Guidelines for Cardiac Management in Noncardiac Surgery Are Poorly Implemented in Clinical Practice: Results from a Peripheral Vascular Survey in The Netherlands

Background: The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery recommend an algorithm for a stepwise approach to preoperative cardiac assessment in vascular surgery patients. The authors' main objective was to determine adherence to the ACC/AHA guidelines on perioperative care in daily clinical practice.

Methods: Between May and December 2004, data on 711 consecutive peripheral vascular surgery patients were collected from 11 hospitals in The Netherlands. This survey was conducted within the infrastructure of the Euro Heart Survey Programme. The authors retrospectively applied the ACC/AHA guideline algorithm to each patient in their data set and subsequently compared observed clinical practice data with these recommendations.

Results: Although 185 of the total 711 patients (26%) fulfilled the ACC/AHA guideline criteria to recommend preoperative noninvasive cardiac testing, clinicians had performed testing in only 38 of those cases (21%). Conversely, of the 526 patients for whom noninvasive testing was not recommended, guidelines were followed in 467 patients (89%). Overall, patients who had not been tested, irrespective of guideline recommendation, received less cardioprotective medications, whereas patients who underwent noninvasive testing were significantly more often treated with cardiovascular drugs ([beta]-blockers 43% vs. 77%, statins 52% vs. 83%, platelet inhibitors 80% vs. 85%, respectively; all P < 0.05). Moreover, the authors did not observe significant differences in cardiovascular medical therapy between patients with a normal test result and patients with an abnormal test result.     

Optimal use of coronary care units: A review

Patients at a low probability of acute cardiac pathology constitute a considerable proportion in many coronary care units (CCUs), such that physicians should consider more effective alternatives than CCU admission “to rule out myocardial infarction.” In this article, strategies to increase the efficiency of managing patients with acute chest pain are reviewed. Algorithms aiming to improve the diagnostic accuracy of the general practitioner have been developed but require an electrocardiogram recorded at the home of the patient. Another method of triage encompasses the identification in the emergency room of the hospital of patients at a low probability of acute cardiac pathology by using predictive models that include laboratory assessments. A third strategy includes alternatives to CCUs for patients at a low risk of acute cardiac pathology, such as the creation of a simple observation unit. Finally, some investigators have sought to identify patients with good prognosis for early transfer from the CCU to lower levels of care. It is concluded that a combination of these approaches will be most efficient, and that the most appropriate choice will be determined by local circumstances.     

Disturbed liver function in heart transplantation candidates: two case reports

Heart transplantation candidates frequently have a disturbed liver function. Two cases with jaundice are described in whom the cause and prognosis of the associated liver disease were analysed. In the 4-yr period during which heart transplantation patients with a disturbed liver function were investigated, "cirrose cardiaque" was not encountered; liver tests usually normalized after a successful heart transplant.     

Implementation of a pre-hospital decision rule in general practice: Triage of patients with suspected myocardial infarction

OBJECTIVE: To improve pre-hospital triage of patients with suspected acutecardiac disease DESIGN: Prospective study SUBJECTS: Patients with symptoms suggestive of acute cardiac pathology,who were seen by a general practitioner, for whom acute admissioninto hospital was requested, and in whom a pre-hospital electrocardiogramwas recorded by the ambulance service METHODS: The study consisted of two phases. In the first phase, a decisionrule was developed based on clinical characteristics and electrocardiographicfindings in 1005 patients with suspected acute cardiac pathology.In the second phase, the decision rule was prospectively validated.Symptoms were recorded by a standardized questionnaire by thegeneral practitioner and a computerized electrocardiogram wasmade by the ambulance nurses at the patient's home. Three electrocardiographicoutcomes were available: ‘normal electrocardiogram’,‘possible myocardial infarction’ or ‘extensivemyocardial infarction’. By use of the predictive model,the general practitioner could decide if hospitalization wasnecessary or not. MAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chestpain, other pathology) and high (myocardial infarction, unstableangina) probability of acute cardiac pathology. RESULTS: Among 977 patients with a complete pre-hospital evaluation inthe validation phase of the study, the decision rule recommended‘no hospitalization’ in 227 patients (23%). Thegeneral practitioner followed this advice in 44% of these patients.Although seven of them developed a non-Q wave myocardial infarction,no complications occurred in patients not admitted. In addition,the general practitioner did not hospitalize 19 (2%) of 750patients for whom the decision rule recommended admission. Prehospitaltriage by the general practitioner resulted in a 12% (118 of977 patients) reduction of the number of patients admitted tothe Coronary Care Units. CONCLUSIONS: Pre-hospital triage by the general practitioner was facilitatedusing a standardized questionnaire and pre-hospital electrocardiography,and resulted in a reduction in the number of patients admittedto the Coronary Care Unit, and proved to be safe.     

lschaemic heart disease: Non-invasive prediction of reperfusion and coronary artery patency by continuous ST segment monitoring in the GUSTO-I trial

In the GUSTO-I ECG ischaemia monitoring substudy, 1067 patientsunderwent continuous ST segment monitoring, using vector-derived12-lead (406 patients), 12-lead (373 patients) and 3-lead Holter(288 patients) ECG recording systems. Simultaneous angiogramsat 90 or 180 min following thrombolytic therapy were performedas a part of the prospective study in 302 patients. Infarct vessel patency was established as TIMI perfusion grades2 or 3 and occlusion as TIMI perfusion grades 0 or 1. Coronaryartery patency was predicted from ST trends up to the time ofangiography. Predictive values at 90 and 180 min after the startof thrombolysis were 70% and 82% for patency and 58% and 64%for occlusion, respectively. In retrospect, accuracy appearedgreatest (79–100%) in patients with extensive ST segmentelevation (400 µV), if both speed of ST recovery and extentof ST segment: elevation were taken into account. Although thethree recording systems differed considerably in signal processing,no significant difference in accuracy was demonstrated amongthese systems. We conclude that continuous ECG monitoring may help select highrisk patients without apparent reperfusion who may benefit fromadditional reperfusion therapy. As ST recovery may occur earlyafter the start of thrombolytics and accuracy of the test isrelated to peak ST levels, the use of on-line ECG monitoringdevices on emergency wards and cardiac care units is recommended.(Eur Heart J 1996; 17: 689–698)     

Persistence of lactase activity among Northern Europeans: A weighing of evidence for the calcium absorption hypothesis

Considered in this paper is a broad range of evidence bearing on the calcium absorption hypothesis that has been advanced to explain high frequencies of the gene for persistence of lactase activity (PLA) among adults in northern Europe. According to that hypothesis, lactase‐sufficient individuals in early northern Europe enjoyed a selective advantage over lactase‐deficient ones that led to high incidences of PLA in adults of the region. Northern Europeans, the hypothesis goes, suffered from a dietary shortage of vitamin D and, in addition, were unable to synthesize adequate vitamin D from the sun's ultraviolet radiation because of northern Europe's cloudiness and its location in higher latitudes. This led to chronic vitamin D deficiency along with a reduced ability to absorb calcium from milk and lactose‐rich dairy products. As a result, the deficiency diseases rickets—which affects infants and children and can leave a child with bowlegs and other bone defects—and osteomalacia—which weakens and deforms the bones of adults—were common in early northern Europe, and represented powerful selective forces that contributed to development of the highly depigmented skin that is typical of the region's peoples. In addition, the hypothesis goes, calcium absorption was enhanced by a process independent of vitamin D. Such enhancement, found especially or solely among lactase‐sufficient individuals, was brought on by ingestion of lactose in milk and milk products. Thus, persons who enjoyed high lactase activity through life were favored in the struggle for survival, which ultimately led northern European peoples to have among the highest incidences of PLA in the world.

In this article, evidence, much of it recent, is presented to show that lactase‐deficient humans are able to absorb calcium from milk as readily, or nearly as readily, as lactase‐sufficient humans. Evidence is also presented that rickets and osteomalacia occur in parts of the world that have an abundance of sunshine, whether originating from customs that limit exposure to sunshine or otherwise; that heavy cloud cover and high latitude need not result in vitamin D deficiency, rickets, and osteomalacia; that, indeed, osteological evidence from archeological sites in northern Europe indicates that rickets and osteomalacia were quite rare in antiquity; that those conditions appear to have become common in northern Europe only with the advent of the Industrial Revolution, too short a time to have been a significant factor in bringing on the high incidences of PLA that prevail today; and that, indeed, the calcium absorption hypothesis is not confirmed by historical, osteoarcheological, or bio‐medical evidence.     

Use of the fluid column in a cardiac catheter for emergency pacing

Given the not infrequent need for intracardiac pacemaking during intensive cardiac care, a new type of cardiac pacemaker has been designed and tested [1]. With this pacemaker the heart can be stimulated through the fluid column of any conventional catheter, provided it is filled with a 0.9% NaCl solution. This fluid column pacemaker (FCP) is of the “constant current” type. The FCP was tested in 37 animals, in 30 patients in sinus rhythm, and also in two critical patients. In addition to the pacemaker circuit, a special connector was designed, enabling a fast, effective, and safe contact between patient and pacemaker. The FCP is considered to be ideally suited for use in emergency cardiac pacing in intensive care units and other areas where sudden bradycardias may occur and where intrathoracic catheters are inserted for a variety of reasons.