Pharmacological thromboembolic prophylaxis for medical patients in a tertiary care, teaching community hospital: room for improvement.

Venous Thrombembolism (VTE) is a potentially lethal complication in hospitalized patients. Studies indicate that pharmacological prophylaxis may reduce the incidence of VTE. However, the use of VTE prophylaxis remains unclear. We aimed to retrospectively assess whether medically ill hospitalized patients with established risk factors receive pharmacological VTE prophylaxis in our 912-bed community-based tertiary care teaching hospital between 1997 and 2003. We randomly selected a sample of 350 medically ill (non surgical) hospitalized patients with risk factors for VTE. A total of 164 of 321 patients (51.1%) received pharmacological VTE prophylaxis. Patients with a platelet count of greater than or equal to 278 K/cu mm, a weight of 146 to 184 lbs, or a weight > or = 185 lbs were found more likely to receive prophylaxis. Patients with cancer as well as other diagnoses (compared to MI patients) were less likely to receive prophylaxis. We conclude that there continues to be a significant underutilization of VTE prophylaxis in this patient population. Strategies for identifying patients at risk for VTE and implementing appropriate protocols to ensure that these patients receive prophylaxis are necessary.

Aspirin under fire: aspirin use in the primary prevention of coronary heart disease.

The issue of aspirin use in the primary prevention of cardiovascular disease is still debated because of conflicting opinions on risks versus benefits. Recently, a United States Food and Drug Administration (FDA) panel rejected the approval of aspirin in the setting of primary prevention in moderate-risk patients. However, the United States Preventive Services Task Force recommends that clinicians discuss aspirin therapy with patients at increased risk for having a future coronary event. During the past 15 years, many large randomized trials have specifically addressed this issue and helped shape the decisions of the FDA panel and the Preventive Services Task Force. These trials lend a handful of experiences and results, with no clear recommendations for antiplatelet therapy in the setting of primary prevention of coronary heart disease (CHD). Recently, trial results have been assimilated into practical tools for risk stratification to guide aspirin use in this setting. An overview and critical evaluation of the work performed thus far is provided in order to lend insight into the ongoing debate and, through use of the Framingham CHD risk prediction score sheets, to better equip practitioners faced with the decision of giving aspirin to "relatively" healthy individuals for CHD primary prevention.

Subendocardial ischemia without coronary artery disease: is elevated left ventricular end diastolic pressure the culprit?

BACKGROUND: The aim was to investigate the association between elevated left ventricular end diastolic pressure (LVEDP) and subendocardial ischemia. METHODS: A retrospective chart review was performed of 1846 consecutive patients admitted between January and September 2002 who had chest pain, stress testing and coronary angiography. RESULTS: 1592 patients were excluded due to a positive coronary angiogram for coronary artery disease (CAD), 254 patients had an angiogram compatible with non-significant CAD and an ejection fraction > 45%; of whom 210 (82.7%) had a positive stress test (study group) and the others 44 (17.3%) had a negative stress test (control group). The mean LVEDP value for the study group (11.8 +/- 6.1 mmHg) was significantly higher than the mean LVEDP value for the control group (7.8 +/- 4.6 mmHg) (p < 0.001). In addition, there were more people with abnormal LVEDP (>or= 12 mmHg) in the study group (n = 103, 49.05%) compared with the control group (n = 10, 22.73%) (p < 0.001). Furthermore, the results of logistic regression revealed that patients with abnormal LVEDP values were 11 times more likely to have had a positive stress test. CONCLUSIONS: There appears to be a positive association between elevated LVEDP and subendocardial ischemia that manifests as a positive stress test in patients without evidence of significant CAD.

Similar success rates with bivalirudin and unfractionated heparin in bare-metal stent implantation.

BACKGROUND: Unfractionated heparin (UFH) is the traditional agent utilized during percutaneous peripheral interventions (PPIs) despite its well-known limitations. Bivalirudin, a thrombin-specific anticoagulant, overcomes many of the limitations of UFH and has consistently demonstrated comparable efficacy with significantly fewer bleeding complications. The purpose of this study was to compare procedural success in patients undergoing bare-metal stent implantation for atherosclerotic blockage of the renal, iliac, and femoral arteries and receiving either bivalirudin (0.75 mg/kg bolus/1.75 mg/kg/hr infusion) or UFH (50-70 U/kg/hr bolus) as the primary anticoagulant. METHODS: This study was an open-label, nonrandomized retrospective registry with the primary endpoint of procedural success. Secondary endpoints included incidence of: death, myocardial infarction (MI), urgent revascularization, amputation, and major and minor bleeding. RESULTS: One hundred and five consecutive patients were enrolled (bivalirudin = 53; heparin = 52). Baseline demographics were comparable between groups. Patients were pretreated with clopidogrel (approx. 71%) and aspirin (approx. 79%). Procedural success was achieved in 97% and 96% of patients in the bivalirudin- and heparin-treated groups, respectively. Event rates were low and similar between groups. CONCLUSION: Bivalirudin maintained an equal rate of procedural success in this cohort without sacrificing patient safety. Results of this study add to the growing body of evidence supporting the safety and efficacy of bivalirudin as a possible substitute for UFH in anticoagulation during peripheral vascular bare-metal stent implantation.