgery (increased intraoperative bleeding and aortic, peripheral vascular, and emergency surgery), poor preoperative cardiac functional status (congestive heart failure, lower ejection fraction, diagnosis of coronary artery disease), and preoperative history of coronary artery bypass grafting are the factors that determine perioperative cardiac morbidity and mortality rates.

Can Predictors of Perioperative Myocardial Infarction in Patients Undergoing Vascular Surgery Be Identified? Sprung et al. (page 129)

Sprung et al. used the Vascular Surgery Registry at The Cleveland Clinic to identify patients from January 1989 through June 1997 who underwent vascular surgery and who had perioperative myocardial infarction (PMI) during the same hospital stay. Patients who underwent abdominal or thoracic aortic reconstructive surgery, carotid endarterectomy, or peripheral vascular surgery, performed with either general or neuraxial anesthesia, were included in the review. The authors analyzed associations among patient characteristics, type of anesthetic, and surgical risk factors for PMI, comparing the patients who experienced PMI with matched control patients (1:1) who did not.Information was collected for patients regarding preoperative cardiac history, comorbid conditions, treated diabetes mellitus, history of stroke, history of preoperative angina, and presence of preoperative coronary artery disease. Also analyzed were preoperative hematocrit and creatinine concentrations, intraoperative fluid use, estimated blood loss, and preoperative presence or absence of electrocardiographic changes consistent with myocardial disease or ischemia.During the time period studied, 107 patients experienced PMI during their hospital stay after vascular surgery. Twenty-two of these patients died. Four patients in the control group died during hospital stay; none of these died of cardiac causes. After a univariate analysis of the data, the authors found that the following factors were associated significantly with a greater risk of PMI: valvular disease, previous congestive heart failure, surgery performed on an emergency basis, general anesthesia, preoperative diagnosis of coronary artery disease, lower preoperative and postoperative hemoglobin concentrations, increased intraoperative bleeding (as determined by the amount of cell-salvaged blood), and a lower ejection fraction. The risk of cardiac death was increased by age, recent congestive heart failure, type of surgery, lower intraoperative diastolic blood pressure, and new intraoperative ST-T changes. Having undergone coronary artery bypass graft surgery even more than 12 months before vascular surgery reduced the mortality rate after PMI by 79%.

Dipyridamole-thallium/sestamibi before vascular surgery: A prospective blinded study in moderate-risk patients

Purpose: This study assessed in a prospective, blinded fashion whether a reversible defect on dipyridamole-thallium (DTHAL)/sestamibi (DMIBI) can predict adverse cardiac events after elective vascular surgery in patients with one or more clinical risk factors. Methods: Consecutive patients with one or more clinical risk factors underwent a preoperative blinded DTHAL/DMIBI. Patients with recent congestive heart failure (CHF) or myocardial infarction (MI) or severe or unstable angina were excluded. Results: Eighty patients (78% men; mean age, 65 years) completed the study. Diabetes mellitus was the most frequent clinical risk factor (73%), followed by age older than 70 years (41%), angina (29%), Q wave on electrocardiogram (26%), history of CHF (7%), and ventricular ectopy (3%). The results of DTHAL/DMIBI were normal in 36 patients (45%); a reversible plus or minus fixed defect was demonstrated in 28 patients (36%), and a fixed defect alone was demonstrated in 15 patients (19%). Nine adverse cardiac events (11%) occurred, including three cases of CHF, and one case each of unstable angina, Q wave MI, non-Q wave MI, and cardiac arrest (successfully resuscitated). Two cardiac deaths occurred (2% overall mortality), one after a Q wave MI and one after CHF and a non-Q wave MI. The cardiac event rate was 14% for reversible defect and 9.8% without reversible defect (P =.71). The cardiac event rate was 12.5% (one of eight cases) for two or more reversible defects, versus 11.1% (eight of 72 cases) for fewer than two reversible defects (P = 1.0). The sensitivity rate of two or more areas of redistribution was 11% (95% CI, 0.3%-48%), the specificity rate was 90%, and the positive and negative predictive values were 12.5% and 89%, respectively. Conclusion: Our study demonstrated no association between reversible defects on DTHAL/DMIBI and adverse cardiac events in moderate-risk patients undergoing elective vascular surgery. (J Vasc Surg 2000;32:77-89.)

Non-rheumatic atrial fibrillation and stroke.

The risk of systemic embolism and stroke in patients with non-rheumatic atrial fibrillation (NRAF) should not be underestimated. The annual embolic rate is approximately 5% and in those with left atrial enlargement and/or left ventricular (LV) dysfunction, or who have already had systemic embolism, this rate may be as high as 20%. Decisions on patient management and the prophylaxis of stroke must always be individualised. The risk of bleeding related to warfarin is almost certainly greater than that encountered in the previous randomised trials. Also, clinical and echocardiographic features can further define absolute risk in an individual patient with NRAF. Clinical markers of increased risk of embolism in patients with NRAF include older age, previous cerebral embolism, recent congestive heart failure, hypertension and diabetes mellitus. Transthoracic echocardiography improves risk stratification and should be performed in the vast majority of patients. Embolic risk is greatest in those with increasing left atrial dilation, atrial dysfunction and LV dysfunction. Transoesophageal echocardiography sharpens the risk profile in selected patients. Overall randomised trials show greater benefit with warfarin than aspirin. In general, increasing age is associated with a greater incidence of structural heart disease and probably implies greater potential benefit with warfarin. Increasing age per se may not increase the risk of warfarin-related bleeding. When the decision is made to warfarinise patients, at the present time data suggest that the target INR should be in the range of 2.0-3.0.

Plasmin-α2-antiplasmin Complex in Patients with Atrial Fibrillation

Plasmin-alpha2-antiplasmin complex (PAP) is an index of recent fibrinolytic activity. We examined PAP levels in patients with atrial fibrillation (AF) to determine whether these levels are correlated with clinical characteristics associated with stroke risk. We obtained blood for measurement of PAP in a non-random sample of 586 patients with AF on entering the Stroke Prevention in Atrial Fibrillation III Study. PAP levels were measured with an ELISA assay. PAP values were transformed with a natural logarithm (PAPln) prior to all analyses. Older age, female gender, recent congestive heart failure, decreasing fractional shortening, recent onset of AF, and coronary artery disease were each univariately associated with higher levels of PAP (all p<0.05, two-sample t-test, simple linear regression). Older age, recent congestive heart failure, decreasing fractional shortening, and recent onset of AF were independently associated with higher PAP levels by multivariate analysis (linear regression). Among patients receiving warfarin, PAP levels were not correlated with INR levels (linear regression, p=0.60). Patients classified as high-risk for thromboembolism by our risk stratification criteria (systolic blood pressure > 160 mm Hg, prior thromboembolism, recent congestive heart failure, poor left ventricular function, and women over age 75) had higher PAP levels than low-risk patients (antilog mean PAPln 5.6 vs 4.9. p<0.001, two-sample t-test). PAP levels in patients with AF are associated with clinical characteristics predictive of thromboembolism. Elevated PAP levels are particularly associated with poor left ventricular function and are not affected by anticoagulation. PAP levels may be a marker of stroke risk in patients with AF.

Clinical efficacy of amiodarone.

To review the clinical efficacy and role of amiodarone in the management of supraventricular and ventricular arrhythmias and its effects on mortality. Review of relevant studies and reports. Amiodarone exerts significant effects on atrial tissue. In most studies it was completely or partly effective in preventing recurrences of atrial fibrillation or flutter in up to 80% of patients. Amiodarone may be superior to class Ia agents for maintaining normal sinus rhythm. Large randomized trials indicate that it is a potent suppressor of ventricular arrhythmia and reduces arrhythmic death after myocardial infarction. In patients with cardiomyopathy, it suppresses asymptomatic arrhythmias and increases left ventricular ejection fraction. Meta-analysis of relevant studies indicated that amiodarone reduces the risk of arrhythmic and sudden death by 29% in high-risk patients with recent myocardial infarction or congestive heart failure. This translates into an overall 13% reduction in total mortality. Because of its effectiveness against a broad range of arrhythmias, amiodarone is a valuable addition to the antiarrhythmic pharmacopeia.