Clinical and research issues regarding chronic advanced coronary artery disease: part I: Contemporary and emerging therapies.

The following report is based on a working group meeting about advanced coronary artery disease for patients with refractory ischemia who cannot receive revascularization. The aims were to review currently available treatment strategies, define unmet clinical needs, explore clinical trial design issues, and identify promising novel therapeutic targets and approaches for patients with chronic ischemia. The Working Group brought together medical experts in the management of refractory angina with representatives from regulatory agencies, Centers for Medicare and Medicaid Services, and industry.

Association between bleeding, blood transfusion, and costs among patients with non-ST-segment elevation acute coronary syndromes.

Background: Bleeding and blood transfusion are associated with increased morbidity and mortality among patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS); however, the economic consequences of these complications are not well defined. We sought to determine the relationship between bleeding, blood transfusion, and measures of costs among patients with non-ST-segment elevation ACS.

Methods: We analyzed data from the economic substudy of the GUSTO IIb trial (n = 1235) to determine the relationship between bleeding; transfusion; and hospital costs, physician costs, total costs, and length of stay.

Intensivist bedside ultrasound (INBU) for volume assessment in the intensive care unit: a pilot study.

Background: Estimation of volume status in the high-acuity surgical population can be challenging. The use of intensivist bedside ultrasound (INBU) to rapidly assess volume status in the surgical intensive care unit (SICU) was hypothesized to be feasible and as accurate as invasive measures.

Methods: Clinician sonographers (CSs) were trained to perform basic cardiac ultrasound and sonographic assessment of the inferior vena cava (IVC).

The rationale and design of the Surgical Treatment for Ischemic Heart Failure (STICH) trial.

Objectives: The rationale and design of the Surgical Treatment for Ischemic Heart Failure trial is described. Before the Surgical Treatment for Ischemic Heart Failure trial, less than 1000 patients with ischemic cardiomyopathy had been studied in randomized comparisons of medical therapy versus coronary artery bypass grafting. Trial data reflect how these therapies were delivered more than 20 years ago and do not indicate the relative benefits of medical therapy versus coronary artery bypass grafting in contemporary practice.

Cardiovascular disease on a global scale: defining the path forward for research and practice.

During the 2006 World Congress of Cardiology meeting in Barcelona, the Virtual Coordinating Centre for Global Collaborative Cardiovascular Research (VIGOUR) group held a symposium examining potential approaches to understanding and controlling the explosive worldwide growth of cardiovascular disease and its attendant morbidity and mortality. Over the last 20 years, the global nature of many problems in health care has become much more evident. In the realm of health, this has meant that countries across the globe have started to experience the same kinds of behavioural shifts (overeating, reduced physical activity and smoking), and with them massive increases in cardiovascular risk factors, observed over the last century particularly in North America and Western Europe.

Directed bedside transthoracic echocardiography: preferred cardiac window for left ventricular ejection fraction estimation in critically ill patients.

Background: Bedside transthoracic echocardiography (TTE) performed by emergency physicians (EPs) is valuable in the rapid assessment and treatment of critically ill patients. We sought to determine the preferred cardiac window for left ventricular ejection fraction (LVEF) estimation by EP sonographers in a critically ill patient population.

Methods: Prospective investigator-blinded study of focused bedside TTE in a convenience sample of surgical intensive care patients.

Percutaneous coronary revascularisation: is it ever worth what it costs?

“How could percutaneous coronary intervention without the risks and morbidities of heart surgery not be of benefit to patients? Hard experience teaches that such attractive “pathophysiological” simplifications are unreliable guides to practice and paradoxically may lead to worse rather than better treatment decisions”

Impact of rate-modulated pacing on quality of life and exercise capacity--evidence from the Advanced Elements of Pacing Randomized Controlled Trial (ADEPT).

Background: Ninety-nine percent of pacemakers implanted in the United States include an option for rate modulation.

Objective: The purpose of this study was to determine whether dual-chamber rate-modulated pacing, when compared with dual-chamber pacing alone, improved quality of life.

Methods: This was a single-blind randomized controlled trial comparing dual-chamber with rate-modulated dual-chamber pacing.

Where patients with mild to moderate heart failure die: results from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT).

Background: Common locations of death in patients with congestive heart failure (CHF) are unknown. In the SCD-HeFT, mortality of patients with CHF was assessed after randomization to an implantable cardioverter/defibrillator (ICD), amiodarone, or placebo. The aim of this study was to evaluate the location of deaths in SCD-HeFT.

Preventing tomorrow's sudden cardiac death today: part II: Translating sudden cardiac death risk assessment strategies into practice and policy.

Although current evidence supporting a more precise strategy for identifying patients at highest risk for sudden cardiac death (SCD) is sparse, strategies for translating existing and future evidence into clinical practice and policy are needed today. A great many unanswered questions exist. Examples include the following: At what level of risk for SCD should we pursue further testing or therapy? How should clinical strategies ethically and economically balance alternative outcomes? How can we best translate optimal strategies into clinical practice so as to prevent tomorrow's SCDs? On July 20 and 21, 2006, a group of individuals with expertise in clinical cardiovascular medicine, biostatistics, economics, and health policy was joined by government (Food and Drug Administration; Centers for Medicare and Medicaid Services; National Heart, Lung, and Blood Institute; Agency for Healthcare Research and Quality), professional societies (Heart Rhythm Society), and industry to discuss strategies for risk assessment and prevention of SCD.

Preventing tomorrow's sudden cardiac death today: part I: Current data on risk stratification for sudden cardiac death.

Accurate and timely prediction of sudden cardiac death (SCD) is a necessary prerequisite for effective prevention and therapy. Although the largest number of SCD events occurs in patients without overt heart disease, there are currently no tests that are of proven predictive value in this population. Efforts in risk stratification for SCD have focused primarily on predicting SCD in patients with known structural heart disease.

Impact of residency status on perfusion times and outcomes for coronary artery bypass graft surgery.

Background: A price of training residents in cardiothoracic surgery is often perceived to be a loss in intraoperative efficiencies, leading to prolonged cardiopulmonary bypass and perfusion time. Because these indicators are also thought to adversely affect operative outcome, we investigated the association between residency training status, perfusion times, and outcomes.

Methods: Using the Society of Thoracic Surgeons (STS) National Cardiac Database, we studied 369,906 CABG patients undergoing isolated coronary artery bypass graft (CABG) procedures during January 2002 through June 2005.

Facets of openness predict mortality in patients with cardiac disease.

Objective: To examine the NEO Personality Inventory (NEO PI) Openness to Experience (O) domain and its facets as predictors of cardiac deaths and all-cause mortality.

Methods: The NEO PI was administered to a sample of 977 coronary catheterization patients with significant coronary artery disease. Over an average 15-year follow-up period, 266 cardiac deaths and 463 total deaths occurred.

Risk of thromboembolism in heart failure: an analysis from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT).

Background: In patients with heart failure, rates of clinically apparent stroke range from 1.3% to 3.5% per year.

Absence of bilateral vision loss from amiodarone: a randomized trial.

Background: Amiodarone's role as a cause of toxic optic neuropathy is based on case reports. Annual frequency estimates of 0.36% to 2.

Myocardial infarction following coronary artery bypass graft surgery increases healthcare resource utilization.

Objective: To assess the health economic impact of perioperative myocardial infarction in a cohort of patients undergoing coronary artery bypass graft surgery.

Design: Retrospective cohort analysis using data from hospital bills and uniform billing forms.

Setting: A total of 147 geographically diverse hospitals in the United States.

Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT).

Background: Recent observations suggest statin treatment may be associated with lower mortality in heart failure (HF). The SCD-HeFT was a study of 2521 functional class II and III HF patients with left ventricular ejection fractions < or = 35% and ischemic and nonischemic cardiomyopathy followed up for a median of 45.5 months.

Long-term costs and resource use in elderly participants with congestive heart failure in the Cardiovascular Health Study.

Background: Although heart failure (HF) afflicts nearly 5 million Americans, the long-term cost of HF care has not been described previously. In a prospective, longitudinal cohort of community-dwelling elderly from 4 regions, we examined the long-term costs and resource use of elderly patients with HF.

Methods: We linked 4860 elderly participants in the National Heart, Lung, and Blood Institute Cardiovascular Health Study to Medicare part A and part B claims from 1992 to 2003.

Noninvasive imaging for coronary artery disease: a technology assessment for the Medicare Coverage Advisory Commission.

This report describes a review of the available scientific evidence through 2005 on direct noninvasive imaging tests (NITs) for coronary artery disease. In particular, the report addresses 6 key questions provided by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services. The questions examine the degree to which current evidence supports confident judgments about the use of NITs in the assessment of native coronary artery stenosis in clinical practice.

A comparison of commercially available demineralized bone matrix for spinal fusion.

In an effort to augment the available grafting material as well as to increase spinal fusion rates, the utilization of a demineralized bone matrix (DBM) as a graft extender or replacement is common. There are several commercially available DBM substances available for use in spinal surgery, each with different amounts of DBM containing osteoinductive proteins. Each product may have different osteoinductivity potential due to different methods of preparation, storage, and donor specifications.

Is early too early? Effect of shorter stays after bypass surgery.

Background: Postoperative stays after coronary artery bypass graft surgery (CABG) decreased substantially in the 1990s. Although shorter stays offer clinical benefits, premature discharge could increase adverse events and offset initial savings. This study examined the effect of early discharge after CABG on readmission/death and cost within 60 days of discharge home.

Adoption of a ventilator-associated pneumonia clinical practice guideline.

Conceptual Framework: The Academic Center for Evidence-based Practice (ACE) Star Model was used to implement an evidence-based clinical practice guideline (CPG) in order to decrease ventilator-associated pneumonia (VAP) incidence rates and ventilator days. The goal was to interrupt person-to-person transmission of bacteria and bacterial colonization using low-cost, evidence-based strategies to prevent VAP. DISCOVERY: Two geographically proximate medical centers, inclusive of five intensive care units located in the southwestern region of the United States had significant variations in their VAP rates.

Trends in postoperative length of stay after bypass surgery.

Background: Although single-site studies have reported reductions in coronary artery bypass graft (CABG) surgery length of stay (LOS) over the last 15 years, less information is available regarding overall temporal trends and interhospital variability. This study examined trends in postoperative LOS, associated rates of transfer at discharge and variation among hospitals in LOS at CABG hospitals in New York State.

Methods: Trends in postoperative LOS and transfers at discharge for 105,842 CABG patients treated in 30 hospitals in New York between 1992 and 1998 were first described graphically.

Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation.

Context: Recent studies of drug-eluting intracoronary stents suggest that current antiplatelet regimens may not be sufficient to prevent late stent thrombosis.

Objective: To assess the association between clopidogrel use and long-term clinical outcomes of patients receiving drug-eluting stents (DES) and bare-metal stents (BMS) for treatment of coronary artery disease.

Design, Setting, And Patients: An observational study examining consecutive patients receiving intracoronary stents at Duke Heart Center, a tertiary care medical center in Durham, NC, between January 1, 2000, and July 31, 2005, with follow-up contact at 6, 12, and 24 months through September 7, 2006.