Comparison of ejection fraction and Goldman risk factor analysis to dipyridamole-thallium 201 studies in the evaluation of cardiac morbidity after aortic aneurysm surgery

Associated coronary artery disease is the critical factor that influences early and late mortality after abdominal aortic aneurysm surgery. Dipyridamole-thallium 201 scintigraphy, left ventricular ejection fraction, and Goldman risk factor analysis have been suggested as preoperative noninvasive screening methods to detect significant coronary artery disease. In this series of 95 elective abdominal aortic aneurysm repairs dipyridamole-thallium 201 scintigraphy was highly predictive of the absence of perioperative cardiac morbidity (96% specificity, 44/46 normal scans, no cardiac morbidity), whereas ejection fraction (73% specificity, 31/42 normal ejection fraction, no cardiac morbidity) and Goldman risk factor analysis (84% specificity, 44/51 class I, no cardiac morbidity) were less. Furthermore, thallium redistribution on dipyridamole-thallium 201 scintigraphy leading to coronary angiography identified a significant number of patients with occult coronary artery disease who required preoperative coronary revascularization (8%, 8/95) and might have remained undetected on the basis of left ventricular ejection fraction or Goldman risk factor analysis. Finally, fixed thallium deficit, which some investigators have interpreted as a low probability finding for cardiac morbidity, was associated with a higher than expected incidence of cardiac complications. Forty-six percent (7/15) of all postoperative cardiac complications (three myocardial infarctions, three ischemic events, one death) occurred in patients with abdominal aortic aneurysms with fixed deficits. This suggests that patients with fixed deficits on dipyridamole-thallium 201 scintigraphy should be considered for later "delayed" (4 hours) thallium images or coronary angiography or both.     

Right ventricular function in adults with pulmonary hypertension with and without atrial septal defect

Using equilibrium (gated) radionuclide ventriculography, right ventricular (RV) function was studied in 22 adults with pulmonary hypertension and in 16 patients without evidence of cardiac disease. To assess the effect of volume overload on RV performance in pulmonary hypertension, RV ejection fractions were compared in patients with and without left-to-right shunts due to atrial septal defect (ASD). In addition, the effect of ASD repair on RV function was examined. In 14 patients with pulmonary hypertension without RV volume overload (group I), the RV ejection fraction (0.35 ± 0.11, mean ± standard deviation [SD]) was significantly lower than in the normal group (0.47 ± 0.11, p < 0.01). In 8 patients with left-to-right shunts due to ASD (group II) and with RV systolic pressures similar to those in group I, the mean RV ejection fraction (0.53 ± 0.15) was normal and was significantly higher than in group I (p < 0.01). Right ventricular end-diastolic volumes, estimated from combined radionuclide and hemodynamic data, were higher (p < 0.01) in group II patients (171 ± 70 ml/m²) than in group I patients (70 ± 13 ml/m²). In 5 patients who underwent isolated shunt repair, mean RV ejection fraction decreased postoperatively from 0.57 ± 0.17 to 0.40 ± 0.12 (p < 0.05). It is concluded that (1) pulmonary hypertension frequently causes a decrease in RV systolic function due to abnormal afterload; (2) in patients with RV volume overload due to left-to-right shunt, systolic function, as measured by the ejection fraction, remains normal despite pulmonary hypertension, possibly through the Starling mechanism; and (3) RV systolic function often decreases after repair of an ASD.     

Cost-effectiveness of screening with B-type natriuretic peptide to identify patients with reduced left ventricular ejection fraction

OBJECTIVES: This study was designed to evaluate the cost-effectiveness of screening patients with a B-type natriuretic peptide (BNP) blood test to identify those with depressed left ventricular systolic function. BACKGROUND: Asymptomatic patients with depressed ejection fraction (EF) may have less progression to heart failure if they can be identified and treated. METHODS: We used a decision model to estimate economic and health outcomes for different screening strategies using BNP and echocardiography to detect left ventricular EF <40% for men and women age 60 years. We used published data from community cohorts (gender-specific BNP test characteristics, prevalence of depressed EF) and randomized trials (benefit from treatment). RESULTS: Screening 1,000 asymptomatic patients with BNP followed by echocardiography in those with an abnormal test increased the lifetime cost of care (176,000 US dollars for men, 101,000 US dollars for women) and improved outcome (7.9 quality-adjusted life years [QALYs] for men, 1.3 QALYs for women), resulting in a cost per QALY of 22,300 US dollars for men and 77,700 US dollars for women. For populations with a prevalence of depressed EF of at least 1%, screening with BNP followed by echocardiography increased outcome at a cost < 50,000 US dollars per QALY gained. Screening would not be attractive if a diagnosis of left ventricular dysfunction led to significant decreases in quality of life or income. CONCLUSIONS: Screening populations with a 1% prevalence of reduced EF (men at age 60 years) with BNP followed by echocardiography should provide a health benefit at a cost that is comparable to or less than other accepted health interventions.     

Prostaglandin mediation of hemodynamic responses to pulmonary microembolism in rabbits: effects of ibuprofen and meclofenamate

The effect of the cyclooxygenase inhibitors ibuprofen and meclofenamate were studied to assess the role of prostaglandin release in mediating the hemodynamic response to acute pulmonary microembolism in awake rabbits. In Group I (n = 10), a control group receiving only saline infusion, there was no change in pulmonary artery pressure, thermodilution cardiac output, or pulmonary vascular resistance. Group II (n = 12) received sequential intravenous doses of polyacrylamide microspheres averaging 34 mu in diameter, and demonstrated a progressive decrease in cardiac output and stroke volume and increases in pulmonary artery pressure and pulmonary vascular resistance. Pretreatment with either ibuprofen (Group III; n = 10) or meclofenamate (Group IV; n = 9) resulted in no change in resting hemodynamics and only minimally altered the effect of microembolism on pulmonary artery pressure. However, both ibuprofen and meclofenamate abolished the microembolism-induced decrease in cardiac output and stroke volume and blunted the increases in pulmonary artery pressure and pulmonary vascular resistance. The hemodynamic consequences of pulmonary microembolism in awake rabbits, particularly the decrease in cardiac output, are partly mediated by prostaglandin release, which alters pulmonary vascular tone and/or myocardial function.     

A comprehensive, longitudinal description of the in-hospital and post-discharge clinical, laboratory, and neurohormonal course of patients with heart failure who die or are re-hospitalized within 90?days: analysis from the EVEREST trial

Hospitalization for worsening chronic heart failure results in high post-discharge mortality, morbidity, and cost. However, thorough characterization, soon after discharge of patients with early post-discharge events has not been previously performed. The objectives of this study were to describe the baseline, in-hospital, and post-discharge clinical, laboratory, and neurohormonal profiles of patients hospitalized for worsening heart failure with reduced ejection fraction (EF) who die or are re-admitted for cardiovascular (CV) causes within 90 days of initial hospitalization. Retrospective analysis of 4,133 patients hospitalized for worsening heart failure with EF ≤40% in the Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study with Tolvaptan (EVEREST) trial, which randomized patients to tolvaptan or placebo, both in addition to standard therapy. Clinical and laboratory parameters were obtained within 48?h of admission, during hospitalization, and post-discharge weeks 1, 4, 8, and every 8?weeks thereafter for a median of 9.9?months. Patients with events within 90?days were compared with those with later/no events. All-cause mortality (ACM) and CV re-hospitalization were independently adjudicated. Within 90?days of admission, 395 patients (9.6%) died and 801 patients (19.4%) were re-hospitalized for CV causes. Significant baseline and longitudinal differences were seen between groups with early versus later (>90?days) or no events at 12?months post-randomization. Post-discharge outcomes were similar in the tolvaptan and placebo groups. Patients with early post-discharge events experienced clinically significant worsening in signs and symptoms, laboratory values, and neurohormonal parameters soon after discharge. Identifying these abnormalities may facilitate efforts to reduce post-discharge mortality and re-hospitalization.     

氯沙坦心衰生存研究（ELITE Ⅱ）：氯沙坦和卡托普利对心衰相关预后和症状的作用比较氯沙坦心衰生存研究（ELITE Ⅱ）：氯沙坦和卡托普利对心衰相关预后和症状的作用比较

背景：利用血管紧张素转换酶抑制剂阻断肾素-血管紧张素系统可以改善心衰（HF）患者的预后和症状。在ELITEⅡ研究中，比较了氯沙坦和卡托普利对心衰患者死亡率、发病率以及功能状态方面的作用。方法和结果：总共3152例年龄≥60岁、NYHA心功能分级为Ⅱ-Ⅳ级、射血分数≤40％的HF患者入选研究，接受氯沙坦50mg1次／d或卡托普利50mg3次／d。判断预后的指标包括：全因或HF相关的死亡、住院和停止治疗；NYHA分级的变化；生活质量（QoL）。各治疗组问HF相关预后无显著性差异。两组的NYHA分级得到了相似的改善（P〈0．01）。观察1856例患者的QoL发现，1343例患者至少存活1年以上；两组中1年存活者的QoL均得到了改善（与基线相比，P〈0．001）。     

The Academic Medical System: Reinvention to Survive the Revolution in Health Care

Academic medical centers (AMCs) are presently facing enormous challenges arising from a prospective decline in government funding for research and education, shifting payment models emphasizing efficiency and value, and increasing competition. Left unabated, these challenges will drive many AMCs to de-emphasize or forsake their core missions in an effort to survive. Stemming from a symposium held at the 2015 Scientific Sessions of the American College of Cardiology titled, “The Academic Medical Center of the Future,” we propose a series of changes, including internal restructuring, system-wide partnership, and novel approaches to support research and education, that are designed to better position AMCs to compete and face their growing challenges in a manner that preserves their essential missions. In aggregate, these changes will facilitate establishing the academic medical system of the future.