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Effectiveness of two intensive treatment methods for
smoking cessation and relapse prevention in patients
with coronary heart disease: study protocol and
baseline description
Background:
There is no more effective intervention for secondary prevention of coronary heart diseasethan smoking cessation. Yet, evidence about the (cost-)effectiveness of smoking cessationtreatment methods for cardiac inpatients that also suit nursing practice is scarce. This protocoldescribes the design of a study on the (cost-)effectiveness of two intensive smoking cessationinterventions for hospitalised cardiac patients as well as first results on the inclusion rates andthe characteristics of the study population.
Methods:
A quasi-experimental study design is used in eight cardiac wards of hospitals throughout theNetherlands to assess the (cost-)effectiveness of two intensive smoking cessation counsellingmethods both combined with nicotine replacement therapy. Randomization was conducted atthe ward level (cross-over). Baseline and follow-up measurements after six and 12 monthsare obtained. Upon admission to the cardiac ward, nurses assess patients' smoking behaviour,provide a quit advice and subsequently refer patients for either telephone counselling or faceto-face counselling. The counselling interventions have a comparable structure and contentbut differ in provider and delivery method, and in duration. Both counselling interventionsare compared with a control group receiving no additional treatment beyond the usual care.Between December 2009 and June 2011, 245 cardiac patients who smoked prior tohospitalisation were included in the usual care group, 223 in the telephone counselling groupand 157 in the face-to-face counselling group. Patients are predominantly male and have amean age of 57 years. Acute coronary syndrome is the most frequently reported admissiondiagnosis. The ultimate goal of the study is to assess the effects of the interventions onsmoking abstinence and their cost-effectiveness. Telephone counselling is expected to bemore (cost-)effective in highly motivated patients and patients with high SES, whereas faceto-face counselling is expected to be more (cost-)effective in less motivated patients andpatients with low SES.DiscussionThis study examines two intensive smoking cessation interventions for cardiac patients byusing a multi-centre trial with eight cardiac wards. Although not all eligible patients could beincluded and the distribution of patients is skewed in the different groups, the results will beable to provide valuable insight into effects and costs of counselling interventions varying indelivery mode and intensity.Trial registrationDutch Trial Register NTR2144
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Idiopathic premature ventricular contractions and
ventricular tachycardias originating from the
vicinity of tricuspid annulus: Results of
radiofrequency catheter ablation in thirty-five
patients
Background:
In recent years, catheter ablation has increasingly been used for ablation of idiopathicpremature ventricular complexes (PVCs) or ventricular tachycardias (IVTs). However, themapping and catheter ablation of the arrhythmias originating from the vicinity of tricuspidannulus (TA) may not be fully understood. This study aimed to investigate electrophysiologiccharacteristics and effects of radiofrequency catheter ablation (RFCA) for patients withsymptomatic PVCs and IVTs originating from the vicinity of TA.
Methods:
Characteristics of body surface electrocardiogram (ECG) and electrophysiologic recordingswere analyzed in 35 patients with symptomatic PVCs/ IVTs originating from the vicinity ofTA. RFCA was performed using pace mapping and activation mapping.
Results:
Among the 35 patients with PVCs/IVTs arising from the vicinity of TA, complete eliminationof PVCs/IVTs could be achieved by RFCA in 32 patients (success rate 91.43%) during amedian follow-up period of 21 months. PVCs/IVTs originating from the vicinity of TA haddistinctive ECG characteristics that were useful for identifying the precise origin. An rSpattern was recorded in lead V1 in 93.1% of patients with PVCs/IVTs from the free wall ofTA, vs 16.7% of patients with PVCs/IVTs from the septal TA, whereas a QS pattern in leadV1 occurred in 83.3% of patients with PVCs/IVTs from the septal TA vs 6.9% of patientswith PVCs from the free wall of the TA. The precordial R wave transition occurred by leadV3 or earlier in all patients with PVCs/IVTs originating from the septal portion of the TA, ascompared to transition beyond V3 in all patients with PVCs/IVTs from the free wall of theTA.
Conclusions:
RFCA is an effective curative therapy for symptomatic PVCs/IVTs originating from thevicinity of TA. There are specific characteristics in ECG and the ablation site could belocated by ECG analysis.
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Age - related treatment strategy and long-term
outcome in acute myocardial infarction patients in
the PCI era
Background:
Older age, as a factor we cannot affect, is consistently one of the main negative prognosticvalues in patients with acute myocardial infarction. One of the most powerful factors thatimproves outcomes in patients with acute coronary syndromes is the revascularizationpreferably performed by percutaneous coronary intervention. No data is currently availablefor the role of age in large groups of consecutive patients with PCI as the nearly sole methodof revascularization in AMI patients. The aim of this study was to analyze age-relateddifferences in treatment strategies, results of PCI procedures and both in-hospital and longtermoutcomes of consecutive patients with acute myocardial infarction.
Methods:
Retrospective multicenter analysis of 3814 consecutive acute myocardial infarction patientsdivided into two groups according to age (1800 patients [less than or equal to] 65 years and 2014 patients > 65years). Significantly more older patients had a history of diabetes mellitus and previousmyocardial infarctions.
Results:
The older population had a significantly lower rate of coronary angiographies (1726; 95.9%vs. 1860; 92.4%, p < 0.0001), PCI (1541; 85.6% vs. 1505; 74.7%, p < 0.001), achievement ofoptimal final TIMI flow 3 (1434; 79.7% vs. 1343; 66.7%, p < 0.001) and higher rate ofunsuccessful reperfusion with final TIMI flow 0-1 (46; 2.6% vs. 78; 3.9%, p = 0.022). A totalof 217 patients (5.7%) died during hospitalization, significantly more often in the olderpopulation (46; 2.6% vs. 171; 8.5%, p < 0.001). The long-term mortality (data for 2847patients from 2 centers) was higher in the older population as well (5 years survival: 86.1%vs. 59.8%). Though not significantly different and in contrast with PCI, the presence ofdiabetes mellitus, previous MI, final TIMI flow and LAD, as the infarct-related artery, hadrelatively lower impact on the older patients. Severe heart failure on admission (Killip III-IV)was associated with the worst prognosis in the whole group of patients, though itssignificance was higher in the youngers (HR 6.04 vs. 3.14, p = 0.051 for Killip III and 12.24vs. 5.65, p = 0.030 for Killip IV). We clearly demonstrated age as a strong discriminator forthe whole population of AMI patients.
Conclusions:
In a consecutive AMI population, the older group (>65 years) was associated with a lesspronounced impact of risk factors on long-term outcome. To ascertain the coronary anatomyby coronary angiography and proceed to PCI if suitable regardless of age is crucial in allpatients, though the primary success rate of PCI in the older age is lower. Age, when viewedas a risk factor, was a dominant discriminating factor in all patients.
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The prognostic importance of a history of
hypertension in patients with symptomatic heart
failure is substantially worsened by a short mitral
inflow deceleration time
Background:
Hypertension is a common comorbidity in patients with heart failure and may contribute todevelopment and course of disease, but the importance of a history of hypertension inpatients with prevalent heart failure remains uncertain.
Methods:
3078 consecutively hospitalized heart failure patients (NYHA classes II-IV) were screenedfor the EchoCardiography and Heart Outcome Study (ECHOS). The left ventricular ejectionfraction (LVEF) was estimated by 2 dimensional transthoracic echocardiography in allpatients and a subgroup of 878 patients had additional data on pulsed wave Dopplerassessment of transmitral flow available. A restrictive filling (RF) was defined as a mitralinflow deceleration time [less than or equal to]140 ms. Patients were followed for a median of 6.8 (Inter QuartileRange 6.6-7.0) years and multivariable Cox regression models were used to assess the risk ofall-cause mortality associated with hypertension.
Results:
The study population had a mean age of 73 +/- 11 years. 39% were female, 27% had a historyof hypertension and 48% had a RF. Over the study period, 64% of the population died.Hypertension was not associated with increased risk of mortality, hazard ratio (HR) 0.95(0.85-1.05). LVEF did not modify this relationship (p for interaction = 0.7), but RF patternsubstantially influenced the outcomes associated with hypertension (p forinteraction < 0.001); HR 0.75 (0.57-0.99) and 1.41 (1.08-1.84) in patients without and withRF, respectively.
Conclusions:
In patients with symptomatic heart failure, a history of hypertension is associated with asubstantially increased relative risk of mortality among patients with a restrictive transmitralfilling pattern.
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Associations among different functional and
structural arterial wall properties and their relations
to traditional cardiovascular risk factors in healthy
subjects: a cross-sectional study
Background:
The arterial wall possesses several functional and structural properties that define arterialhealth. Once they become impaired, cardiovascular risk increases. We aimed to ascertain thepattern of correlations among different arterial wall properties and to explore their relations totraditional risk factors and cardiovascular risk stratification. To allow such an investigation amiddle-aged healthy population was recruited.
Methods:
This cross-sectional study included 100 healthy males (aged 41.9 +/- 6.4 years). Pulse wavevelocity (PWV), beta-stiffness and intima-media thickness (IMT) of the carotid artery, andbrachial artery flow-mediated dilation (FMD) were measured by a standardized ultrasoundapproach.
Results:
No correlation between FMD and IMT was found; only relatively poor correlations betweenPWV (or beta-stiffness) and FMD existed, as well as between PWV (or beta-stiffness) and IMT.PWV and beta-stiffness highly correlated. Unexpectedly, only weak associations between PWV,beta-stiffness, FMD, IMT and traditional risk factors were revealed. Hence, traditional riskfactors (mainly age) explained only 10-50% of variability for PWV, beta-stiffness, FMD andIMT. Although the subjects had low cardiovascular risk according to their Framingham score,their arterial wall properties were already impaired, particularly FMD.
Conclusions:
In healthy middle-age males we found: i) absent or poor correlations among arterial stiffness,IMT and endothelial function; ii) a low impact of traditional risk factors on the studiedvariables, and iii) the presence of impaired arterial wall properties despite low calculatedcardiovascular risk. These results provide a deepened understanding of arterial wallproperties and could help to improve cardiovascular risk stratification.
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Cardiac tamponade related to a coronary injury by a pericardial calcification: an unusual complication
Background:
Cardiac tamponade is a rare but severe complication of pericardial effusion with a poor prognosis. Prompt diagnosis using transthoracic echocardiography allows guiding initial therapeutic management. Although etiologies are numerous, cardiac tamponade is more often due to a hemopericardium. Rarely, a coronary injury may result in such a hemopericardium with cardiac tamponade. Coronary artery aneurysm are the main etiologies but blunt, open chest trauma or complication of endovascular procedures have also been described.Case presentationA 83-year-old hypertensive man presented for dizziness and hypotension. The patient had oliguria and mottled skin. Transthoracic echocardiography disclosed a circumferential pericardial effusion with a compressed right atrium, confirmed by contrast-enhanced thoracic CT scan. A pig-tail catheter allowed to withdraw 500 mL of blood, resulting in a transient improvement of hemodynamics. Rapidly, recurrent hypotension prompted a reoperation. An active bleeding was identified at the level of the retroventricular coronary artery. The pericardium was thickened with several "sharping" calcified plaques in the vicinity of the bleeding areas. On day 2, vasopressors were stopped and the patient was successfully extubated. Final diagnosis was a spontaneous cardiac tamponade secondary to a coronary artery injury attributed to a "sharping"calcified pericardial plaque.
Conclusion:
Cardiac tamponade secondary to the development of a hemopericardium may develop as the result of a myocardial and coronary artery injury induced by a calcified pericardial plaque.
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QRS pattern and improvement in right and left ventricular function after cardiac resynchronization therapy: a radionuclide study
Background:
Predicting response to cardiac resynchronization therapy (CRT) remains a challenge. We evaluated the role of baseline QRS pattern to predict response in terms of improvement in biventricular ejection fraction (EF).
Methods:
Consecutive patients (pts) undergoing CRT implantation underwent radionuclide angiography at baseline and at mid-term follow-up. The relationship between baseline QRS pattern and mechanical dyssynchrony using phase analysis was evaluated. Changes in left and right ventricular EF (LVEF and RVEF) were analyzed with regard to baseline QRS pattern.
Results:
We enrolled 56 pts, 32 with left bundle branch block (LBBB), 4 with right bundle branch block (RBBB) and 20 with non-specific intraventricular conduction disturbance (IVCD). A total of 48 pts completed follow-up. LBBB pts had significantly greater improvement in LVEF compared to RBBB or non-specific IVCD pts (+9.6 ± 10.9% vs. +2.6 ± 7.6%, p = 0.003). Response (defined as ≥ 5% increase in LVEF) was observed in 68% of LBBB vs. 24% of non-specific IVCD pts (p = 0.006). None of the RBBB pts were responders. RVEF was significantly improved in LBBB (+5.0 ± 9.0%, p = 0.007), but not in non-specific IVCD and RBBB pts (+0.4 ± 5.8%, p = 0.76). At multivariate analysis, LBBB was the only predictor of LVEF response (OR, 7.45; 95% CI 1.80-30.94; p = 0.006), but not QRS duration or extent of mechanical dyssynchrony.
Conclusions:
Presence of a LBBB is a marker of a positive response to CRT in terms of biventricular improvement. Pts with non-LBBB pattern show significantly less benefit from CRT than those with LBBB.
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Choice of generic antihypertensive drugs for the primary prevention of cardiovascular disease - A cost-effectiveness analysis
Background:
Hypertension is one of the leading causes of cardiovascular disease (CVD). A range of antihypertensive drugs exists, and their prices vary widely mainly due to patent rights. The objective of this study was to explore the cost-effectiveness of different generic antihypertensive drugs as first, second and third choice for primary prevention of cardiovascular disease.
Methods:
We used the Norwegian Cardiovascular Disease model (NorCaD) to simulate the cardiovascular life of patients from hypertension without symptoms until they were all dead or 100 years old. The risk of CVD events and costs were based on recent Norwegian sources.
Results:
In single-drug treatment, all antihypertensives are cost-effective compared to no drug treatment. In the base-case analysis, the first, second and third choice of antihypertensive were calcium channel blocker, thiazide and angiotensin-converting enzyme inhibitor. However the sensitivity and scenario analyses indicated considerable uncertainty in that angiotensin receptor blockers as well as, angiotensin-converting enzyme inhibitors, beta blockers and thiazides could be the most cost-effective antihypertensive drugs.
Conclusions:
Generic antihypertensives are cost-effective in a wide range of risk groups. There is considerable uncertainty, however, regarding which drug is the most cost-effective.
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The aging Canadian population and hospitalizations for acute myocardial infarction: projection to 2020
Background:
The risk of experiencing an acute myocardial infarction (AMI) increases with age and Canada's population is aging. The objective of this analysis was to examine trends in the AMI hospitalization rate in Canada between 2002 and 2009 and to estimate the potential increase in the number of AMI hospitalizations over the next decade.
Methods:
Aggregated data on annual AMI hospitalizations were obtained from the Canadian Institute for Health Information for all provinces and territories, except Quebec, for 2002/03 and 2009/10. Using these data in a Poisson regression model to control for age, gender and year, the rate of AMI hospitalizations was extrapolated between 2010 and 2020. The extrapolated rate and Statistics Canada population projections were used to estimate the number of AMI hospitalizations in 2020.
Results:
The rates of AMI hospitalizations by gender and age group showed a decrease between 2002 and 2009 in patients aged [greater than or equal to]65 years and relatively stable rates in those aged <64 years in both males and females. However, the total number of AMI hospitalizations in Canada (excluding Quebec) is projected to increase by 4667 from 51847 in 2009 to 56514 in 2020, a 9.0% increase. Inflating this number to account for the unavailable Quebec data results in an increase of approximately 6200 for the whole of Canada. This would amount to an additional cost of between $46 and $54 million and sensitivity analyses indicate that it could be between $36 and $65 million.
Conclusions:
Despite projected decreasing or stable rates of AMI hospitalization, the number of hospitalizations is expected to increase substantially as a result of the aging of the Canadian population. The cost of these hospitalizations will be substantial. An increase of this extent in the number of AMI hospitalizations and the ensuing costs would significantly impact the already over-stretched Canadian healthcare system.
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Oversized vein grafts develop advanced atherosclerosis in hypercholesterolemic minipigs
Background:
Accelerated atherosclerosis is the main cause of late aortocoronary vein graft failure. We aimed to develop a large animal model for the study of pathogenesis and treatment of vein graft atherosclerosis.
Methods:
An autologous reversed jugular vein graft was inserted end-to-end into the transected common carotid artery of ten hypercholesteroemic minipigs. The vein grafts were investigated 12-14 weeks later with ultrasound and angiograpy in vivo and microscopy post mortem.
Results:
One minipig died during follow up (patent vein graft at autopsy), and one vein graft thrombosed early. In the remaining eight patent vein grafts, the mean (standard deviation) intima-media thickness was 712 μm (276 μm) versus 204 μm (74 μm) in the contralateral control internal jugular veins (P < .01). Advanced atherosclerotic plaques were found in three of four oversized vein grafts (diameter of graft > diameter of artery). No plaques were found in four non-oversized vein grafts (P < .05).
Conclusions:
Our model of jugular vein graft in the common carotid artery of hypercholesterolemic minipigs displayed the components of human vein graft disease, i.e. thrombosis, intimal hyperplasia, and atherosclerosis. Advanced atherosclerosis, the main cause of late failure of human aortocoronary vein grafts was only seen in oversized grafts. This finding suggests that oversized vein grafts may have detrimental effects on patient outcome.
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