Angiotensin II receptor antagonists: different or equivalent?

ARA-II: Angiotensin II receptor antagonists (ARA-II) belong to a recent class of antihypertensive drugs whose mechanism of action is similar to converting enzyme inhibitors (CEI). ARA-II are particularly interesting due to the excellent clinical and biological tolerance, similar to placebo, and their antihypertensive efficacy, comparable with classical drug classes. PUBLISHED TRIALS: A meta-analysis, published by Conlin in the American Journal of Hypertension, suggests that ARA-II, specifically losartan, valsartan, irbesartan and candesartan, have an equipotent blood pressure lowering effect. The careful lecture of this meta-analysis however discloses a faulty methodology from which no valid conclusion can be drawn. Since this early publication, several other comparative studies have been published. These multicentric, randomized double-blind studies enrolled a sufficient number of patients and demonstrated a clinical difference between certain ARA-II at usual dosages. CLINICAL PRACTICE: These studies do have an impact on everyday practice. For the practitioner, the goal is to obtain and then maintain a long-term and optimal reduction in the blood pressure level (reduction or prevention of target-organ disorders and cardiovascular complications of high blood pressure). This reduction in the cardiovascular risk will also depend directly on tolerance and compliance to the antihypertensive treatment. This element must also be considered in assessing treatment efficacy, independent of the blood pressure lowering effect. The results of several other studies will be published in 2001-2003. These large-scale studies on ARA-II related morbidity and mortality will be most useful in determining the role of these drugs in different therapeutic strategies compared with other drug classes.     

BioGlue? in 2011: What Is Its Role in Cardiac Surgery?

BioGlue surgical adhesive was developed as an adjunct for achieving hemostasis during cardiovascular surgery, and it was approved for use in the United States by the Food and Drug Administration in 2001. When applied to cardiovascular tissues, the glutaraldehyde and bovine serum albumin that comprise BioGlue produce strong crosslinking that bonds tissues and seals defects. These features have made BioGlue particularly well suited for preventing bleeding from fragile cardiovascular anastomoses such as those inherent in the repair of acute aortic dissection. Over the 10-year period since its approval, several studies and clinical reports have illuminated the relative risks and benefits of using BioGlue during cardiovascular operations. Understanding these merits and limitations of BioGlue is essential to ensuring its safe and effective use.     

Has Microsoft? Left Behind Risk Modeling in Cardiac and Thoracic Surgery?

This concept paper examines a number of key areas central to quality and risk assessment in cardiac surgery. The effect of surgeon and institutional factors with regard to outcomes in cardiac surgery is utilized to demonstrate the need to sub analyze cardiac surgeons performance in a more sophisticated manner than just operation type and patient risk factors, as in current risk models. By utilizing the mathematical/engineering concept of Fourier analysis in the breakdown of cardiac surgical results the effects of each of the core components that makes up the care package of a patient's experiences are examined. The core components examined include: institutional, regional, patient, and surgeon effects. The limitations of current additive (Parsonnet, Euroscore) and logistic (Euroscore, SouthernThoracic Society) regression risk analysis techniques are discussed. The inadequacy of current modeling techniques is demonstrated via the use of known medical formula for calculating flow in the internal mammary artery and the calculation of blood pressure. By examining the fundamental limitations of current risk analysis techniques a new technique is proposed that embraces modern software computer technology via the use of structured query language.     

Reducing Emboli in Cardiac Surgery: Does It Make a Difference?

Particulate embolization remains a serious complication of cardiac surgery. Adverse events associated with particulate embolization affect patient morbidity and long-term survival, and increase the length of hospital stay and the cost of health care. Today, atherosclerosis plays a role in at least two-thirds of all adverse events after coronary artery revascularization, and postoperative stroke is the second most common cause of operative mortality. Because many lower-risk patients now undergo interventional revascularization, higher-risk patients are now typically referred for surgical revascularization. These patients are older and sicker, and have multiple comorbidities, making them more susceptible to adverse events. For these high-risk patients, surgeons should be proactive in attempting to reduce the possibility of emboli. Patients must be carefully assessed before surgery to determine their risk, and if the risk is high, surgeons should consider using newer, innovative devices, and techniques in their operative strategy that have proven to be effective in mitigating some of the potential embolic adverse events. A multifaceted, preventive strategy can make a difference, not only in reducing particulate emboli, but also in reducing morbidity and in lowering the economic burden on the health-care system. This brief review will address three areas of focus that are important for the prevention of particulate embolization: (i) prevalence and morbidity of atherosclerotic disease; (ii) risk factors for adverse neurologic events; and (iii) prevention/mitigation of adverse events for patients undergoing cardiac surgery.