Prognostic significance of present atrial fibrillation on a single office electrocardiogram in patients with atrial fibrillation.

BACKGROUND: Evidence for the association of atrial fibrillation (AF) present on the ECG and cardiovascular outcomes in AF patients is limited. OBJECTIVE: To investigate the prognostic significance of AF on a single surface ECG for cardiovascular outcomes in AF patients. METHODS: A total of 3642 AF patients were prospectively enrolled. Main exclusion criteria were rhythms other than sinus rhythm (SR) or AF. The primary end-point was a composite of all-cause death and hospitalizations for congestive heart failure (CHF). Secondary end-points were all-cause death, CHF hospitalizations, cardiovascular death, myocardial infarction, any stroke and stroke subtypes. Associations were assessed with multivariable Cox proportional hazards models. RESULTS: Mean age was 71 years, 28% were female, and mean follow-up was 3.4 years. Patients with SR on the ECG at study enrolment (56%) were younger (69 vs. 74 years, P < 0.0001), had more often paroxysmal AF (73 vs. 18%, P < 0.0001) and fewer comorbidities. The incidence of the primary end-point was 1.8 and 3.1 per 100 person-years in patients with SR and AF, respectively. The multivariable-adjusted hazard ratio was 1.4 (95% confidence intervals 1.1; 1.7; P = 0.001) for patients with AF on the ECG compared to patients with SR. The hazard ratios (95% confidence intervals) were 1.4 (1.1; 1.8; P = 0.006) for all-cause death, 1.5 (1.2; 1.9; P = 0.001) for CHF and 1.6 (1.1; 2.2; P = 0.006) for cardiovascular death. None of the other associations were statistically significant. CONCLUSIONS: The presence of AF in a single office ECG had significant prognostic implications with regard to mortality and CHF hospitalizations in patients with AF. These patients present a high-risk group and might benefit from intensified treatment.

A comparison of four risk models for the prediction of cardiovascular complications in patients with a history of atrial fibrillation undergoing non-cardiac surgery.

It is unclear how best to predict peri-operative cardiovascular risk in patients with atrial fibrillation undergoing non-cardiac surgery. This study examined the accuracy of the revised cardiac risk index and three atrial fibrillation thrombo-embolic risk models for predicting 30-day cardiovascular events after non-cardiac surgery in patients with a pre-operative history of atrial fibrillation. We conducted a prospective cohort study in 28 centres from 2007 to 2013 of 40,004 patients ≥ 45 years of age undergoing inpatient non-cardiac surgery who were followed until 30 days after surgery for cardiovascular events (defined as myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death). The 2088 patients with a pre-operative history of atrial fibrillation were at higher risk of peri-operative cardiovascular events compared with the 34,830 patients without a history of atrial fibrillation (29% vs. 13%, respectively, adjusted odds ratio 1.30 (95%CI 1.17-1.45). Compared with the revised cardiac risk index (c-index 0.60), all atrial fibrillation thrombo-embolic risk scores were significantly better at predicting peri-operative cardiovascular events: CHADS2 (c-index 0.62); CHA2 DS2 -VASc (c-index 0.63); and R2 CHADS2 (c-index 0.65), respectively. Although the three thrombo-embolic risk prediction models were significantly better than the revised cardiac risk index for prediction of peri-operative cardiovascular events, none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri-operative risk prediction model.

The quest for indicators of paroxysmal atrial fibrillation in sinus rhythm - the DETECT AF trial.

Background: Atrial fibrillation (AF) is related to an increased stroke risk. At present, differentiation between patients with paroxysmal AF (pAF) and without is only possible during AF episodes and not during sinus rhythm. If AF could be diagnosed more quickly and reliably, anticoagulation therapy may be administered and prevent from cardioembolic strokes. The DETECT AF trial evaluated the hypothesis that propagation of electric activities in patients with pAF differs from propagation in healthy atria and that this can be detected with a three-dimensional electrocardiogram in patients during sinus rhythm. Methods: We conducted a case-control study including patients with a history of pAF and a control group with no history of AF. Vectorcardiographic beat-to-beat variability of atrial activation in sinus rhythm was tested and compared between the two groups. Results: One hundred and eight patients with a history of pAF in sinus rhythm and 121 controls in sinus rhythm were included. With a combination of specific vectorcardiographic beat-to-beat variability parameters discrimination between the two groups was possible with a specificity of 82% and a sensitivity of 71% (p≤.01). Using heart rate independent parameters, both specificity and sensitivity were reduced to 70%. Conclusions: Analysis of atrial vectorcardiographic beat-to-beat variability indicates that atrial conduction variability in patients with pAF differs from patients without AF and may be used as an indicator to estimate the risk for pAF in patients during sinus rhythm. Further studies to investigate the potential of this parameter are needed. Clinical trial registration number: NCT02270112.

[Assessment, frequency, causes, and prevention of medication errors - a critical analysis]. / Erfassung, Häufigkeit, Ursachen und Präventionvon Medikationsfehlern - eine kritische Analyse.

Medication errors are responsible for up to 50% of errors in healthcare. Therefore, they are an important target for the improvement of patient safety. The application of evidence-based methods for the analysis of institution-specific medication safety hotspots is crucial. Recommended methods for the identification of medication safety problems have individual strengths and weaknesses, but there is little overlap. Consequently, a combination of methods is recommended. While the analysis of critical incident reporting systems preferentially identifies serious medication errors, trigger tool represents an effective and cost-efficient approach. Evidence-based data for improvement methods is limited. However, the implementation of clinical pharmacy services, IT tools (electronic prescribing, barcoding) and standardized double-check showed a significant impact on error reduction. In addition, the support of institutional leadership is an important prerequisite.

[Measures to enhance patient safety. Importance of efficiency evaluation]. / Maßnahmen zur Verbesserung der Patientensicherheit. Bedeutung einer Wirksamkeitsevaluation.

Over the last 10 years, there has been increasing awareness of medical errors and harm to patients in healthcare. There is now widespread acceptance of the problem of medical harm and a determination to tackle major patient safety problems. Safety is defined as freedom from accidental injury. Thus, clinical risk management has been increasingly requested by professionals and their professional organizations to make healthcare safer. Clinical risk management is one of a number of organizational systems or processes aimed to improve the quality of healthcare, but one which is primarily concerned with creating and maintaining safe systems of care. A definition of this form--identifying, analyzing, and controlling risks--fits more comfortably with the culture and mission of healthcare organizations and is more likely to achieve the support and involvement of clinical professionals because it better reflects their purpose and values. Patient safety needs to become embedded in the culture of healthcare, not just in the sense of individual high standards, but a widespread acceptance of understanding of risk and safety and the need of everyone to actively promote patient safety. Measures taken to enhance patient safety encompass a wide range of activities with regard to the errors in the process of medication, to surgical errors and surgical outcome ("safer surgery saves lives"), and to hospitalism and hospital-acquired infections taking into consideration adherence to hand hygiene. An evaluation of the added value to patient safety, when processes are systematically changed and the patients become involved in making healthcare safer, is needed.

Epidemiology of atrial fibrillation.

Atrial fibrillation is the most common sustained cardiac arrhythmia in the general population. Unfortunately, current treatment strategies aiming at the elimination of atrial fibrillation have limited long term success rates and significant risks. In this context, recent publications have provided many insights on potentially treatable risk factors for the occurrence of atrial fibrillation, such as alcohol, blood pressure, obesity, inflammation and nutritional factors. In this review, we summarise the current evidence on these risk factors and indicate areas in need of further investigation. The current evidence shows that blood pressure, hypertension and obesity seem to play a key role in the pathogenesis of atrial fibrillation. Preliminary evidence also suggests that inflammation is an important mediator of these associations. Knowledge of these interrelationships may eventually help to develop new treatment strategies and decrease the burden of atrial fibrillation in the general population.

Twenty-four hour ambulatory blood pressure for the management of antihypertensive treatment: a randomized controlled trial.

The aim of this study was to assess whether the use of 24-h blood pressure (BP) measurement in the management of antihypertensive therapy improves BP in patients with sustained hypertension. Patients with sustained hypertension (office BP > or =140/90 mm Hg, and 24-h systolic BP > or =130/80 mm Hg) were randomly assigned to a strategy using 24-h BP to manage antihypertensive treatment (target <130/80 mm Hg) or to a standard strategy using office BP (target <140/90 mm Hg). The primary end point was change in 24-h systolic BP at 1 year of follow-up. We included 136 patients in the primary analysis. After 1 year of follow-up, the change in 24-h systolic BP was significantly greater in the ambulatory BP group compared with the office BP group (mean difference (95% confidence interval) -3.6 (-7.0, -0.3), P=0.03). Intention-to-treat analysis revealed essentially unchanged results. The mean number of antihypertensive drugs per participant at 1 year of follow-up was 1.76+/-1.1 and 1.95+/-0.9 in the ambulatory and office BP group, respectively (P=0.049). The benefit of ambulatory BP monitoring was mainly seen in patients with previously known hypertension (mean difference -7.2 (-11.6, -2.8), P=0.002), but not in those with newly detected hypertension (mean difference 0.2 (-4.9, 5.4), P=0.93). In conclusion, using 24-h BP for the management of antihypertensive therapy in patients with sustained hypertension leads to a greater BP reduction compared with a standard treatment strategy using office BP, although fewer antihypertensive drugs were used in the ambulatory BP group.

[False non-response in hypertensive patients treated in general practice]. / Falsch-Non-Response bei Hypertonie-Behandlung in der Hausarztpraxis.

Many hypertensive patients still have elevated blood pressure values despite antihypertensive treatment. However, which patients really do not respond to antihypertensive treatment? 41 primary care patients with treated essential arterial hypertension with office blood pressure > 140/90 mmHg received 24-hour ambulatory blood pressure measurement. The patients were categorized into a group with elevated blood pressure both in office (> or = 140/90 mmHg) and daytime ambulatory blood pressure measurement (> 135/85 mmHg) and into a group with False Non-Response to treatment (office blood pressure > or = 140/90 mmHg but normal daytime mean ambulatory blood pressure < 135/85 mmHg). Patients in the group with False NonResponse were significantly more likely to be female compared to patients with both office and ambulatory hypertension (67% vs. 23%, p = 0.009), whereas diabetes mellitus was a significant predictor of elevated blood pressure both in office and ambulatory measurement (7% vs. 39%, p = 0.033). False-Non-Response is common in primary care patients treated for hypertension. These patients have normal ambulatory BP values despite elevated office BP values. Female gender and absence of diabetes mellitus are significant predictors of False Non-response to antihypertensive treatment.

Effect of valsartan compared with valsartan/hydrochlorothiazide on plasma levels of cellular adhesion molecules: the Val-MARC trial.

BACKGROUND: The Val-MARC trial showed that the angiotensin receptor blocker valsartan reduces high-sensitivity C reactive protein (hsCRP) levels, an effect that is independent of blood pressure, and seems to be neutralised by the addition of hydrochlorothiazide. OBJECTIVE: To evaluate whether valsartan influences soluble intercellular adhesion molecule 1 (sICAM-1) or vascular cell adhesion molecule 1 (sVCAM-1). DESIGN: Post-hoc analysis from a randomised trial. SETTING: Val-MARC trial. PATIENTS: 1188 patients with stage 2 hypertension. INTERVENTION: Random allocation to either valsartan 320 mg (n = 607) or combination therapy with valsartan/hydrochlorothiazide 320 mg/12.5 mg (n = 581) for 6 weeks. MAIN OUTCOME MEASURE: Change in sICAM-1 and sVCAM-1 from baseline to 6 weeks of follow-up RESULTS: After treatment, median (interquartile range) sICAM-1 levels were reduced by both valsartan alone (-4 (-25 to 16) ng/ml, p = 0.005) and valsartan/hydrochlorothiazide (-4 (-22 to 17) ng/ml, p = 0.028), such that the between-group difference was not significant (p = 0.7). The median percentage change from baseline was small in both groups (-1.6% and -1.3%). Median (interquartile range) sVCAM-1 levels were reduced by both valsartan alone (-13 (-70 to 42) ng/ml, p = 0.001) and valsartan/hydrochlorothiazide (-26 (-88 to 38), p<0.001); the between-group difference was of borderline significance (p = 0.051). The median percentage change from baseline was small (-2.1% and -4.4%). The reduction of sICAM-1 and sVCAM-1 was independent of blood pressure reduction (rs = 0.03 and rs = 0.06 for the relationship of change in systolic blood pressure with change in sICAM-1 and sVCAM-1, respectively). CONCLUSION: In contrast to hsCRP, both valsartan and valsartan/hydrochlorothiazide induced reductions of sICAM-1 and sVCAM-1 in the Val-MARC trial. These effects, although statistically significant, were small and independent of changes in blood pressure.

Renin-angiotensin and endothelial nitric oxide synthase gene polymorphisms are not associated with the risk of incident type 2 diabetes mellitus: a prospective cohort study.

OBJECTIVE: The renin-angiotensin system and endothelial function have both been implicated in the pathogenesis of type 2 diabetes. The aim of this study was to assess the relationship between a set of well-characterized genetic variants of the renin-angiotensin system and the endothelial nitric oxide synthase (NOS3) gene and the incidence of type 2 diabetes. DESIGN: Prospective cohort study. SETTING: Women's Health Study, United States. SUBJECTS: A total of 24,309 Caucasian women free of diabetes at baseline. MAIN OUTCOME MEASURES: Six previously characterized single nucleotide polymorphisms (NOS3 rs1800779, NOS3 rs3918226, NOS3 rs1799983, ACE rs1799752, AGT rs699 and AGTR rs5186) were genotyped. Cox proportional-hazards models were constructed to compare the incidence of type 2 diabetes according to the different genotypes. RESULTS: During a median follow-up of 10.2 years (interquartile range 9.6-10.6 years), 999 women developed type 2 diabetes. The age-adjusted incidence rates across the six genotypes were very similar, and ranged from 3.7 to 4.8 cases/1000 person-years of follow-up. The multivariable adjusted hazard ratios (95% confidence intervals) for rs1800779, rs3918226, rs1799983, rs1799752, rs699, and rs5186 were 1.01 (0.92-1.10), 1.09 (0.93-1.27), 0.95 (0.86-1.05), 1.04 (0.95-1.14), 1.08 (0.98-1.18), 1.01 (0.91-1.11), confirming the lack of association between the genotypes and incident type 2 diabetes. Stratification by body mass index revealed essentially unchanged results. Finally, there was no association between NOS3-haplotypes and incident type 2 diabetes. CONCLUSION: We did not find an association between six well-characterized genetic polymorphisms of the renin-angiotensin system or the NOS3 gene and the occurrence of type 2 diabetes.

[Myositis with pulmonary fibrosis and eosinophilia]. / Myositis mit Lungenfibrose und Eosinophilie.

A 74-year old female patient suffered from dyspnoea, subfebrile body temperature, myalgias, arthralgias and presented a transitory skin rash. Further findings were an eosinophilia, synovitis, a myositis and pulmonary fibrosis. There was no evidence for a malignancy or an infectious disease. We diagnosed an Anti-Jo-1-Syndrome with a secondary Sjoegren syndrome. Immunsuppressive therapy with steroids, later in addition methotrexate led to improvement of the patient's clinical condition. Above mentioned symptoms and its differential diagnosis are discussed in this article.

C-reactive protein and echocardiography have little impact on risk stratification in never-treated hypertensive patients.

The aim of this study was to assess the contribution of increased concentrations of high-sensitivity C-reactive protein (hsCRP) and echocardiography to risk stratification according to the 2003 European guidelines for the management of arterial hypertension in patients with untreated hypertension. A total of 207 consecutive medical outpatients with untreated hypertension were included. History and clinical examination, electrocardiography, laboratory analyses including the measurement of hsCRP and echocardiography were performed in all patients. Patients were classified into four risk groups with and without using echocardiography and hsCRP concentrations of at least 10 mg/l according to the 2003 guidelines for the management of hypertension. The majority of the 207 patients (81%) were at moderate or high cardiovascular risk before adding echocardiography and/or hsCRP to the risk stratification process. When echocardiography was included, only three patients were reclassified from the moderate added risk to the high added risk group. Adding hsCRP concentrations of at least 10 mg/l had no impact on risk stratification. Using an hsCRP cutoff level of 3 mg/l, one patient was at moderate instead of low added risk, eight patients were at high instead of moderate added risk and one patient was at very high instead of high added risk. We conclude that hsCRP at the proposed cutoff level of 10 mg/l has no impact on risk stratification in outpatients with untreated hypertension. An hsCRP cutoff level of 3 mg/l may be more suitable for risk stratification. Finally, our data suggest that depending on the population studied, there is minimal impact of echocardiography on risk stratification.

Substantial intraindividual variability of BNP concentrations in patients with hypertension.

Plasma concentrations of B-type natriuretic peptides (BNP) independently predict the risk of death and cardiovascular events. In the present study, we investigated the intraindividual variability of BNP concentrations, a potential confounder of risk prediction. Consecutive outpatients with blood pressure (BP) values of at least 140/90 mm Hg and not taking BP lowering therapy were asked to participate. Exclusion criteria were renal insufficiency, structural heart disease on echocardiography, except left ventricular hypertrophy and any other severe concomitant illness. Plasma BNP levels were determined on two different days using the same assay. In total, 77 patients were included. Mean age was 54+/-12 years, 55% were male and mean systolic/diastolic BP was 163+/-16/96+/-8 mm Hg. Mean creatinine was 70+/-14 micromol/l. The median interval between the two BNP assays was 10 days (interquartile range 1-23 days). Median BNP concentrations were 17 and 16 pg/ml for the first and second visit, respectively (P=0.48). However, there was a wide range of differences in BNP values among individual patients, 34 patients (44%) having an absolute difference of at least 10 pg/ml. When patients were categorized according to tertiles of BNP levels, 25 (32%) changed from one tertile at the first visit to another at the second visit. In conclusion, these data indicate that BNP levels may be used on a population level. However, the high intraindividual variability seems to preclude useful risk stratification in the individual patient. Care should be taken in the interpretation of single BNP values below the currently accepted thresholds for heart failure.

Pancreatic necrosis infection due to Lactobacillus paracasei in an immunocompetent patient.

An immunocompetent patient recovering from gallstone-induced pancreatitis had to be readmitted due to abdominal pain, fever, and rapid deterioration. Computed tomography guided needle aspiration established the diagnosis of pancreatic necrosis infection; microbiological investigations revealed monoinfection with Lactobacillus paracasei subspecies tolerans. To our knowledge, this is the first description of a pancreatic necrosis infection due to L. paracasei in an immunocompetent patient without any known risk factors for Lactobacillus infections.

[Anaphylactic reaction after Fe-injection]. / Anaphylaktische Reaktion nach intravenöser Fe-Injektion. 84-jährige Patientin mit anaphylaktischer Reaktion nach einer intravenösen Eiseninjektion.

An anaphylactic reaction after intravenous Fe injection (Ferrum Hausmann) occurred in an 84-year-old female patient on treatment for iron deficiency anemia. After emergency admission to hospital, it emerged that she suffered an acute anteroseptal myocardial event, but could be mobilized without any problems on adequate cardiac medication. After ruling out any hyporegenerative pathology, the hemoglobin level of 101 g/L registered can probably be explained within the scope of mild renal insufficiency. Instead of the intravenous form of iron (III) sucrose (saccharate) complex (Ferrum Hausmann i.v. / Venofer), the attending general practitioner had administered parenteral iron replacement i.v. in the form of Ferrum Hausmann (iron (III) hydroxide dextran complex), which is intended for intramuscular administration. This is the reason why, firstly, the oral form of administration should be preferred over the parenteral and, secondly, parenteral replacement using the iron saccharate complex should be only initiated in the case of a pathological oral iron load test indicating an iron resorption disorder.

[Glossary on patient safety -- a contribution to on-target-definition and to appreciate the subjects of "patient safety"]. / Das Glossar Patientensicherheit -- Ein Beitrag zur Definitionsbestimmung und zum Verständnis der Thematik "Patientensicherheit" und "Fehler in der Medizin".

Since the release of the report "To Err is Human" by the American Institute of Medicine (IOM) the subject "Medical Risks, Errors and Patient Safety" has gained increasing interest in literature. In Germany, neither extensive statistics nor generally significant epidemiological studies regarding common errors associated with damages caused to patients' health exist. In recent years the subject has become increasingly interesting both in specialist discussion and it the lay press; it has become evident that the different use of terms, especially those originating from the Anglo-Saxon language, can lead to misunderstandings. Hence, as one of the first steps of its action programme, the expert panel "Patient Safety" of the German Agency for Quality in Medicine has compiled a glossary of technical terms to provide adequate support to the discussion this important subject of nomenclature.

Women's experiences with low-risk singleton in-hospital delivery in Switzerland.

OBJECTIVE: To assess maternal and neonatal clinical short-term outcomes and women's experiences with singleton low-risk in-hospital deliveries in a routine care setting. METHODS: In 13 community hospitals in the Cantons of Zurich (10), St. Gallen (2) and Schwyz (1), participating in the "Canton of Zurich Outcomes Project", trained hospital staff recorded clinical outcome data. Patients completed a questionnaire at the end of the hospital stay. Over two measurement cycles, 3395 eligible women entered the study and 2079 (61%) returned the questionnaire. RESULTS: Sixty-seven percent of women had spontaneous and 11% had assisted vaginal deliveries, 12% delivered by emergency, and 10% by elective Caesarean section. The episiotomy rate in vaginal deliveries was 46% (95% CI 44-48%). Ten percent of neonates had umbilical cord artery pH < or =7.15 (95% CI 9-11%) and Apgar scores at five minutes were < or = 7 in 3% (95% CI 2.5-3.6%). Reporting negative experiences with hospital care and an insufficient state of knowledge at discharge were strongly associated with mode of delivery. The top three issues new mothers were most likely to report about feeling little or not informed about were postpartum pelvic floor exercises (22%), management of vaginal bleedings (12%), and alternatives of infant feeding (10%). CONCLUSION: In a setting of routine care poor short-term outcomes were rare in women giving birth in hospitals, and neonates and most mothers were discharged with a level of information that at least ensured a smooth transition to follow-up maternal care. Poor clinical results and patient-reported negative experiences concentrate in few individuals. Restrictive approaches that reduce the frequency of instrumental vaginal delivery, and routine episiotomy remain an important objective for quality improvement.

Prevalence of hyperuricemia and relation of serum uric acid with cardiovascular risk factors in a developing country.

BACKGROUND: The prevalence of hyperuricemia has rarely been investigated in developing countries. The purpose of the present study was to investigate the prevalence of hyperuricemia and the association between uric acid levels and the various cardiovascular risk factors in a developing country with high average blood pressures (the Seychelles, Indian Ocean, population mainly of African origin). METHODS: This cross-sectional health examination survey was based on a population random sample from the Seychelles. It included 1011 subjects aged 25 to 64 years. Blood pressure (BP), body mass index (BMI), waist circumference, waist-to-hip ratio, total and HDL cholesterol, serum triglycerides and serum uric acid were measured. Data were analyzed using scatterplot smoothing techniques and gender-specific linear regression models. RESULTS: The prevalence of a serum uric acid level >420 micromol/L in men was 35.2% and the prevalence of a serum uric acid level >360 micromol/L was 8.7% in women. Serum uric acid was strongly related to serum triglycerides in men as well as in women (r = 0.73 in men and r = 0.59 in women, p < 0.001). Uric acid levels were also significantly associated but to a lesser degree with age, BMI, blood pressure, alcohol and the use of antihypertensive therapy. In a regression model, triglycerides, age, BMI, antihypertensive therapy and alcohol consumption accounted for about 50% (R2) of the serum uric acid variations in men as well as in women. CONCLUSIONS: This study shows that the prevalence of hyperuricemia can be high in a developing country such as the Seychelles. Besides alcohol consumption and the use of antihypertensive therapy, mainly diuretics, serum uric acid is markedly associated with parameters of the metabolic syndrome, in particular serum triglycerides. Considering the growing incidence of obesity and metabolic syndrome worldwide and the potential link between hyperuricemia and cardiovascular complications, more emphasis should be put on the evolving prevalence of hyperuricemia in developing countries.