IMPROVED LEFT VENTRICULAR FUNCTION DURING NITROPRUSSIDE INFUSION IN ACUTE MYOCARDIAL INFARCTION

In 15 patients with acute myocardial infarction intravenous infusion of the potent vasodilator, nitroprusside, produced an average 50% fall in the elevated left ventricular filling pressure and a modest reduction in arterial pressure (average 15·5%) without a change in heart-rate. Careful dose adjustment in several patients resulted in a significant fall in left ventricular filling pressure with little or no change in arterial pressure. Cardiac output consistently rose during nitroprusside infusion in patients with clinical signs of left ventricular failure or shock and a low control cardiac index, whereas output changed little in those patients with normal control cardiac index. A fall in pressure-time per minute as well as the fall in left ventricular filling pressure indicated a reduction in myocardial oxygen consumption during the vasodilator infusion. Drug infusion was usually accompanied by subjective improvement, including relief of dyspnœa and of chest pain, and reduction in ventricular irritability. These data suggest that vaso dilator therapy, by reducing left ventricular afterload, can improve left ventricular performance in patients with acute myocardial infarction. Such treatment may be a rational approach to the management of patients with heart-failure, pulmonary œdema, or early shock.     

Influence of carvedilol on hospitalizations in heart failure: incidence, resource utilization and costs. U.S. Carvedilol Heart Failure Study Group

BACKGROUND: Carvedilol reduces disease progression in heart failure, but to our knowledge, its effects on hospitalizations and costs have not been evaluated. OBJECTIVES: We examined the effects on hospitalization frequency and costs in the U.S. Carvedilol Heart Failure Trials Program. This program consisted of four concurrent, multicenter, double-blind, placebo-controlled studies involving 1,094 patients with New York Heart Association class II to IV heart failure, which treated patients with placebo or carvedilol for up to 15 months (median, 6.5 months). METHODS: Detailed resource utilization data were collected for all hospitalizations occurring between randomization and the end of follow-up. In-patient care costs were estimated based on observed levels of resource use. RESULTS: Compared with placebo, carvedilol reduced the risk of hospitalization for any reason by 29% (p = 0.009), cardiovascular hospitalizations by 28% (p = 0.034) and heart failure hospitalizations by 38% (p = 0.041). Carvedilol also decreased the mean number of hospitalizations per patient (for cardiovascular reasons 30% [p = 0.02], for heart failure 53% [p = 0.03]). Among hospitalized patients, carvedilol reduced severity of illness during hospital admission, as reflected by shorter length of stay and less frequent use of intensive care. For heart failure hospital admissions, carvedilol decreased mean length of stay by 37% (p = 0.03) and mean number of intensive care unit/coronary care unit days by 83% (p = 0.001), with similar effects on cardiovascular admissions. As a result, estimated inpatient care costs with carvedilol were 57% lower for cardiovascular admissions (p = 0.016) and 81% lower for heart failure admissions (p = 0.022). CONCLUSIONS: Carvedilol added to angiotensin-converting enzyme inhibition reduces hospitalization risk as well as severity of illness and resource utilization during admission in patients with chronic heart failure.     

Antihypertensive Utility of Perindopril in a Large, General Practice-Based Clinical Trial

The authors evaluated, in a community-based open-label trial, the effectiveness and safety of perindopril in 13,220 US hypertensive patients and studied how physicians adhere to hypertension treatment guidelines. Patients received perindopril 4 mg q.d. for 6 weeks. Based on physicians' perception of blood pressure response, the patient was either maintained on 4 mg or the dose was increased to 8 mg for an additional 6 weeks. From baseline to week 12, the mean sitting blood pressure significantly declined from 156.9/94.5 mm Hg to 139.2/84.0 mm Hg. Further dose titration resulted in a clinically significant reduction in blood pressure in all patients with inadequate response on 4 mg at week 6. Blood pressure control (<140/<90 mm Hg) was achieved at 12 weeks in 48.8% patients. The subpopulation analyses demonstrated that perindopril monotherapy was effective in both men and women, in patients of all ethnicities, and in patients <65 and ≥65 years of age. Perindopril was safe and well tolerated in all hypertensive subgroups including high-risk patients. Physicians were more attuned to controlling diastolic than systolic blood pressure, and their adherence to the treatment guidelines was found to be not optimal.     

Clarithromycin or rifabutin alone or in combination for primary prophylaxis of Mycobacterium avium complex disease in patients with AIDS: A randomized, double-blind, placebo-controlled trial. The AIDS Clinical Trials Group 196/Terry Beirn Community Programs for Clinical Research on AIDS 009 Protocol Team

The efficacy and safety of clarithromycin and rifabutin alone and in combination for prevention of Mycobacterium avium complex (MAC) disease were compared in 1178 patients with AIDS who had < or =100 CD4 T cells/microL in a randomized, double-blind, placebo-controlled trial. MAC disease occurred in 9%, 15%, and 7% of those randomized to clarithromycin or rifabutin alone or in combination, respectively; time-adjusted event rates per 100 patient-years (95% confidence interval [CI]) were 6.3 (4.2-8.3), 10.5 (7.8-13.2), and 4. 7 (2.9-6.5). Risk of MAC disease was reduced by 44% with clarithromycin (risk ratio [RR], 0.56; 95% CI, 0.37-0.84; P=.005) and by 57% with combination therapy (RR, 0.43; 95% CI, 0.27-0.69; P=. 0003), versus rifabutin. Combination therapy was not more effective than clarithromycin (RR, 0.79; 95% CI, 0.48-1.31; P=.36). Of those in whom clarithromycin or combination therapy failed, 29% and 27% of MAC isolates, respectively, were resistant to clarithromycin. There were no survival differences. Clarithromycin and combination therapy were more effective than rifabutin for prevention of MAC disease, but combination therapy was associated with more adverse effects (31%; P<.001).     

Treatment of latent tuberculosis infection: renewed opportunity for tuberculosis control.

New recommendations for targeted tuberculin testing and treatment of latent tuberculosis (TB) infection have recently been published. Changes in nomenclature from screening to targeted tuberculin testing and from preventive therapy to treatment of latent TB infection (LTBI) are intended to promote more widespread implementation by programs and health care providers. Targeted tuberculin testing is designed to identify persons at high risk for TB and is discouraged for persons at low risk. New recommendations for treatment of LTBI in both human immunodeficiency virus (HIV)-infected and HIV-uninfected patients include isoniazid for 9 months as the preferred regimen: isoniazid for 6 months based on local program conditions, rifampin and pyrazinamide for 2 months, and rifampin for 4 months. Treatment monitoring now places greater emphasis on clinical, rather than routine, laboratory monitoring. More widespread implementation of targeted tuberculin testing and treatment of LTBI is an important control strategy that will enhance efforts to eliminate TB in the United States.     

Estrogen is associated with improved survival in aging women with congestive heart failure: analysis of the vesnarinone studies

OBJECTIVES: This study sought to evaluate the effects of postmenopausal estrogen use on mortality in aging women with congestive heart failure (CHF). BACKGROUND: The age-related increase in CHF mortality in women may be related to a menopause-associated increased incidence of coronary artery disease. In addition to inhibiting coronary atherosclerosis, estrogen may also have protective effects on cardiac myocytes independent of the coronary vasculature. We hypothesized that estrogen use is associated with improved survival in elderly women with CHF. METHODS: Associations between survival, estrogen use and patient characteristics were assessed in 1,134 women who were at least 50 years of age, had CHF and left ventricular ejection fraction (EF) < or =30% and were enrolled in one of three clinical trials of vesnarinone. RESULTS: All-cause 12-month mortality was 15.0% among the 237 estrogen users versus 27.1% among the 897 estrogen nonusers (p = 0.004 for unadjusted comparison of survival). Similar results were observed for cardiac mortality. Regression analysis demonstrated that estrogen use was independently associated with improved survival (relative risk of mortality = 0.68, 95% confidence interval 0.48 to 0.96, p = 0.03). Advanced age, low EF, New York Heart Association class IV CHF, Caucasian race and abnormal serum creatinine, sodium, potassium and transaminase were independently associated with increased mortality. CONCLUSIONS: Estrogen use among older women with CHF is associated with decreased overall and cardiac mortality.     

Minimally invasive valve surgery

Minimally invasive heart valve surgery has evolved significantly over the past 10 years and now comprises safe and efficient operations for most patients. The main goals of minimally invasive heart valve surgery are to reduce surgical trauma, increase patient satisfaction, reduce morbidity, and lower costs while still providing durable and safe valve repair or replacement. After a decade of refinements, studies have shown that minimally invasive heart valve surgery is a safe and effective procedure with similar if not improved perioperative morbidity and mortality rates compared with conventional valve surgery. Patients derive a variety of tangible benefits from these new surgical approaches, including less pain, shorter lengths of hospital stay, and faster return to preoperative functional levels. Minimally invasive heart valve surgery should be an option for any patient undergoing heart valve surgery today.     

Endotoxin exposure is a risk factor for asthma: the national survey of endotoxin in United States housing

BACKGROUND: Although research has shown that early life exposure to household endotoxin protects against development of allergies, studies are less clear on the relationship between household endotoxin exposure and prevalence of wheezing and asthma. We assayed 2,552 house dust samples in a representative nationwide sam- ple to explore relationships between endotoxin exposures and risk factors for asthma, asthma symptoms, and medication use. METHODS: House dust was vacuum-sampled from five locations within homes and assayed for endotoxin. Health, demographic, and housing information was assessed through questionnaire and on-site evaluation of 2,456 residents of 831 homes selected to represent the demographics of the United States. RESULTS: Endotoxin concentration (EU/mg) and load (EU/m(2)) were highly correlated (r = 0.73-0.79). Geometric mean endotoxin concentrations were as follows (in EU/mg): bedroom floors, 35.3 (5th-95th percentile, 5.0-260); bedding, 18.7 (2.0-142); family room floors, 63.9 (11.5-331); sofas, 44.8 (6.4-240); and kitchen floors, 80.5 (9.8-512). Multivariate analysis demonstrated significant relationships between increasing endotoxin levels and diagnosed asthma, asthma symptoms in the past year, current use of asthma medications, and wheezing among residents of the homes. These relationships were strongest for bedroom floor and bedding dust and were observed in adults only. Modeling the joint effect of bedding and bedroom floor endotoxin on recent asthma symptoms yielded an adjusted odds ratio of 2.83 (95% confidence interval, 1.01-7.87). When stratified by allergy status, allergic subjects with higher endotoxin exposure were no more likely to have diagnosed asthma or asthma symptoms than nonallergic subjects. CONCLUSION: This study demonstrates that household endotoxin exposure is a significant risk factor for increased asthma prevalence.     

Promoting HIV Testing Among Never-Tested Hispanic Men: A Doctor's Recommendation May Suffice

This study examined factors associated with HIV testing intentions among a community sample of 255 never-tested Hispanic men. It compared (1) men who intended to test in the next 6 months with those who did not and (2) men who intended to test only on the day of the interview with those who intended to test in the next 6 months. Eighty-four percent of men had never been offered testing. Yet, 86% would accept testing if recommended by their doctor. The strongest multivariate predictor of testing intention was willingness to accept a physician-endorsed test. Almost 49% of men who intended to test in the next 6 months would only do so if the test were offered on the interview day. These findings highlight the importance of encouraging physicians, particularly in high-prevalence areas, to routinely recommend testing. They also suggest that for some men, there is a window of opportunity for testing that does not endure.     

Percutaneous mitral valve repair: a feasibility study in an ovine model of acute ischemic mitral regurgitation.

Annuloplasty is the cornerstone of surgical mitral valve repair. A percutaneous transvenous catheter-based approach for mitral valve repair was tested by placing a novel annuloplasty device in the coronary sinus of sheep with acute ischemic mitral regurgitation. Mitral regurgitation was reduced from 3-4+ to 0-1+ in all animals (P < 0.03). The annuloplasty functioned by reducing septal-lateral mitral annular diameter (30 +/- 2.1 mm preinsertion vs. 24 +/- 1.7 mm postinsertion; P < 0.03). These preliminary experiments demonstrate that percutaneous mitral annuloplasty is feasible. Further study is necessary to demonstrate long-term safety and efficacy of this novel approach.