Efficacy and safety of transulnar coronary angiography and interventions--a single center experience.

OBJECTIVES: To evaluate the efficacy and long-term safety of transulnar approach in complex coronary interventions. BACKGROUND: The success rate of transulnar approach in complex coronary interventions and its long-term safety remains to be proven. METHODS: We conducted a retrospective chart review of patients undergoing transulnar coronary angiography and interventions at our institution from January 2004 through July 2009. Primary endpoint of the study was the success rate of the procedure. Secondary endpoints were major bleeding, local vascular and neurological complications, cerebrovascular accident (CVA)/transient ischemic attack (TIA), myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE) rate that was a composite of MI, CVA/TIA, and all-cause mortality. RESULTS: Of 81 patients undergoing transulnar approach, 41 (50.6%) patients underwent intervention on 65 lesions. Twelve percent of the interventions were performed on coronary bypass grafts and 9.2% on the left main coronary artery. Success rates for transulnar access, coronary angiography, and coronary/bypass graft interventions were 93.8%, 100%, and 92.6%, respectively. Follow-up data was available on 71 patients at short term (30 days) and 58 patients at long term (1 year). At 30-day follow-up, vascular complication rate was 2.8 %. At 1-year follow-up, there were no residual deficits from vascular or neurological complications associated with the index procedure and the overall MACE rate was 3.4%. CONCLUSION: In this first study evaluating long-term safety and feasibility of transulnar coronary angiography and complex coronary interventions, we conclude that transulnar approach appears to be safe and effective.

Reducing Heart Failure Hospital Readmissions: A Systematic Review of Disease Management Programs.

The recent enactment of the Patient Protection and Affordable Care Act which established the federal Hospital Readmissions Reduction Program (HRRP) has accelerated efforts to develop heart failure (HF) disease management programs (DMPs) that reduce readmissions in patients hospitalized for HF. This systematic review identified randomized controlled trials of HF DMPs which included home care, outpatient clinic interventions, structured telephone support, and non-invasive and invasive telemonitoring. These different types of DMPs have been associated with conflicting results. No specific type of DMP has produced consistent benefit in reducing HF hospitalizations. Although probably effective at reducing readmissions, home visits and outpatient clinic interventions have substantial limitations including cost and accessibility. Telemanagement has the potential to reach a large number of patients at a reasonable cost. Structured telephone support follow-up has been shown to significantly reduce HF readmissions, but does not significantly reduce all-cause mortality or all-cause hospitalization. A meta-analysis of 11 non-invasive telemonitoring studies demonstrated significant reductions in all-cause mortality and HF hospitalizations. Invasive telemonitoring is a potentially effective means of reducing HF hospitalizations, but only one study using pulmonary artery pressure monitoring was able to demonstrate a reduction in HF hospitalizations. Other studies using invasive hemodynamic monitoring have failed to demonstrate changes in rates of readmission or mortality. The efficacy of HF DMPs is associated with inconsistent results. Our review should not be interpreted to indicate that HF DMPs are universally ineffective. Rather, our data suggest that one approach applied to a broad spectrum of different patient types may produce an erratic impact on readmissions and clinical outcomes. HF DMPs should include the flexibility to meet the individualized needs of specific patients.

Development and validation of a risk calculator for prediction of cardiac risk after surgery.

BACKGROUND: Perioperative myocardial infarction or cardiac arrest is associated with significant morbidity and mortality. The Revised Cardiac Risk Index is currently the most commonly used cardiac risk stratification tool; however, it has several limitations, one of which is its relatively low discriminative ability. The objective of the present study was to develop and validate a predictive cardiac risk calculator. METHODS AND RESULTS: Patients who underwent surgery were identified from the American College of Surgeons' 2007 National Surgical Quality Improvement Program database, a multicenter (>250 hospitals) prospective database. Of the 211 410 patients, 1371 (0.65%) developed perioperative myocardial infarction or cardiac arrest. On multivariate logistic regression analysis, 5 predictors of perioperative myocardial infarction or cardiac arrest were identified: type of surgery, dependent functional status, abnormal creatinine, American Society of Anesthesiologists' class, and increasing age. The risk model based on the 2007 data set was subsequently validated on the 2008 data set (n=257 385). The model performance was very similar between the 2007 and 2008 data sets, with C statistics (also known as area under the receiver operating characteristic curve) of 0.884 and 0.874, respectively. Application of the Revised Cardiac Risk Index to the 2008 National Surgical Quality Improvement Program data set yielded a relatively lower C statistic (0.747). The risk model was used to develop an interactive risk calculator. CONCLUSIONS: The cardiac risk calculator provides a risk estimate of perioperative myocardial infarction or cardiac arrest and is anticipated to simplify the informed consent process. Its predictive performance surpasses that of the Revised Cardiac Risk Index.

Impact of statin use on heart failure mortality.

BACKGROUND: There is conflicting data regarding the mortality benefit of statins in patients with heart failure. The objectives of our study were to determine whether statin therapy is associated with decreased all-cause mortality and to assess the effect of incremental duration of therapy. METHODS: We studied 10,510 consecutive patients from the Veterans Affairs health system with a diagnosis of heart failure from January 2002 through December 2006. Mean follow-up was 2.66 years. Statin use and duration of therapy were identified. Veterans were classified into four groups based on duration of statin use during the study period (none, 1-25%, 26-75% and >75% use of statins). Logistic regression was performed to identify the association between incident statin use and all-cause mortality following a diagnosis of heart failure. The Kaplan-Meier method was employed to assess for differences in survival time between the four statin use classifications. RESULTS: Statin use was significantly associated with decreased all-cause mortality following a diagnosis of heart failure after controlling for age, gender, concurrent medications and comorbid diagnoses [χ(3)(2) (N = 10,510) = 1077.82, p < 0.001]. The benefit was seen within a relatively short duration (within 1 year) after starting statins, and in patients with <25% use of statins, there was no mortality benefit. CONCLUSION: Veterans who were not exposed to statin therapy at any time during the study period were 1.56 times more likely to suffer all-cause mortality.

Transient midventricular ballooning: a case report and review of the literature.

BACKGROUND: We describe a case of transient left midventricular ballooning in 68-year-old male patient presented with picture of acute coronary syndrome. CASE PRESENTATION: The left ventriculogram showed mid ventricular akinesis and dilatation along with hypercontractile apex and basal segments. Follow up echocardiogram after one month showed resolution of wall motions abnormalities and normalization of the left ventricular function. CONCLUSION: This is considered as a new variant of previously reported transient left ventricular apical ballooning; the only difference in our case is the location of wall motions abnormalities.

Intensive smoking cessation intervention reduces mortality in high-risk smokers with cardiovascular disease.

PURPOSES: To compare an intensive smoking cessation intervention against usual care in hospitalized high-risk smokers with acute cardiovascular disease. METHODS: A total of 209 hospitalized smokers were randomized to the intensive intervention (n = 109) or to usual care (n = 100). Usual care consisted only of counseling and printed educational material provided prior to hospital discharge. Intensive treatment consisted of a minimum of 12 weeks of behavior modification counseling and individualized pharmacotherapy provided at no cost to the participant. Smoking status in all subjects was confirmed biochemically (ie, by measuring expired carbon monoxide) at 3, 6, 12, and 24 months after randomization. Outcomes included point prevalence and continuous abstinence smoking cessation rates, hospitalizations, and all-cause mortality. RESULTS: At each follow-up interval, point prevalence and continuous abstinence smoking cessation rates were significantly greater in the intensive-treatment group compared to the usual-care group. At 24 months, continuous abstinence smoking cessation rates were 33% in the intensive-treatment group and 9% in the usual-care group (p < 0.0001). Over the 2-year follow-up period, 41 patients in the usual-care group were hospitalized compared to 25 patients in the intensive-treatment group (relative risk reduction [RRR], 44%; 95% confidence interval [CI], 16 to 63%; p = 0.007). The all-cause mortality rate was 2.8% in the intensive-treatment group and 12.0% in the usual-care group (RRR, 77%; 95% CI, 27 to 93%; p = 0.014). The absolute risk reduction in mortality was 9.2% with a number needed to treat of 11. CONCLUSION: Hospitalized smokers, especially those with cardiovascular disease, should undergo treatment with a structured intensive cessation intervention. The duration of the initial treatment should be 3 months.

Pharmacological management of atrial fibrillation following cardiac surgery.

Atrial fibrillation (AF) is the most common complication following coronary artery bypass graft surgery (CABG). Post-CABG AF occurs most commonly on the second postoperative day and declines in incidence thereafter. A number of risk factors have been found to be associated with a higher frequency of post-CABG AF. These risk factors include advanced age, a prior history of AF, hypertension, and heart failure. Postoperative complications--including low cardiac output, use of an intra-aortic balloon pump, pneumonia, and prolonged mechanical ventilation--are also associated with higher rates of post-CABG AF. Post-CABG AF increases the risk of stroke, and the length and cost of hospitalization. Prophylactic administration of conventional beta-adrenoceptor antagonists (beta-blockers) or sotalol produces a consistent and significant reduction in the incidence of post-CABG AF; however, results with prophylactic amiodarone or magnesium are less consistent. Termination of post-CABG AF, once it occurs, can be accomplished with a number of antiarrhythmic agents. Ibutilide has been the most widely studied agent for this indication. Sotalol is not indicated for cardioversion of AF and has not been studied in the post-CABG setting. Electrical cardioversion and biatrial pacing have also been used to terminate post-CABG AF. Ventricular rate is best controlled with beta-blockers and calcium channel antagonists. Esmolol has a rapid onset of action and is easily titrated to effect. Digoxin can control the ventricular rate, but has a slow onset of action. There are limited data available to guide decisions regarding the optimal management of post-CABG AF.

Nesiritide for heart failure: impact on costs and complications.

Decompensated heart failure accounts for approximately 1 million hospitalizations in the USA each year with an estimated cost of US$11,000 per hospitalization. Despite this prevalence and cost burden, relatively few therapies for decompensated heart failure have been developed over the past 30 years. Although once the mainstay of treatment of decompensated heart failure, the use of positive inotropic agents has fallen into disfavor. Although these agents improve hemodynamics and ejection fraction, there is evidence that the positive inotropes increase the risk of adverse clinical outcomes and mortality. Nesiritide is a naturetic peptide that produces balance vasodilation, inhibits sympathetic nervous system activity, and promotes diuresis and naturesis. At the time the drug received Food and Drug Administration approval for marketing in the USA, it had been shown to produce hemodynamic improvements to an extent greater than placebo or nitroglycerin. However, evidence of benefit in terms of clinical improvement and other outcomes was lacking. Recent trials have found that nesiritide reduces hospital length of stay (although not statistically significant in all trials) and healthcare resource utilization in patients admitted to hospital with decompensated heart failure. In a randomized, controlled trial, nesiritide given in the emergency room reduced hospital admissions for heart failure compared with placebo/usual care. Preliminary data from an outpatient intermittent infusion trial of nesiritide found that patients receiving nesiritide had fewer hospital admissions than patients randomized to standard care. There is currently little objective evidence that therapies used routinely in the management of patients with decompensated heart failure are associated with improved outcomes. Data with positive inotropic agents suggest that they do more harm than good. There is a growing body of evidence that nesiritide is associated with improvements in clinical outcomes in decompensated heart failure including fewer complications, less healthcare resource utilization, and lower costs when compared with standard therapy. Despite this evidence, larger, prospective trials demonstrating the impact of nesiritide on the costs and complications in decompensated heart failure are needed.

Impact of nesiritide on health care resource utilization and complications in patients with decompensated heart failure.

STUDY OBJECTIVE: To determine the impact of nesiritide on health care resource utilization and complications in patients hospitalized with decompensated heart failure. DESIGN: Retrospective case-control study. SETTING: United States hospitals. PATIENTS: Two hundred sixteen patients hospitalized for decompensated heart failure. MEASUREMENTS AND MAIN RESULTS: One hundred eight patients who received a nesiritide infusion for a minimum of 12 hours during the first 48 hours after hospital admission were matched with 108 patients not receiving nesiritide. Health care resource utilization, consisting of hospital length of stay (LOS), rate of rehospitalization within 90 days, concomitant drugs administered, and laboratory and diagnostic tests, was determined for each hospital admission. Rates of adverse events also were recorded. Patients receiving nesiritide had a significantly shorter LOS in a critical care unit (p=0.03). General medical ward or step-down unit LOS was not different between the treatment groups. A favorable trend toward a lower rate of rehospitalization over the 90-day follow-up period was observed with nesiritide (p=0.07). The number of patients who developed life-threatening ventricular arrhythmias and hypotension was similar for both treatment groups. However, in patients receiving nesiritide, significantly less atrial fibrillation (p=0.03) and renal dysfunction (p=0.04) occurred compared with patients not receiving nesiritide. CONCLUSION: Nesiritide therapy is associated with significant reductions in both health care resource utilization and complications in patients with decompensated heart failure.