Perioperative beta-blocker withdrawal and mortality in vascular surgical patients.

OBJECTIVE: Our purpose was to determine the effect of postoperative beta-blocker withdrawal on mortality and cardiovascular events after vascular surgery. METHODS: Detailed data were collected on perioperative cardiovascular medication use and discontinuation and cardiovascular risk factors among consecutive major vascular surgical procedures at two university hospitals. RESULTS: A total of 140 patients received beta-blockers preoperatively. Mortality in the 8 patients who had beta-blockers discontinued postoperatively (50%) was significantly greater than in 132 patients who had beta-blockers continued (1.5%, odds ratio 65.0, P<.001). The effect of beta-blocker discontinuation was unaffected by adjustment by stratification for risk factors (all P< or =.01), for contraindications to restarting beta-blockers (P = .006), and by multivariable analyses adjusting for potential confounders (adjusted odds ratio 17.0, P =.01). beta-Blocker discontinuation also was associated with increased cardiovascular mortality (0% vs 29%, P =.005) and postoperative myocardial infarction (odds ratio 17.7, P =.003). CONCLUSION: Discontinuing beta-blockers immediately after vascular surgery may increase the risk of postoperative cardiovascular morbidity and mortality.

Long-term survival of emergency department patients with acute chest pain.

To evaluate the long-term prognosis of patients with acute chest pain, prospective clinical data and long-term follow-up data (mean 30.1 +/- 9.4 months) were collected for 1,956 patients who presented to the emergency department of an urban teaching hospital with this chief complaint. During follow-up of the 1,915 patients who were discharged alive from the emergency department or hospital, there were 113 (6%) cardiovascular deaths. No differences were detected in the post-discharge cardiovascular survival rates after 3 years of experience with patients who were discharged from the emergency department with a known prior diagnosis of angina or myocardial infarction (89%) and patients who had been admitted and found to have acute myocardial infarction (85%), angina (87%), or other cardiovascular diagnoses (87%). Patients who were discharged from either the hospital or the emergency department without cardiovascular diagnoses had an excellent prognosis. Multivariate Cox regression analysis identified 5 independent correlates of cardiovascular mortality after discharge: age, prior history of coronary disease, ischemic changes on the emergency department electrocardiogram, congestive heart failure and cardiogenic shock. These findings indicate that the postdischarge cardiovascular mortality of patients with chest pain who are discharged from the emergency department with a known history of coronary disease is similar to that of admitted patients with angina or myocardial infarction. These data suggest that the same types of prognostic evaluation strategies that have been developed for admitted patients with ischemic heart disease should also be considered when such patients present to the emergency department but are not admitted.

Massive gastric distention due to duodenal involvement by retroperitoneal tumors.

We present three patients with retroperitoneal tumor involving the duodenum in whom upper gastrointestinal (GI) studies revealed delayed gastric emptying and massive gastric dilatation out of proportion to the degree of duodenal dilatation. While the radiographic findings mimicked acute gastric outlet obstruction, delayed films demonstrated narrowing and encasement of the duodenum at the site of obstruction in all three patients. Thus, the duodenum should be carefully evaluated radiographically in patients with acute gastric dilatation, particularly if there is a known history of malignancy.

Impact of initial triage decisions on nursing intensity for patients with acute chest pain.

The results of a prospective evaluation of the patient-specific correlates of nursing intensity for 183 consecutive emergency room patients admitted for evaluation of acute chest pain, including 33 (18%) with acute myocardial infarction (AMI), are reported. These correlates were measured with a previously-validated, commercially-available patient classification tool (Medicus). In multiple linear regression analysis that adjusted for the effects of 31 clinical variables from the initial presentation and subsequent course, initial triage to the coronary care unit had a significant independent correlation with initial Medicus score (P less than 0.0001) and mean Medicus score from the first three days of hospitalization (P less than 0.0001). In a subset of 74 uncomplicated non-AMI patients, coronary care unit admissions were more likely to have vital signs taken every 2 hours, to receive oxygen therapy and assistance with feeding, and to be transferred to another unit within three days. Findings suggest that, after adjusting for severity of illness, initial triage of patients with acute chest pain to the coronary care unit is associated with increased nursing utilization because of 1) the routine application of standard coronary care unit protocols that were developed for high-risk patients, and 2) the nursing efforts required by early transfer of patients out of the coronary care unit.