上海市普陀区高血压社区规范管理的模式和效果探讨

目的在社区进行高血压规范管理,观察高血压治疗率和控制率,了解血压水平和心血管危险分层的变化。方法 2009-04-2010-04在上海市普陀区4个社区2048人中检查出高血压患者977例,按照心血管危险因素分层实行分级管理1年,设立健康管理专员进行管理,随访包括血压测量、健康教育和治疗方案调整。结果高血压患者977例一年的规范管理率88.9%;管理前后高血压的治疗率从66.7%(652/977)提高到73.6%(655/890),高血压控制率从41.3%(403/977)提高到61.8%(550/890),分别增加了6.9%和20.5%,差异有统计学意义(P<0.01);与基线调查时相比,1级高血压患者减少22.8%,2级高血压患者减少4.3%,3级高血压患者减少0.3%;在重新评估的心血管危险因素分层状况中,低危患者人数增加0.2%,中危患者人数减少0.6%,高危患者人数增加1.2%,很高危患者人数减少0.8%;吸烟者、超重者、缺少运动者分别减少0.8%、0.4%、2.0%,血脂异常者减少4.9%(P<0.05);总胆固醇、三酰甘油和低密度脂蛋白总胆固醇分别降低0.20、0.30和0.14mmol/L(P<0.01)。结论健康管理专员模式在社区是能被患者接受的,规范管理后,使社区高血压患者的血压水平下降,高血压控制率得到了明显的提高。     

中国冠心病二级预防研究——老年高血压人群的干预结果分析

目的探讨血脂康对合并高血压的老年患者和无高血压史的老年患者冠心病二级预防结果。方法对一项随机、双盲、安慰剂对照试验中的1 530例合并高血压的老年患者(治疗组772例,对照组758例)和1 020例无高血压史的老年患者(治疗组508例,对照组512例)平均服用血脂康胶囊4年后的冠心病二级预防结果进行统计分析。结果与无高血压史的老年患者比较,合并高血压的老年患者的冠心病事件发生率增加38.1%(P=0.0097),脑卒中事件发生率增加156.3%(P=0.0003),总死亡率增加48.2%(P=0.0035)。在合并高血压的老年患者中,治疗组与对照组比较,冠心病事件减少38.2%(P=0.0009);总死亡事件减少36.3%(P=0.0030);新发肿瘤事件减少49.2%(P=0.0395),其中肿瘤死亡减少67.1%(P=0.0123)。在无高血压史的老年患者中,治疗组与对照组比较,冠心病事件减少47.8%(P=0.0025),其中冠心病死亡减少43.7%(P=0.0369);对经皮冠状动脉介入治疗和(或)冠状动脉旁路移植术的需求减少71.3%(P=0.0018);总死亡事件减少32.0%(P=0.0936)。两类老年患者中均没有发现治疗组临床不良事件或实验室安全指标的增加。结论合并高血压的老年冠心病患者较无高血压史的老年患者处于更高危状态,血脂康胶囊用于老年患者的冠心病二级预防是安全有效的。     

Relationship between reduced b cell susceptibility to igm antibodies and reduced igd-bearing b cells in patients with systemic lupus erythematosus

Peripheral blood lymphocytes from 14 patients with systemic lupus erythematosus, 5 patients with rheumatoid arthritis, and 10 normal subjects were cultured for 7 days with or without anti-IgM or anti-IgD antibodies, and IgG- and IgM-secreting cells were assayed by reverse hemolytic plaque assay. Surface immunoglobulin (Ig) isotypes on peripheral blood B cells were also examined by a direct anti-Ig resetting reaction. In normal subjects and rheumatoid arthritis patients, the spontaneous development of IgG- and IgM-secreting cells was markedly suppressed by anti-IgM or anti-IgD antibodies. Over 50% of peripheral blood B cells were IgD- and/or IgM-bearing cells in normal subjects and in most patients with rheumatoid arthritis. In lupus patients, however, the suppression of IgG and IgM production by anti-IgM or anti-IgD antibodies was remarkably reduced, especially in the active stage. Furthermore, the percentage of IgD-bearing cells in peripheral blood B cells was remarkably reduced, especially in patients with active disease. There was a good correlation between reduced susceptibility of B cells to anti-IgM antibody-mediated suppression and reduced percentage of IgD-bearing cells in lupus patients.     

Defective non-insulin-mediated and insulin-mediated glucose transport and metabolism in adipocytes from obese and lean patients with untreated type 2 diabetes mellitus

Insulin binding, glucose transport, and glucose metabolism were investigated in isolated adipocytes from 11 lean and 13 obese patients with non-insulin-dependent diabetes mellitus. Insulin binding at 15 degrees C was reduced by 35% (p less than 0.01) in both lean and obese diabetic patients, whereas insulin binding (or uptake) at 37 degrees C was similar in diabetic patients and healthy controls. In lean diabetic patients both non-insulin-mediated (basal) and maximally insulin-stimulated glucose transport and metabolism were significantly reduced (all p less than 0.01). The percentage responses to insulin were also markedly reduced (p less than 0.05, p less than 0.02). In obese diabetic patients basal glucose transport was reduced (p less than 0.01) but basal glucose metabolism was not. Insulin-stimulated glucose transport and metabolism were significantly reduced (p less than 0.01, p less than 0.05). The percentage responses were reduced compared to healthy controls (p less than 0.05, p less than 0.05) but higher than in lean diabetic patients (p less than 0.05). We conclude that adipocytes isolated from both lean and obese patients with non-insulin-dependent diabetes mellitus are characterized by severely depressed non-insulin-mediated and insulin-mediated glucose transport and depressed insulin-mediated glucose metabolism. The major defect seems to be a reduced maximal effect of insulin on glucose metabolism, suggesting post-binding and post-transport abnormalities.     

Lipid-lowering drug use is associated with reduced prevalence of atrial fibrillation in patients with left ventricular systolic dysfunction

BACKGROUND: Inflammation and oxidative stress have been implicated in the pathogenesis of atrial fibrillation (AF). Lipid-lowering drugs, particularly statins and fibrates, possess anti-inflammatory and antioxidant properties. OBJECTIVES: The purpose of this study was to assess the impact of lipid-lowering drug use on AF prevalence in patients with reduced left ventricular ejection fraction (LVEF). METHODS: Data were obtained from ADVANCENT(SM), a multicenter registry of patients with reduced LVEF (相似文献   

Comparison of antiarrhythmic effects of oral prajmalium bitartrate and intravenous lidocaine in acute myocardial infarction

In 35 patients with acute myocardial infarction premature ventricular complexes were quantified from stored continuous electrocardiographic tape recordings using a semiautomated arrhythmia detection system. Seventeen patients, separated at random, received no antiarrhythmic drug and formed the control group. In nine patients prajmalium bitartrate was given orally at a dose of 60 mg. (20 mg. every 4 hours). Nine patients had permanent infusions of 2.1 mg./minute lidocaine (corresponding to a daily dose of 3 g.). In both treated groups premature ventricular complexes decreased significantly as compared to the spontaneous frequency in the control group. Six hours after the onset of therapy premature ventricular complexes were reduced to 37% of the initial value in the prajmalium bitartrate group and to 51% in the lidocaine group, whereas in the control group frequency increased (169%). The peak effect was reached after ten hours when premature ventricular complexes were reduced to 5% under prajmalium bitartrate and to 20% under lidocaine administration.Runs of premature ventricular complexes were nearly completely suppressed after administration of prajmalium bitartrate. Under lidocaine administration runs were moderately and not significantly reduced. Eight hours after the onset of therapy, runs were reduced to 8% of the initial value under prajmalium bitartrate and to only 79% under lidocaine. The effect of prajmalium bitartrate on runs of premature ventricular complexes was significantly more pronounced than the effect of lidocaine.The present study documents that orally administered prajmalium bitartrate is an alternative to intravenous administration of lidocaine in the treatment of ventricular arrhythmias after acute myocardial infarction.     

Peripheral percutaneous transluminal laser angioplasty in humans: in vitro investigations and clinical results with a novel laser catheter system

Percutaneous transluminal laser angioplasty has become an accepted method of treatment of peripheral arterial occlusive disease. To minimize the risk of arterial wall perforation during laser angioplasty, a novel laser catheter system was developed. In 113 obliterated postmortem human arteries the perforation rate was 0.9%. The mean degree of stenosis was reduced from 89 +/- 9% before, to 53 +/- 11% after laser irradiation. Clinical Nd:YAG laser angioplasty was performed in 19 patients suffering from peripheral arterial occlusive disease. The Fontaine stage improved in 16 patients; in no case did it deteriorate. The mean degree of stenosis was reduced by laser angioplasty from 91 +/- 12% to 31 +/- 19%. A further reduction down to 13 +/- 18% was achieved by subsequent percutaneous transluminal balloon angioplasty. The systolic Doppler ankle-arm pressure gradient was improved from 0.58 +/- 0.26 to 0.89 +/- 0.25. In 7 patients microembolisms were detectable on the final angiogram. There was no acute reocclusion and no perforation. Within a follow-up period of 12 months, four restenoses were diagnosed by digital subtraction angiography. On average, the Doppler index was 0.75 +/- 0.32.     

Effects of coronary thrombolysis on left ventricular ejection fraction in patients with acute myocardial infarction

Left ventriculograms were performed on 65 patients with acute myocardial infarction, once upon admission and again 3 months later. In 29 cases urokinase was injected intravenously and/or intracoronarily. The other 17 were treated without urokinase. In 8 out of 29 patients whose infarct-related coronary arteries remained completely occluded following urokinase therapy, the global ejection fraction was reduced from 54 +/- 3% during the acute stage to 46 +/- 5% during the chronic stage (p less than 0.001). However, for the 21 patients whose coronary arteries were successfully recanalized, the 2 values were the same (52 +/- 2%). The highest global ejection fractions were seen in 19 spontaneously recanalized patients (acute: 54 +/- 2%, chronic: 55 +/- 2%). For the 8 unsuccessful patients, the regional ejection fraction for the infarcted portion was reduced from 20 +/- 5% during the acute stage to 18 +/- 6% during the chronic stage. But for the successful patients there was an improvement from 22 +/- 2% during the acute stage to 27 +/- 2% during the chronic stage. Again, the regional ejection fraction was the highest for the spontaneously recanalized group, being 31 +/- 2% and 36 +/- 3% during the acute and chronic stages, respectively. These results indicate that if the coronary artery remains occluded during the acute stage the reduced left ventricular function continues to deteriorate even more during the chronic stage. Successful coronary thrombolysis, however, might salvage the infarcted myocardium as well as preserve the function of the left ventricle.     

Mortality rates and clinical predictors of reduced survival after cardioverter defibrillator implantation

We aimed to identify mortality rates and clinical predictors of reduced survival in a large cohort of patients after implantation of an implantable cardioverter-defibrillator (ICD). Although existing data from clinical trials report annual mortality after ICD implantation from 2% to 9%, there are few data available on mortality rates or predictors of reduced survival in this patient population in clinical practice. In this single-center, retrospective analysis of 286 patients who underwent ICD implantation between June 1, 2000 and December 30, 2003, candidate predictors of mortality were assessed and subjected to multivariable analysis. Outcomes were documented using the Social Security Death Master File and hospital medical records. Overall annualized mortality was 11.3% after ICD implantation. Mortality rates in patients with left ventricular ejection fraction (LVEF) <25% were 27.2% at 1 year and 50.5% at 3 years. Digoxin (hazard ratio 1.86, 95% confidence interval [CI] 1.21 to 2.86, p = 0.0046) and loop diuretics (hazard ratio 1.59, 95% CI 1.06 to 2.38, p = 0.024) were associated with reduced survival. Angiotensin-converting enzyme inhibitor or aldosterone receptor blocker use was associated with reduced mortality (hazard ratio 0.50, 95% CI 0.31 to 0.80, p = 0.0038). In conclusion, mortality after ICD implantation is higher than demonstrated in primary or secondary prevention ICD trials; LVEF remains a potent predictor of mortality after ICD implantation, particularly in patients with an LVEF <25%; loop diuretic and digoxin use is associated with an approximate twofold increase in mortality in this population; and angiotensin-converting enzyme inhibitor or aldosterone receptor blocker use is associated with improved survival after ICD implantation.     

von Willebrand factor cleaving protease (ADAMTS-13) and ADAMTS-13 neutralizing autoantibodies in 100 patients with thrombotic thrombocytopenic purpura

The congenital or acquired deficiency of the von Willebrand factor (VWF) cleaving protease, ADAMTS-13 has been specifically associated with a diagnosis of thrombotic thrombocytopenic purpura (TTP), a microangiopathy characterized by the formation of occlusive platelet thrombi. The mechanisms of TTP were investigated in 100 patients diagnosed on the basis of the presence of at least three of the following: thrombocytopenia, haemolytic anaemia, elevated serum levels of lactate dehydrogenase and neurological symptoms. Plasma levels of ADAMTS-13 were severely reduced (<10% of normal) in 48%, moderately reduced (between 10% and 46%) in 24% and normal (>46%) in 28%. A neutralizing antibody was the cause of the deficiency in 38% of the cases, with a higher prevalence of this mechanism (87%) in the 48 patients with severely reduced ADAMTS-13. Double heterozygosity for a 29 base pair (bp) deletion and a nucleotide insertion and homozygosity for a 6 bp deletion in the ADAMTS13 gene were identified only in two patients born from consanguineous marriages. In conclusion, this study indicated that ADAMTS-13 was normal in nearly one-third of patients with TTP and that ADAMTS-13 deficiency was not associated with the presence of neutralizing antibodies in more than half of the patients.     

Percutaneous transluminal coronary angioplasty--effect of the moveable guide wire on the complication rate

Beginning with the first percutaneous transluminal coronary angioplasty (PTCA) performed at Baystate Medical Center, 152 consecutive procedures were analyzed. Sixty were done using USCI-G (nonsteerable) series catheters. In two patients both a G and S (steerable) catheter were used. In 90 procedures the S system was used exclusively. Among the attempted angioplasties with the G series catheter, the percutaneous transluminal coronary angioplasty was successful in 47 (78%). Eight coronary occlusions were induced and all these patients underwent coronary bypass surgery. There were no deaths, but three patients (5%) had acute myocardial infarctions (MI). The two patients in whom both G and S catheters were used had occlusions. One went to surgery and died postoperatively of uncontrollable ventricular arrhythmias. The other patient had a myocardial infarction and recovered. Of the 90 attempts with the exclusive use of the steerable system, 75 were successful (83%). Three coronary occlusions were induced in the 90 attempts and two of the patients had coronary artery bypass surgery. None of the three sustained a myocardial infarction. In summary, the proportion of patients requiring emergency surgery was significantly reduced from 13.3% (8 of 60) to 2.2% (2 of 90) (p=0.02), the incidence of myocardial infarction was reduced from 5 to 0%, and there was a slight increase in the siccess rate of the procedure after the introduction of the steerable system. It is concluded that the steerable system increases the safety of PTCA.     

Intraoperative bypass flow measurement reduces the incidence of postoperative ventricular fibrillation and myocardial markers after coronary revascularisation

OBJECTIVE: Sudden ventricular fibrillation (VF) and myocardial infarction (MI) are life-threatening complications after coronary artery bypass grafting (CABG). We prospectively analysed the impact of intraoperative bypass flow measurement with the transit time flow Doppler method (TTFD) on the incidence and outcome of postoperative VF and MI. METHODS: In 1995 a standardized algorithm for the treatment of postoperative VF was introduced in our institution. The rate of postoperative VF was therefore exactly registered. In 1998 the TTFD method was implemented as a standard in all CABG cases. Whenever insufficient bypass graft flow was detected, anastomoses were redone and technical problems affecting the grafts were excluded. The incidence of postoperative VF and CK/CK-MB fraction was observed prospectively and the new data was compared to the data from 1995 to 1998. RESULTS: From 1/95 to 7/98 a total of 4321 patients (group A) were operated on with isolated CABG procedures using extracorporeal circulation. In the period from 8/98 to 10/02 a total of 3421 patients (group B) was operated on with isolated CABG procedures under the same conditions, except that the TTFD method was used in every case. The treatment of VF was standardised in both groups according to the algorithm. The most striking effect was the significant reduction of VF from 0.66% to 0.44% when TTFD was introduced and the steep decrease in mortality from 30% to 12.2% in patients with VF when the algorithm and TTFD were routinely applied. Furthermore the rate of insufficient bypass flow detected by angiography was reduced by 66%. CONCLUSION: Routinely the use of TTFD significantly reduced the incidence of postoperative VF, postoperative CK/CK-MB fraction, and angiographically detected bypass malfunction. A simultaneously implemented algorithm reduced the mortality with VF after CABG. The consequent use of TTFD intraoperatively reduced the incidence of postoperative anastomosis and technically related complications of bypass surgery and led to a significant reduction of postoperative mortality in CABG procedures.     

Abciximab reduces mortality in diabetics following percutaneous coronary intervention

OBJECTIVES: We sought to determine whether abciximab therapy at the time of percutaneous coronary intervention (PCI) would favorably affect one-year mortality in patients with diabetes. BACKGROUND: Diabetics are known to have increased late mortality following PCI. METHODS: Data from three placebo-controlled trials of PCI, EPIC, EPILOG, and EPISTENT, were pooled. The one-year mortality rate for patients with a clinical diagnosis of diabetes mellitus was compared with the rate for nondiabetic patients treated with either abciximab or placebo. RESULTS: In the 1,462 diabetic patients, abciximab decreased the mortality from 4.5% to 2.5%, p = 0.031, and in the 5,072 nondiabetic patients, from 2.6% to 1.9%, p = 0.099. In patients with the clinical syndrome of insulin resistance--defined as diabetes, hypertension, and obesity--mortality was reduced by abciximab treatment from 5.1% to 2.3%, p = 0.044. The beneficial reduction in mortality with abciximab use in diabetics classified as insulin-requiring was from 8.1% to 4.2%, p = 0.073. Mortality in diabetics who underwent multivessel intervention was reduced from 7.7% to 0.9% with use of abciximab, p = 0.018. In a Cox proportional hazards survival model, the risk ratio for mortality with abciximab use compared with placebo was 0.642 (95% confidence interval 0.458-0.900, p = 0.010). CONCLUSIONS: Abciximab decreases the mortality of diabetic patients to the level of placebo-treated nondiabetic patients. This beneficial effect is noteworthy in those diabetic patients who are also hypertensive and obese and in diabetics undergoing multivessel intervention. Besides its potential role in reducing repeat intervention for stented diabetic patients, abciximab therapy should be strongly considered in diabetic patients undergoing PCI to improve their survival.     

The importance of pre- and postinfarction angina on timolol-related reduction in mortality and reinfarction

The importance of a history of angina pectoris on long-term timolol treatment after myocardial infarction was studied with respect to mortality and reinfarction. The analyses were performed retrospectively using cohorts from the Norwegian timolol multicenter study. In patients without angina pectoris prior to the infarction, timolol treatment reduced mortality by 61% and the occurrence of first nonfatal reinfarction by 16.9% as compared with placebo. Patients with preinfarction angina had a reduction in mortality of 21.8% and in first nonfatal reinfarction of 48.6%. The frequency of angina pectoris increased from 38% in both treatment groups before the infarction to 59% in the placebo group and 52% in the timolol group the first 6 months after the infarction. In patients without postinfarction angina pectoris, timolol treatment reduced mortality by 30.7% and the number of first nonfatal reinfarctions by 22.7%. The reductions in mortality and reinfarction in patients with postinfarction angina were 43.8% and 38.5%, respectively. Thus, the decision for timolol treatment after myocardial infarction should not be dependent on pre- and postinfarction angina.     

The contribution of computerized tomography to the differential diagnosis of confusion in elderly patients

Two hundred and eighty elderly patients who were referred because of a principal problem of confusion were investigated by computerized tomography; 94% were suffering from a 'dementia syndrome' and unrecognized receptive dysphasia was the commonest problem in the remainder. One hundred and twenty-four patients were suffering from senile dementia of the Alzheimer type, and 79 from multi-infarct dementia. Space-occupying lesions (tumour, subdural haematoma or hygroma) were found in 32 (11%). Of the 25 with other intracranial and extracranial causes, 64% had potentially treatable lesions (PTL). In only four cases was no diagnosis made. PTL were found in 31% of 170 patients with a duration of confusion of less than a year compared with 1% of 110 patients with a longer duration. In 48 of the former group, confusion was an isolated phenomenon; 12 of these (25%) had a PTL, as had 27 of 88 with confusion and a focal neurological deficit (31%). All five patients with recognized seizures, and six of 15 of those with reduced alertness had PTL. Twenty of 37 patients with neurosurgical lesions underwent surgery.     

Working status among Dutch patients with rheumatoid arthritis: work disability and working conditions

OBJECTIVES: To assess work disability and variables associated with work disability among Dutch patients with rheumatoid arthritis (RA). METHODS: A questionnaire on working status was filled out by 296 patients of working age. Employment and work disability rates adjusted for age and sex from the Dutch population were determined using indirect standardization. Cox proportional hazard analysis was used to assess baseline predictors of work disability in a subgroup of patients (n = 195). RESULTS: After a mean disease duration of 4.3 yr, patients had a 0.78 (95% CI 0.67-0.88) chance of being employed and a 2.14 (95% CI 1.75-2.54) risk of being work disabled when compared with the Dutch population. Functional disability and job type at the start of the disease were predictors of future work disability. In total, 48 (37%) currently employed patients had changed their working conditions, of which reduced working hours (46%), reduced pacing of work (42%) and help from colleagues (49%) were the most important alterations. Of the 60 work disabled patients without a paid job, only 11 patients (18%) would be willing to work again. CONCLUSION: This study shows that the adjusted employment rates were lower and that work disability rates were higher in patients with RA when compared with the general Dutch population. In addition, a substantial number of employed patients had to change their working conditions due to RA. Only a minority of work disabled RA patients was willing to return to the paid labour force.     

Reduced GFR and microalbuminuria are independently associated with prevalent cardiovascular disease in Type 2 diabetes: JDDM study 16

Aims We investigated whether a reduced estimated glomerular filtration rate (eGFR) was associated with cardiovascular disease (CVD) prevalence, independent of the effect of microalbuminuria in patients with diabetes. Methods In a multicentre, large‐scale cohort including 3002 Japanese patients with Type 2 diabetes without macroalbuminuria, the relationship of a reduced eGFR and microalbuminuria with CVD was investigated. Results Of those patients, 4.8% had a reduced eGFR and microalbuminuria, 12.7% had a reduced eGFR without microalbuminuria and 18.7% had microalbuminuria but normal eGFR. A reduced eGFR and microalbuminuria were each associated with a doubling of the prevalence of CVD. Compared with patients with no microalbuminuria/normal eGFR [odds ratio (OR) 1.0], the OR for CVD was significantly higher in those with a reduced eGFR without microalbuminuria (OR 1.97) and similarly higher in those with microalbuminuria without a reduced eGFR (OR 1.85). The OR was highest in those with both a reduced eGFR and microalbuminuria (OR 3.97, 95% confidence interval 2.55–6.20). The OR for CVD remained significant after adjustments for age, sex, hypertension, dyslipidaemia, smoking, body mass index, glycated haemoglobin and the duration of diabetes, and remained significant if the cut‐off point for microalbuminuria was set at the median albumin : creatinine ratio (13.7 mg/g creatinine). In patients without microalbuminuria, a reduced eGFR was associated with CVD only in the older and male groups. Conclusion A reduced eGFR and the presence of microalbuminuria were each associated with a near doubling of the prevalence of CVD, independently of traditional CVD risk factors and glycaemic control in patients with Type 2 diabetes.     

Ventricular arrhythmias before and late after aortic valve replacement

The influence of aortic valve replacement on the incidence of ventricular arrhythmias was studied by 24-hour Holter electrocardiographic monitoring in 45 patients immediately before and 14 ± 7 months after operation. Ventricular arrhythmias were graded according to the Lown criteria. Preoperative left ventricular (LV) ejection fraction (EF) was determined by angiography and postoperative LVEF by gated blood pool scintigraphy. Repetitive ventricular arrhythmias (Lown grade 4A/B) were associated with a reduced LVEF (< 55%) before and after operation. In 24 patients with preoperative normal LVEF (>- 55%) (group A), mean LVEF remained unchanged after operation (72% vs 71 %). Pre- and postoperative ventricular premature complex (VPC) frequency (45 ± 99 vs 39 ± 94 VPC/24 hours and grade (1.3 vs 1.4) were not significantly different. However, in 17 patients with preoperative impaired LVEF (< 55%) (group B, LVEF preoperatively 40 ± 8%) and marked postoperative improvement (> 10%) (LVEF postoperatively 64 ± 7%), mean VPC frequency decreased from 536 to 69 VPCs/24 hours and mean VPC grade was reduced from 3.8 to 1.5. Complex VPCs were found preoperatively in all 17 patients of group B, but in only 5 patients after operation. Four patients had a reduced LVEF preoperatively and it did not improve postoperatively (group C). Postoperative Holter monitoring detected ventricular tachycardia in all 4 patients.This study indicates that repetitive VPCs are infrequent in patients with normal LVEF before and late after aortic valve replacement. In patients with impaired LVEF and complex VPCs preoperatively, the postoperative improvement of LV function is usually accompanied by a reduction of frequent and complex VPCs.     

Impact of Early Revascularization on Major Adverse Cardiovascular Events in Relation to Automatically Quantified Ischemia

ObjectivesUsing a contemporary, multicenter international single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) registry, this study characterized the potential major adverse cardiovascular event(s) (MACE) benefit of early revascularization based on automatic quantification of ischemia.BackgroundPrior single-center data reported an association between moderate to severe ischemia SPECT-MPI and reduced cardiac death with early revascularization.MethodsConsecutive patients from a multicenter, international registry who underwent ^99mTc SPECT-MPI between 2009 and 2014 with solid-state scanners were included. Ischemia was quantified automatically as ischemic total perfusion deficit (TPD). Early revascularization was defined as within 90 days. The primary outcome was MACE (death, myocardial infarction, and unstable angina). A propensity score was developed to adjust for nonrandomization of revascularization; then, multivariable Cox modeling adjusted for propensity score and demographics was used to predict MACE.ResultsIn total, 19,088 patients were included, with a mean follow-up of 4.7 ± 1.6 years, during which MACE occurred in 1,836 (9.6%) patients. There was a significant interaction between ischemic TPD modeled as a continuous variable and early revascularization (interaction p value: 0.012). In this model, there was a trend toward reduced MACE in patients with >5.4% ischemic TPD and a significant association with reduced MACE in patients with >10.2% ischemic TPD.ConclusionsIn this large, international, multicenter study reflecting contemporary cardiology practice, early revascularization of patients with >10.2% ischemia on SPECT-MPI, quantified automatically, was associated with reduced MACE.     

Critical illness in systemic lupus erythematosus and the antiphospholipid syndrome

OBJECTIVES: To investigate the causes, course, and outcome of critical illness requiring emergency admission to the intensive care unit (ICU) in patients with systemic lupus erythematosus (SLE) or the antiphospholipid syndrome (APS), or both. METHODS: Critically ill patients with SLE or APS, or both, admitted to a London teaching hospital ICU over a 15 year period were studied. Demographic, diagnostic, physiological, laboratory, and survival data were analysed. Kaplan-Meier survival curves were constructed by age, time from first diagnosis of SLE, and time from first ICU admission. The log rank test and a backwards stepwise Cox regression were used to identify factors associated with reduced survival. RESULTS: Sixty one patients with SLE alone (39%) and/or APS (61%) required 76 emergency admissions to the ICU. Patients had high severity of illness scores (median APACHE II 22 (range 8-45)) and multiorgan dysfunction. The primary diagnoses for patients admitted were infection in 31/76 (41%), renal disease in 16/76 (21%), cardiovascular disease in 12/76 (16%), and coagulopathies in 11/76 (14%). The commonest secondary diagnosis was renal dysfunction (49%). Factors associated with an increased risk of death were cyclophosphamide before admission, low white cell count, and high severity of illness score. Before adjustment for these factors renal disease had a strong adverse effect on long term survival (analysis by age at diagnosis p=0.005, analysis by time since first ICU admission, p=0.07). After adjustment, infection at admission to ICU was associated with an increased ICU mortality (p=0.02) and was the cause of death in 13/17 patients who died in the ICU. Similarly, after adjustment, APS was associated with reduced ICU survival (p=0.1) and reduced long term (p=0.03) survival. Seventeen patients (28%) died in the ICU, and 31 patients (51%) had died by the last follow up. Median time from ICU admission to death was four years. Overall five year survival from the first ICU admission was 43%. CONCLUSION: Critical illness requiring ICU admission may occur in patients with SLE and APS. In this study, ICU survival was better than previously described, but long term survival was poor. Cyclophosphamide administration, low white cell count, and high severity of illness score were associated with reduced survival. Before adjustment for these factors, only renal disease had an adverse effect on outcome but after adjustment, infection and APS reduced survival.