Search

Black patients have a higher prevalence of peripheral artery disease (PAD) than white patients, and also tend to have a greater extent and severity of disease, and poorer outcomes. The association of race with quality of health (QOH) after peripheral vascular intervention (PVI), however, is less well-known. In our study, we hypothesized that after PVI, black patients experience worse QOH than white patients. We retrospectively assessed racial differences in health status using responses to the Peripheral Arterial Questionnaire (PAQ) at baseline (pre-PVI) and up to 6 months following PVI among 387 patients. We used the PAQ summary score (which includes physical limitation, symptoms, social function and quality of life) as a measure of QOH. We compared QOH scores at baseline and at follow-up after PVI between black (n=132, 34.1%) and white (n=255, 65.9%) patients. We then computed the change in score from baseline to follow-up for each patient (the delta) and compared the median delta between the two groups. Multivariable regression was used to model the delta QOH after controlling for factors associated with race or with the delta QOH. There was no significant difference in mean QOH by race either at baseline (p=0.09) or at follow-up (p=0.45). There was no significant difference in the unadjusted median delta by race (white 25.3 vs black 21.5, p=0.28) and QOH scores improved significantly at follow-up in both groups, albeit the improvement was marginally lower in black compared with white patients after adjustment for baseline confounders (b = -6.6, p=0.05, 95% CI -13.2, -0.11). [ABSTRACT FROM AUTHOR]

Background Teaching practice-based learning and improvement and systems-based practice are challenging. Cardiology fellows at St John Hospital & Medical Center participate in a national registry of outpatient cardiology care. Objective We assessed the use of the registry, hypothesizing that it could serve as an effective foundation for studying ambulatory care, identifying gaps in care, and planning interventions to advance competence in practice-based learning and improvement and systems-based practice. Methods Starting in 2009, trainees prospectively entered data for ambulatory cardiac patients into the PINNACLE Registry database where compliance with 28 performance measures was calculated and reported quarterly. Fellows met with the program director individually and in groups to identify performance gaps and to develop and implement plans for quality improvement. Cardiology fellows were surveyed annually to assess this process. Results Through March 2012, the fellows had completed 2400 patient visits. Participation was feasible because it was cost neutral, with data form completion averaging 5 minutes. It was acceptable, with most fellows describing positive effects on practice-based learning and improvement without significant detriment to work flow. Performance achievement for drug therapies ranged from 69% (77 of 111) of the patients with atrial fibrillation receiving anticoagulation to 99% (486 of 489) of patients with coronary disease receiving lipidlowering therapy. Gaps in system performance included low levels for diabetes screening (5%; 20 of 422) and lipid monitoring (10%; 58 of 573). Initial quality improvement projects addressed practice gaps with straightforward solutions. Improving system performance was more challenging. Conclusions Using a registry in cardiology trainees' outpatient practice is feasible, acceptable, and valuable. It allows for planning and studying the effects of quality improvement projects. [ABSTRACT FROM AUTHOR]

Doppler methods for assessing left ventricular (LV) diastolic function have increased in number and complexity. However, time constraints may prevent measurement of all parameters during routine transthoracic echocardiography. Therefore, we designed a study to determine which Doppler parameters could be most successfully and quickly obtained. The recording success rate and time required to record different LV diastolic function parameters were evaluated in 80 patients. A specific recording protocol was followed by an experienced, credentialed sonographer and time intervals to record each parameter were measured. In comparison with color Doppler M-mode of LV inflow propagation velocities (Vp) and pulmonary venous (PV) flow measurements, transmitral valve (MV) flow and tissue Doppler imaging (TDI) of the mitral annulus had the highest recording success rate and required the shortest time to record. PV flow and Vp took longer to obtain (80.1 ± 34.3 sec and 57.1 ± 29.1 sec, respectively) than did mitral valve inflow (36.3 ± 20.7sec) and mitral valve annular TDI (29.3 ± 18.4 sec for septal and 33.3 ± 14.5sec for lateral). MV flow velocities, Vp, and TDI were successfully recorded in virtually all patients (99–100%). In comparison, the PV flow velocities and durations were successfully recorded less often. The range of success rates for the six PV flow parameters was 49–84%. Since MV flow and TDI also have been shown by us to have the lowest interreader variability, measurement of these two parameters may be preferred for routine clinical evaluation of LV diastolic function in a busy echocardiography laboratory. [ABSTRACT FROM AUTHOR]

Aneurysmal dilatation of saphenous vein graft (SVG), first reported in 1975, is secondary to true aneurysm or pseudoaneurysm. We report 1 case and review 107 cases published since 1975. Severe SVG dilatations are large (6 ± 3 cm), occur remote from surgery (12 ± 4 years) and are life threatening, with 15.7% in-hospital mortality. Symptoms are nonspecific and the abnormality is initially observed by chest X-ray in 57% of cases. The chest X-ray abnormalities have a distinctive appearance that may suggest both diagnosis and which SVG is involved. Diagnosis is made clinically by imaging, i.e. computed tomography, echocardiography, magnetic resonance and/or surgical observation (66 cases), or most accurately by tissue evaluation by the pathologist (42 cases). Aneurysm is more common than pseudoaneurysm by a 6:1 ratio. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The article presents a study on the utility of B-type natriuretic peptide and N-terminal pro B-type natriuretic peptide in evaluation of respiratory failure in critically ill patients. The subjects used in the study were 41 consecutive patients with hypoxic respiratory failure undergoing pulmonary artery catheterization enrolled between January and December 2003. The methods used in the study were presented and offers an explanation on the result of the study.

The safety of glycoprotein (GP) IIb/IIIa inhibitors has been well documented in clinical trials. Although these trials have included a broad patient population, the strict enrollment criteria may have resulted in exclusion of patients at a higher risk of bleeding complications. The authors conducted a retrospective chart review of 1020 consecutive patients who received GP IIb/IIIa inhibitors and underwent percutaneous coronary intervention in a large community hospital. They used Thrombolysis in Myocardial Infarction (TIMI) criteria to define major or minor bleeding complications. Bleeding complications developed in 214 (21%) patients, with major bleeding in 89 (9%). Univariate predictors of bleeding were older age, lower body weight, elevated serum creatinine, higher activated partial thromboplastin time (aPTT) level, history of diabetes mellitus (DM), peripheral vascular disease (PVD), congestive heart failure (CHF), and emergency procedure for acute myocardial infarction (AMI). Multivariate predictors of major bleeding were PVD (20% in bleeding group vs 11% in nonbleeders, odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.2-2.6, P < .004), age (68 ± 2 years, 95% CI = 66-70 in bleeding group vs 63 ± 13 years, 95% CI = 61.2-63 in nonbleeders, P < .001), and higher aPTT level (66 ± 27 seconds, 95% CI = 63-70 in bleeding group vs 53 ± 28 seconds, 95% CI = 51-56 in nonbleeders, P < .001). The risk of bleeding in the large community hospital setting may be higher than in randomized clinical trials. This increased risk is associated with higher hospitalization costs. Recognition of predictors of bleeding should further enhance the safety of these antiplatelet agents. [ABSTRACT FROM PUBLISHER]

Study objectives: To identify the risk of thromboembolism after withholding or reversing the effect of warfarin therapy following a major hemorrhage. Design: Retrospective medical record review. Setting: Tertiary-care hospital. Patients: Twenty-eight patients with prosthetic heart valves receiving warfarin were hospitalized for major hemorrhage from 1990 to 1997. The mean ± SD age was 61 ± 11 years (15 men and 13 women). Twenty patients had St. Jude valves, 4 patients had Carpentier-Edwards bioprosthetic valves, 2 patients had Start Edwards valves, and 2 patients had Bjork-Shiley valves. Valves were in the mitral position in 12 patients, the aortic position in 12 patients, and both mitral and aortic positions in 4 patients. The average interval from valve surgery to index bleeding was 7 years. Twenty-five patients had GI or retroperitoneal hemorrhage, 2 patients had an intracranial hemorrhage, and 1 patient had a subdural hematoma. Interventions: Vitamin K was administered to five patients and fresh frozen plasma was given to seven patients to reverse anticoagulation. The mean duration of antieoagulation withholding was 15 ± 4 days. Measurements and results: None of the patients had thromboembolic complications. There were four in-hospital deaths. Twenty-two of the 24 hospital survivors resumed warfarin therapy at hospital discharge. At 6-month follow-up, 10 of 19 patients remaining on warfarin therapy had recurrent GI bleeding. Conclusions: Thromboembolic risk is low in prosthetic heart valve patients hospitalized with major hemorrhage when their warfarin therapy is reversed or withheld. Recurrent bleeding within 6 months of the resumption of anticoagulation is common, and aggressive treatment of the bleeding source and the risk-benefit ratio of continued anticoagulation need to be considered. [ABSTRACT FROM AUTHOR]

Clinical and transthoracic echocardiographic findings in 92 patients who had atrial mass lesions identified by transesophageal echocardiography were retrospectively analyzed. Transthoracic echocardiography failed to diagnose or misdiagnosed 16 patients with small (< 3 cm) atrial thrombi, patients with thrombi localized to the appendage, or patients with technically difficult studies. The 3 patients with atrial myxoma who were not detected or were misdiagnosed by transthoracic echocardiography had small tumors (< 3 cm) or origin from the free wall of the atrium away from the atrial septum. Transthoracic study also failed to diagnose or misdiagnosed normal anatomic variants in 17 of 32 patients. In conclusion, transesophageal echocardiography is superior to the transthoracic study in evaluating the etiology and significance of atrial mass lesions. [ABSTRACT FROM AUTHOR]

Serial echocardiographic and color flow Doppler studies were performed in 38 mitral and aortic bioprosthetic valves. In the ensuing three to four months of follow-up, 7 patients developed clinical, angiographic evidence of severe valve regurgitation due to structural valve degeneration. Analysis of ultrasound studies revealed that increased thickness of the cusp by echocardiography and presence of mild to moderate color flow Doppler regurgitation preceded clinical regurgi tation in 5 and 4 bioprostheses respectively.In conclusion, echo and cardiac Doppler features of thickened and/or regur gitant valves are markers for degenerating bioprostheses and these features usually precede clinical dysfunction. [ABSTRACT FROM PUBLISHER]

Serial echocardiographic and color flow Doppler studies were performed in 38 mitral and aortic bioprosthetic valves. In the ensuing three to four months of follow-up, 7 patients developed clinical, angiographic evidence of severe valve regurgitation due to structural valve degeneration. Analysis of ultrasound studies revealed that increased thickness of the cusp by echocardiography and presence of mild to moderate color flow Doppler regurgitation preceded clinical regurgitation in 5 and 4 bioprostheses respectively. In conclusion, echo and cardiac Doppler features of thickened and/or regurgitant valves are markers for degenerating bioprostheses and these features usually precede clinical dysfunction. [ABSTRACT FROM AUTHOR]

A response by Dane Jefic to a letter to the editor about his article "Utility of B-type natriuretic peptide and N-terminal pro B-type natriuretic peptide in evaluation of respiratory failure in critically ill patients," in July 2005 issue is presented.