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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2005.05.010 Byline: Artyom Sedrakyan (a)(b), Heping Zhang (c), Tom Treasure (d), Harlan M. Krumholz (c)(e) Abstract: Knowledge of the risk of atrial fibrillation (AF) for patients undergoing coronary artery bypass graft surgery (CABG) can guide decisions about prophylactic therapy. Accordingly, we sought to use tree-based methods to stratify patients into groups that will have similar risk of AF after CABG and informed decision making regarding aggressive prophylaxis of AF. Author Affiliation: (a) Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD (b) Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom (c) Yale University School of Medicine, New Haven, CT (d) Cardiothoracic Unit, Guy's Hospital, London, United Kingdom (e) Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, CT Article History: Received 8 October 2004; Accepted 9 May 2005

Beta blockers do not increase the risk of depression, fatigue, or sexual problems, according to researchers who analyzed 15 studies involving more than 35,000 patients who took beta blockers to treat heart attack, heart failure, or hypertension. This is important because beta blockers can benefit many patients, but many doctors do not prescribe them., Context: [beta]-Blocker therapy remains substantially underused in cardiac patients despite its proven mortality benefits. Reluctance to prescribe these agents may derive from concerns about their association with symptoms of depression, fatigue, and sexual dysfunction. Objective: To determine the association of [beta]-blockers with depressive symptoms, fatigue, and sexual dysfunction by performing a quantitative review of randomized trials that tested [beta]-blockers in myocardial infarction, heart failure, and hypertension. Data Sources: Randomized trials of [beta]-blockers used in the treatment of myocardial infarction, heart failure, or hypertension were identified by searching the MEDLINE database for English-language articles (1966-2001). In addition, we searched the reference lists of previously published trials and reviews of [beta]-blockers for additional studies. Study Selection: Criteria for inclusion of trials in the review were: random allocation of study treatments, placebo control, noncrossover design, enrollment of at least 100 patients, and a minimum of 6 months of follow-up. The initial search produced 475 articles, 42 of which met these criteria. Fifteen of these trials reported on depressive symptoms, fatigue, or sexual dysfunction and were selected for inclusion. Data Extraction: For each trial, 1 author abstracted the frequency of adverse events in the [beta]-blocker and placebo groups and the numbers of patients randomized to the treatment groups. Two other authors verified the counts of events, and all authors adjudicated any discrepancies. Two different types of information on adverse events were abstracted: patient-reported symptoms and withdrawal of therapy due to a specified symptom. We categorized the tested [beta]-blockers by generation (early vs late) and lipid solubility (high vs low to moderate). Data Synthesis: The 15 trials involved more than 35000 subjects. [beta]-Blocker therapy was not associated with a significant absolute annual increase in risk of reported depressive symptoms (6 per 1000 patients; 95% confidence interval [CI], -7 to 19). [beta]-Blockers were associated with a small significant annual increase in risk of reported fatigue (18 per 1000 patients; 95% CI, 5-30), equivalent to 1 additional report of fatigue for every 57 patients treated per year with [beta]-blockers. [beta]-Blockers were also associated with a small, significant annual increase in risk of reported sexual dysfunction (5 per 1000 patients; 95% CI, 2-8), equivalent to one additional report for every 199 patients treated per year. None of the risks of adverse effects differed significantly by degree of [beta]-blocker lipid solubility. The risk associated with reported fatigue was significantly higher for early-generation than for late-generation [beta]-blockers (P=.04). Conclusion: The conventional wisdom that [beta]-blocker therapy is associated with substantial risks of depressive symptoms, fatigue, and sexual dysfunction is not supported by data from clinical trials. There is no significant increased risk of depressive symptoms and only small increased risks of fatigue and sexual dysfunction. The risks of these adverse effects should be put in the context of the documented benefits of these medications.

Objective: Use of cardiac devices has been increasing rapidly along with concerns over their safety and effectiveness. This study used hospital administrative data to assess cardiac device implantations in the United States, selected perioperative outcomes, and associated patient and hospital characteristics.Methods: We screened hospital discharge abstracts from the 1997-2004 Healthcare Cost and Utilization Project Nationwide Inpatient Samples. Patients who underwent implantation of pacemaker (PM), automatic cardioverter/defibrillator (AICD), or cardiac resynchronization therapy pacemaker (CRT-P) or defibrillator (CRT-D) were identified using ICD-9-CM procedure codes. Outcomes ascertainable from these data and associated hospital and patient characteristics were analyzed.Measurements and Main Results: Approximately 67,000 AICDs and 178,000 PMs were implanted in 2004 in the United States, increasing 60% and 19%, respectively, since 1997. After FDA approval in 2001, CRT-D and CRT-P reached 33,000 and 7,000 units per year in the United States in 2004. About 70% of the patients were aged 65 years or older, and more than 75% of the patients had 1 or more comorbid diseases. There were substantial decreases in length of stay, but marked increases in charges, for example, the length of stay of AICD implantations halved (from 9.9 days in 1997 to 5.2 days in 2004), whereas charges nearly doubled (from $66,000 in 1997 to $117,000 in 2004). Rates of in-hospital mortality and complications fluctuated slightly during the period. Overall, adverse outcomes were associated with advanced age, comorbid conditions, and emergency admissions, and there was no consistent volume-outcome relationship across different outcome measures and patient groups.Conclusions: The numbers of cardiac device implantations in the United States steadily increased from 1997 to 2004, with substantial reductions in length of stay and increases in charges. Rates of in-hospital mortality and complications changed slightly over the years and were associated primarily with patient frailty. [ABSTRACT FROM AUTHOR]

Provides letters to the editor on a variety of medical issues. Medical residents' emotional well-being; Role of regional anesthesia and preeclampsia; Guidelines for the treatment of anthrax.