2009 June 21

The prognostic value of individual NT-proBNP values in chronic heart failure does not change with advancing age.

Jun 212009

The prognostic value of individual NT-proBNP values in chronic heart failure does not change with advancing age.

Heart. 2009 May;95(10):825-9

Authors: Frankenstein L, Clark AL, Goode K, Ingle L, Remppis A, Schellberg D, Grabs F, Nelles M, Cleland JG, Katus HA, Zugck C

BACKGROUND: It is unclear whether age-related increases in N-terminal pro-brain natriuretic peptide (NT-proBNP) represent a normal physiological process-possibly affecting the prognostic power-of NT-proBNP-or reflect age-related subclinical pathological changes. OBJECTIVE: To determine the effect of age on the short-term prognostic value of NT-proBNP in patients with chronic heart failure (CHF). DESIGN: Prospective observational study with inclusion and matching of consecutive patients aged >65 years (mean (SD) 73.1 (6.0) years) to patients <65 years (53.7 (8.6) years) with respect to NT-proBNP, New York Heart Association stage, sex and aetiology of CHF (final n = 443). SETTING: University hospital outpatient departments in the UK and Germany. PATIENTS: Chronic stable heart failure due to systolic left ventricular dysfunction. INTERVENTION: None. OUTCOME MEASURE: All-cause mortality. RESULTS: In both age groups, NT-proBNP was a significant univariate predictor of mortality, and independent of age, sex and other established risk markers. The prognostic information given by NT-proBNP was comparable between the two groups, as reflected by the 1-year mortality of 9% in both groups. The prognostic accuracy of NT-proBNP as judged by the area under the receiver operating characteristics curve for the prediction of 1-year mortality was comparable for elderly and younger patients (0.67 vs 0.71; p = 0.09). CONCLUSION: NT-proBNP reflects disease severity in elderly and younger patients alike. In patients with chronic stable heart failure, the NT-proBNP value carries the same 1-year prognostic information regardless of the age of the patient.

PMID: 19147626 [PubMed - indexed for MEDLINE]

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Immediate versus deferred coronary angioplasty in non-ST-segment elevation acute coronary syndromes.

Heart Start a Discussion »

Jun 212009

Immediate versus deferred coronary angioplasty in non-ST-segment elevation acute coronary syndromes.

Heart. 2009 May;95(10):807-12

Authors: Riezebos RK, Ronner E, Ter Bals E, Slagboom T, Smits PC, ten Berg JM, Kiemeneij F, Amoroso G, Patterson MS, Suttorp MJ, Tijssen JG, Laarman GJ,

BACKGROUND: The field of acute coronary syndromes is characterised by an increasing tendency towards early invasive catheter-based diagnostics and therapeutics-a practice based on observational and retrospective data. OBJECTIVE: To compare immediate versus deferred angioplasty in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) METHODS: A randomised, prospective multicentre trial was performed in patients admitted with NSTE-ACS, eligible for percutaneous coronary intervention (PCI). Interim analysis was performed after enrolment of 251 patients; PCI was appropriate in 142 patients. These patients were randomised to immediate PCI (n = 73) or deferred PCI (24-48 h) (n = 69). Patients received protocol-driven glycoprotein IIb/IIIa blockers, aspirin and clopidogrel. The primary end point was a composite of death, non-fatal myocardial infarction (MI) or unplanned revascularisation, at 30 days. After hospital discharge outpatient follow-up was performed at 30 days and 6 months. RESULTS: The incidence at 30 days of the primary end point was 60% in the group receiving immediate PCI and 39% in the group receiving deferred PCI (relative risk (RR) = 1.5, 95% CI 1.09 to 2.15; p = 0.004). No deaths occurred in either group. MI was significantly more common in the group receiving immediate PCI (60% vs 38%, RR = 1.6, 95% CI 1.12 to 2.28, p = 0.005). Unplanned revascularisation was similar in both groups. The observed difference was preserved over 6-months' follow-up. CONCLUSIONS: Immediate PCI was associated with an increased rate of MI in comparison with a 24-48 h deferred strategy, despite aggressive antithrombotic treatment. The results suggest that PCI for high-risk patients with non-refractory NSTE-ACS should be delayed for at least 24 h after hospital admission. TRIAL REGISTRATION NUMBER: ISRCTN80874637.

PMID: 19098058 [PubMed - indexed for MEDLINE]

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Does clinician’s knowledge of B-type natriuretic peptide levels translate to improvement of quality of life and less hospitalization days in patients with heart failure?

Prog Cardiovasc Nurs Start a Discussion »

Jun 212009

Does clinician's knowledge of B-type natriuretic peptide levels translate to improvement of quality of life and less hospitalization days in patients with heart failure?

Prog Cardiovasc Nurs. 2009 Mar;24(1):12-8

Authors: Ancheta IB, Evans M, Miller AB, Chiong JR, Battie C

This pilot study was conducted to determine whether clinicians' knowledge of b-type natriuretic peptide (BNP) levels in individuals with heart failure (HF) correlates with better outcomes including quality of life (QOL) and hospital length of stay (LOS) over a 90-day period. HF clinic patients were randomized into 2 groups: clinician aware (BNP group; n=50) or blinded to BNP levels (control group; n=42). BNP levels were measured at baseline using the BNP Immunoassay Kit. QOL was measured by the Minnesota Living with Heart Failure (MLWHF) questionnaire, and hospital LOS were measured at baseline and 90 days. There was no significant difference in BNP levels between groups. Compared with baseline scores (46.87+/-29.63), mean QOL scores at 90 days (37.46+/-28.67) were not significantly different for both groups. Hospital LOS was also similar for both groups (mean=3 days). BNP levels were significantly correlated with New York Heart Association classification (P=.05), ejection fraction (P=0.0001), creatinine levels (P=0.05), and overall Minnesota Living with Heart Failure Questionnaire scores (P=.01). Clinician's knowledge of BNP levels is not associated with better outcomes of QOL or hospital LOS in HF patients. However, BNP levels are correlated with functional status and physiological parameters. Further research is needed to determine whether other factors influence QOL and hospital LOS of HF patients.

PMID: 19261138 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Choice of ACE inhibitor combinations in hypertensive patients with type 2 diabetes: update after recent clinical trials.

Vasc Health Risk Manag Start a Discussion »

Jun 212009

Choice of ACE inhibitor combinations in hypertensive patients with type 2 diabetes: update after recent clinical trials.

Vasc Health Risk Manag. 2009;5(1):411-27

Authors: Reboldi G, Gentile G, Angeli F, Verdecchia P

The diabetes epidemic continues to grow unabated, with a staggering toll in micro- and macrovascular complications, disability, and death. Diabetes causes a two- to fourfold increase in the risk of cardiovascular disease, and represents the first cause of dialysis treatment both in the UK and the US. Concomitant hypertension doubles total mortality and stroke risk, triples the risk of coronary heart disease and significantly hastens the progression of microvascular complications, including diabetic nephropathy. Therefore, blood pressure reduction is of particular importance in preventing cardiovascular and renal outcomes. Successful antihypertensive treatment will often require a combination therapy, either with separate drugs or with fixed-dose combinations. Angiotensin converting enzyme (ACE) inhibitor plus diuretic combination therapy improves blood pressure control, counterbalances renin-angiotensin system activation due to diuretic therapy and reduces the risk of electrolyte alterations, obtaining at the same time synergistic antiproteinuric effects. ACE inhibitor plus calcium channel blocker provides a significant additive effect on blood pressure reduction, may have favorable metabolic effects and synergistically reduce proteinuria and the rate of decline in glomerular filtration rate, as evidenced by the GUARD trial. Finally, the recently published ACCOMPLISH trial showed that an ACE inhibitor/calcium channel blocker combination may be particularly useful in reducing cardiovascular outcomes in high-risk patients. The present review will focus on different ACE inhibitor combinations in the treatment of patients with type 2 diabetes mellitus and hypertension, in the light of recent clinical trials, including GUARD and ACCOMPLISH.

PMID: 19475778 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care.

Ann Emerg Med Start a Discussion »

Jun 212009

Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care.

Ann Emerg Med. 2009 Jun;53(6):701-10.e4

Authors: Horwitz LI, Meredith T, Schuur JD, Shah NR, Kulkarni RG, Jenq GY

STUDY OBJECTIVE: We identify, describe, and categorize vulnerabilities in emergency department (ED) to internal medicine patient transfers. METHODS: We surveyed all emergency medicine house staff, emergency physician assistants, internal medicine house staff and hospitalists at an urban, academic medical center. Respondents were asked to describe any adverse events occurring because of inadequate communication between emergency medicine and the admitting physician. We analyzed the open-ended responses with standard qualitative analysis techniques. RESULTS: Of 139 of 264 survey respondents (53%), 40 (29%) reported that a patient of theirs had experienced an adverse event or near miss after ED to inpatient transfer. These 40 respondents described 36 specific incidents of errors in diagnosis (N=13), treatment (N=14), and disposition (N=13), after which patients experienced harm or a near miss event. Six patients required an upgrade in care from the floor to the ICU. Although we asked respondents to describe communication failures, analysis of responses identified numerous contributors to error: inaccurate or incomplete information, particularly of vital signs; cultural and professional conflicts; crowding; high workload; difficulty in accessing key information such as vital signs, pending data, ED notes, ED orders, and identity of responsible physician; nonlinear patient flow; "boarding" in the ED; and ambiguous responsibility for sign-out or follow-up. CONCLUSION: The transfer of a patient from the ED to internal medicine can be associated with adverse events. Specific vulnerable areas include communication, environment, workload, information technology, patient flow, and assignment of responsibility. Systems-based interventions could ameliorate many of these and potentially improve patient safety.

PMID: 18555560 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

The safety of emergency care systems: Results of a survey of clinicians in 65 US emergency departments.

Ann Emerg Med Start a Discussion »

Jun 212009

The safety of emergency care systems: Results of a survey of clinicians in 65 US emergency departments.

Ann Emerg Med. 2009 Jun;53(6):715-23.e1

Authors: Magid DJ, Sullivan AF, Cleary PD, Rao SR, Gordon JA, Kaushal R, Guadagnoli E, Camargo CA, Blumenthal D

STUDY OBJECTIVE: Well-functioning systems are critical to safe patient care, but little is known about the status of such systems in US health care facilities, including high-risk settings such as the emergency department (ED). The purpose of this study is to assess the degree to which EDs are designed, managed, and supported in ways that ensure patient safety. METHODS: This was a validated, psychometrically tested survey of clinicians working in 65 US EDs that assessed clinician perceptions about the EDs' physical environment, staffing, equipment and supplies, nursing, teamwork, safety culture, triage and monitoring, information coordination and consultation, and inpatient coordination. RESULTS: Overall 3,562 eligible respondents completed the survey (response rate=66%). Survey respondents commonly reported problems in 4 systems critical to ED safety: physical environment, staffing, inpatient coordination, and information coordination and consultation. ED clinicians reported that there was insufficient space for the delivery of care most (25%) or some (37%) of the time. Respondents indicated that the number of patients exceeded ED capacity to provide safe care most (32%) or some of the time (50%). Only 41% of clinicians indicated that most of the time specialty consultation for critically ill patients arrived within 30 minutes of being contacted. Finally, half of respondents reported that ED patients requiring admission to the ICU were rarely transferred from the ED to the ICU within 1 hour. CONCLUSION: Reports by ED clinicians suggest that substantial improvements in institutional design, management, and support for emergency care are necessary to maximize patient safety in US EDs.

PMID: 19054592 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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