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The term precision medicine refers to the tailoring of diagnostics or therapeutics to individual patients based on their unique genetic and physiologic characteristics. (1) Although 'personalized or individualized care' (i.e., [...]

Background: Baseline Q waves may provide additional value compared with time from the onset of symptoms in predicting outcomes for patients with ST-segment elevation. We evaluated whether baseline Q waves superseded time from symptom onset as a prognostic marker of one-year mortality in patients with ST-segment elevation acute coronary syndrome. Our study was derived from data from patients undergoing primary percutaneous coronary intervention within 24 hours in the PLATelet inhibition and patient Outcomes trial Methods: Q waves on the baseline electrocardiogram were evaluated by a blinded core laboratory. We assessed the associations between baseline Q waves and time from symptom onset to percutaneous coronary intervention with peak biomarkers, ST-segment resolution on the discharge electrocardiogram, and one-year all-cause and vascular mortality. Results: Of 4341 patients with ST-segment elevation, 46% had baseline Q waves. Compared to those without Q waves, those with baseline Q waves were older, more frequently male, had higher heart rates, more advanced Killip class and had a longer time between the onset of symptoms and percutaneous coronary intervention. They also had higher one-year all-cause mortality than patients without baseline Q waves (baseline Q waves: 4.9%; no baseline Q waves: 2.8%; hazard ratio [HR] 1.78, 95% confidence interval [CI] 1.29-2.45, p < 0.001). Complete ST-segment resolution was greatest and all-cause mortality lowest among those with symptom onset three hours or less before percutaneous coronary intervention and no baseline Q waves. After multivariable adjustment, baseline Q waves, but not time from symptom onset, were associated with a significant increase in all-cause mortality (adjusted HR 1.42, 95% CI 1.10-2.01, p = 0.046) and vascular mortality (adjusted HR 1.58, 95% CI 1.09-2.28, p = 0.02). Interpretation: The presence of baseline Q waves provides useful additional prognostic insight into the clinical outcome of patients with ST-segment elevation. Clinical Trials.gov registration no. NCT00391872, The clinical outcome of patients with ST-segment elevation myocardial infarction (STEMI) is directly related to the extent of myocardial necrosis. (1) Because the extent of necrosis is strongly influenced by [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2009.09.015 Byline: Renato D. Lopes (a), Aijing Starr (a), Carl F. Pieper (b), Sana M. Al-Khatib (a), L. Kristin Newby (a), Rajendra H. Mehta (a), Frans Van de Werf (c), Kenneth W. Mahaffey (a), Paul W. Armstrong (d), Robert A. Harrington (a), Harvey D. White (e), Lars Wallentin (f), Christopher B. Granger (a) Keywords: Acute coronary syndrome; Antithrombotics; Atrial fibrillation; Bleeding risk Abstract: We examined warfarin use at discharge (according to Congestive heart failure, Hypertension, Age75 years, Diabetes, Prior Stroke/transient ischemic attack score and bleeding risk) and its association with 6-month death or myocardial infarction in patients with post-acute coronary syndrome atrial fibrillation. Author Affiliation: (a) Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (b) Department of Biostatistics and Bioinformatics, School of Medicine, Duke University, Durham, NC (c) Department of Cardiology, University Hospital Gasthuisberg and Leuven Coordinating Center, Leuven, Belgium (d) Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada (e) Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (f) Uppsala Clinical Research Center, Uppsala, Sweden Article Note: (footnote) Funding: The Duke Clinical Research Institute., Conflict of Interest: The authors state that they have no conflict of interest regarding the content of the article., Authorship: All authors had access to the data and played a role in writing this manuscript.

Background: Guidelines recommend that patients with heart failure receive [beta]-blockers in doses used in the trials that have proven their efficacy. Although the adverse effects of [beta]-blockade are dose-related, it is unclear whether the benefits are. Purpose: To determine whether the survival benefits of [beta]-blockade in heart failure are associated with the magnitude of heart rate reduction or the [beta]-blocker dose. Data Sources: MEDLINE, EMBASE, CINAHL, SIGLE, Web of Science, and the Cochrane Central Register of Controlled Trials, supplemented by hand-searches of bibliographies. Study Selection: Randomized, placebo-controlled heart failure trials that reported all-cause mortality. Data Extraction: Two reviewers independently extracted data on study characteristics, [beta]-blocker dosing and heart rate reduction, and death. Data Synthesis: The mean left ventricular ejection fraction in the 23 [beta]-blocker trials ranged from 0.17 to 0.36, and more than 95% of the 19 209 patients had systolic dysfunction. The overall risk ratio for death was 0.76 (95% CI, 0.68 to 0.84); however, heterogeneity testing revealed moderate heterogeneity among trials ([l.sup.2] = 30%), which was associated with the magnitude of heart rate reduction achieved within each trial (P for meta-regression = 0.006). For every heart rate reduction of 5 beats/min with [beta]-blocker treatment, a commensurate 18% reduction (CI, 6% to 29%) in the risk for death occurred. No significant relationship between all-cause mortality and [beta]-blocker dosing was observed (risk ratio for death, 0.74 [CI, 0.64 to 0.86]) in high-dose [beta]-blocker trials vs. 0.78 [CI, 0.63 to 0.96] in low-dose [beta]-blocker trials; P for meta-regression = 0.69). Limitations: The analysis is based on aggregate data and resting heart rates. Few patients in these trials had bradycardia or diastolic dysfunction at baseline. Conclusion: The magnitude of heart rate reduction is statistically significantly associated with the survival benefit of [beta]-blockers in heart failure, whereas the dose of [beta]-blocker is not.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2006.05.056 Byline: Wei-Ching Chang, Padma Kaul, Cynthia M. Westerhout, Michelle M. Graham, Paul W. Armstrong Keywords: Acute myocardial infarction; Socioeconomic status; Emergency department; Revascularization Abstract: To assess the effects of socioeconomic status on mortality in patients with acute myocardial infarction. Author Affiliation: University of Alberta, Edmonton, Alberta, Canada. Article Note: (footnote) This study was supported by a grant from the Canadian Institute of Health Research. Although the study is based in part on data provided by Alberta Health and Wellness, the interpretation and conclusions contained herein are those of the researchers and do not necessarily represent the views of the Government of Alberta. Neither the Government nor Alberta Health and Wellness express any opinion in relation to this study.

Background: Sudden cardiac death is common in persons with cardiovascular disease. Purpose: To assess the efficacy of implantable cardioverter defibrillators (ICDs) in persons at increased risk for sudden cardiac death. Data Sources: MEDLINE (1980-2002), EMBASE (1980-2002), Cochrane Controlled Clinical Trial Registry (2002, Volume 3), other databases, and conference proceedings. Primary study authors and device manufacturers were contacted, and bibliographies of relevant papers were hand searched. Study Selection: Randomized, controlled clinical trials evaluating ICDs versus usual care were selected. Data Extraction: Two reviewers extracted data independently. Data Synthesis: Eight trials were included in the final analysis (4909 patients, 1154 deaths). Compared with usual care (most commonly amiodarone therapy), ICDs significantly reduced sudden cardiac death (relative risk [RR], 0.43 [95% CI, 0.35 to 0.53]) and all-cause mortality (RR, 0.74 [CI, 0.67 to 0.82]). The included trials were divided a priori into two categories: secondary prevention (involving patients resuscitated after cardiac arrest or unstable ventricular tachycardia or ventricular fibrillation [n=1963]) and primary prevention (involving patients at increased risk for sudden cardiac death but without documented cardiac arrest, ventricular fibrillation, or ventricular tachycardia [n=2946]). Regardless of baseline risk, ICDs were equally efficacious in preventing sudden cardiac death in both types of trials (RR, 0.50 [CI, 0.38 to 0.66] for secondary prevention vs. 0.37 [CI, 0.27 to 0.50] for primary prevention). However, the magnitude of benefit in total mortality varied within the primary prevention trials depending on baseline risk for sudden cardiac death. Conclusions: Implantable cardioverter defibrillators prevent sudden cardiac death regardless of baseline risk. However, their impact on total mortality is sensitive to baseline risk for arrhythmic death. Decisions about resource allocation for ICDs depend on accurate stratification of patients according to risk.

Clinical practice guidelines are consensus statements systematically developed to help physicians, and ultimately patients, make decisions about appropriate health care for specific clinical circumstances. Over 20 years ago the American [...]

Background and Purpose. Nondistally fixated (ie, what is often referred to as 'open kinetic chain' [OKC]) knee extensor resistance training appears to have lost favor for some forms of rehabilitation due partly to concerns that this exercise will irritate the extensor mechanism. In this randomized, single-blind clinical trial, nondistally fixated versus distally fixated (ie, often called 'closed kinetic chain' [CKC]) leg extensor training were compared for their effects on knee pain. Subjects. Forty-three patients recovering from anterior cruciate ligament (ACL) reconstruction surgery (34 male, 9 female; mean age=29 years, SD=7.9, range= 16-54). Methods. Knee pain was measured at 2 and 6 weeks after ACL reconstruction surgery using visual analog scales in a self-assessment questionnaire and during maximal isometric contractions of the knee extensors. Between test sessions, subjects trained 3 times per week using either OKC or CKC resistance of their knee and hip extensors as part of their physical therapy. Results. No differences in knee pain were found between the treatment groups. Discussion and Conclusion. Open kinetic chain and CKC leg extensor training in the early period after ACL reconstruction surgery do not differ in their immediate effects on anterior knee pain. Based on these findings, further studies are needed using different exercise dosages and patient groups. [Morrissey MC, Drechsler WI, Morrissey D, et al. Effects of distally fixated versus nondistally fixated leg extensor resistance training on knee pain in the early period after anterior cruciate ligament reconstruction. Phys Ther. 2002;82:35-43.] Key Words: Anterior knee pain, Patellofemoral joint, Resistance training., We believe that since the early 1990s, there has been a shift among clinicians regarding the type of resistance exercise used for the knee extensors in knee rehabilitation. The shift, [...]

Abstract Objective To determine whether multidisciplinary disease management programmes for patients with coronary heart disease improve processes of care and reduce morbidity and mortality. Data sources Randomised clinical trials of [...]