Heparin after percutaneous intervention (HAPI): a prospective multicenter randomized trial of three heparin regimens after successful coronary intervention

OBJECTIVES

The purpose of this study was to determine the incidence of bleeding, vascular, and ischemic complications using three different heparin regimens after successful intervention.

BACKGROUND

The ideal dose and duration of heparin infusion after successful coronary intervention is unknown.

METHODS

Patients were randomized to one of three heparin strategies after coronary intervention: Group 1 (n = 157 patients) received prolonged (12 to 24 h) heparin infusion followed by sheath removal; Group 2 (n = 120 patients) underwent early removal of sheaths, followed by reinstitution of heparin infusion for 12 to 18 h; Group 3 (n = 137 patients) did not receive any further heparin after intervention with early sheath removal. The primary end point of the study was the combined incidence of in-hospital bleeding and vascular events. Secondary end points included in-hospital ischemic events, length of stay, cost and one-month outcome.

RESULTS

After successful coronary intervention, 414 patients were randomized. Unstable angina or postinfarction angina was present in 83% of patients before intervention. The combined incidence of bleeding and vascular events was 21% in Group 1, 14% in Group 2 and 8% in Group 3 (p = 0.01). The overall incidence of in-hospital ischemic complications was 2.2%; there were no differences between groups. Length of hospital stay was shorter (p = 0.033) and adjusted hospital cost was lower (p < 0.001) for Group 3. At 30 days, the incidence of delayed cardiac and vascular events was similar for all three groups.

CONCLUSIONS

Heparin infusion after successful coronary intervention is associated with more minor bleeding and vascular injury, prolonged length of stay and increased cost. In-hospital and one-month ischemic events rarely occur after successful intervention, irrespective of heparin use. Routine postprocedure heparin is not recommended, even in patients who present with unstable ischemic syndromes.

The influence of perceived responsibility and personality characteristics on the emotional and behavioral reactions to people with AIDS

The present study examined the effect of a target's personality and responsibility for a misdeed on a perceiver's emotions and behavior by determining the variables' impact on the perceiver's emotional reactions and willingness to help the target. A total of 134 Germans and 171 Americans were given information about the level of responsibility (low, medium, or high) for a person's infection with HIV, 2 variations of information about the target's personality (positive vs. negative), and the transmission mode of the virus (needle vs. unsafe sex). Although B. Weiner's (1995) model of responsibility partially explained the findings, the results showed that the target's personality also contributed to the perceiver's emotional and behavioral reactions.

Thrombolytic therapy for acute myocardial infarction

Numerous factors must be considered when determining the formulary status of thrombolytic agents for the treatment of acute myocardial infarction. Defined treatment options, predicted outcomes, and the economic consequences of this disorder continue to evolve from clinical trials. Pharmacists have a major role in delivering patient care, with responsibility for evaluating, procuring, and monitoring thrombolytic agents and drug therapy in general. By participating in the development and implementation of treatment guidelines, evaluating economic and therapeutic outcomes, providing timely optimal drug therapy, and educating health care providers and the public, they contribute significantly to the health care team.

Pharmacologic prophylaxis of supraventricular tachyarrhythmias after coronary artery bypass

Coronary artery bypass surgery is an accepted treatment for patients with coronary artery disease. Perioperative morbidity includes development of supraventricular arrhythmias. To prevent this, prophylactic administration of drugs such as calcium channel blockers, digoxin, and beta-blockers have been advised.

Efficacy and safety of pravastatin in the treatment of patients with type I or type II diabetes mellitus and hypercholesterolemia

PURPOSE

Patients with type I and type II diabetes mellitus have an increased risk of coronary heart disease. In many diabetics, hypercholesterolemia is present and further exacerbates this risk. We investigated the efficacy and safety of pravastatin in the treatment of patients with type I or type II diabetes mellitus and hypercholesterolemia.

PATIENTS AND METHODS

In this 24-week, multi-center, double-blind, placebo-controlled study, 94 patients (45 men, 49 women), 18 to 70 years of age, with type I or type II diabetes mellitus and hypercholesterolemia (fasting plasma low-density lipoprotein cholesterol [LDL-C] levels > 150 mg/dL and above the 75th percentile for the US population by age and gender) were randomized to receive pravastatin 20 mg hs or matching placebo. Two patients were randomized to treatment with drug for every 1 randomized to placebo. The dose could be doubled after 10 weeks, and cholestyramine or colestipol could be added after 18 weeks, as needed, to attempt to lower the LDL-C levels to below the 50th percentile for the US population.

RESULTS

Significant reductions in LDL-C (-27.6%), total cholesterol (-22.1%), very-low-density lipoprotein cholesterol (-22.6%), and triglycerides (-12.8%) (P < or = 0.001 versus placebo for all reductions), and significant increases in high-density lipoprotein cholesterol (4.4%) (P < or = 0.05 versus placebo) were noted in the pravastatin treatment group (average dose 29.5 mg) at 16 weeks. The beneficial lipid-lowering effects of pravastatin were maintained throughout the 24 weeks of the study. Pravastatin was well tolerated, and the frequency of side effects was similar in the pravastatin and placebo groups. No clinically significant changes in the control of diabetes, as assessed by fasting blood glucose levels and glycosylated hemoglobin measurements, were seen during this study.

CONCLUSION

The results of this study demonstrate that pravastatin is well tolerated and effective in lowering total cholesterol and LDL-C in patients with type I or type II diabetes mellitus and hypercholesterolemia.

On sin versus sickness. A theory of perceived responsibility and social motivation

Lack of effort as a cause of achievement failure evokes more punishment than does lack of ability. Perceptions of the controllability of these causes, inferences about personal responsibility, and affective reactions of sympathy and anger mediate between the causal perceptions of ability and effort and punishment responses. This general theory of social motivation explains some reactions to stigmatized persons as well as observations related to help giving, peer rejection, and aggression. The proposed conceptual system distinguishes the reactions to sin versus sickness.

Thrombolytic agents in critical care

Thrombolytic therapy, when instituted early in optimum dosage, has had an important role in improving the survival of critically ill patients. Thrombolysis is but one component of the processes associated with hemostasis, the mechanism by which humans are protected from death by hemorrhage following injury to a blood vessel. The natural process of thrombolysis is mediated by plasmin, the primary protein responsible for clot lysis. Recent studies have established the efficacy of the intravenous administration of thrombolytic agents in decreasing mortality and improving patient outcome.

A new method to assess contact lens care compliance

Failure to comply with contact lens care instructions is a conspicuous finding among both symptomatic and asymptomatic patients. We used a new methodology to quantify the extent of noncompliance and its clinical significance among 170 soft lens wearers. All patients were interviewed and asked to demonstrate their lens care practices. The significance of deviations from package insert instructions was assessed by 22 ophthalmologists and optometrists with regard to potential impact on safety and comfort. Virtually all patients were noncompliant with at least one required procedure. Noncompliant behavior that could significantly affect safety was more common and judged by practitioners to be of more concern than deviations that could affect comfort. Fifty-seven percent of the patients used disinfection procedures that could seriously affect safety. Overall, the study methodology was found to be very effective both for quantifying noncompliance and for evaluating its clinical significance.

Color Doppler mapping of aortic regurgitation in aortic stenosis: comparison with angiography

Color flow Doppler mapping has become the principal noninvasive method used for the qualitative grading of aortic regurgitation (AR). However, the performance of the color Doppler method in patients with AR accompanying aortic stenosis (AS) has not been studied. We therefore compared results of color Doppler and semiquantitative angiographic grading of AR in 32 patients with AS (mean valve area = 0.7 cm2) undergoing supravalvular aortography in the course of cardiac catheterization. Color Doppler demonstrated AR in all 27 patients who had AR by aortography. As expected, neither the maximal jet area nor the jet length discriminated patients by angiographic grade. The best correlation between color Doppler and aortography occurred when the ratio of maximal jet height (JH) to left ventricular outflow tract (LVOT) height was used to grade AR on a scale of 0-4. Four of 5 patients without AR by aortography had either absent or grade 1 AR by color Doppler. Although there was considerable overlap of color Doppler grades in patients with 1+ AR by aortography, grade 3 or 4 AR by color Doppler was always associated with III+ or IV+ AR by aortography. Thus, color Doppler sensitively depicts AR in patients with AS, and the ratio of JH to LVOT height by color Doppler correctly identifies patients with III+ or IV+ AR by aortography. Methods for distinguishing among milder grades require further evaluation.

Hemodynamic effects of antidysrhythmic drugs

Antidysrhythmic medications, when administered in the clinical setting, demonstrate a variety of effects on cardiac electrophysiology, inotropy, and peripheral vascular smooth muscle. The resultant hemodynamic effects may be of profound importance to the clinical well-being of the patient being treated for dysrhythmias. The following review will discuss the hemodynamic effects of the Class I agent moricizine; Class IA agents: quinidine, procainamide hydrochloride, and tocainide hydrochloride; Class IC agents: flecainide acetate, encainide hydrochloride, and propafenone; Class II agents: propranolol hydrochloride, esmolol hydrochloride, and acebutolol; Class III agents: bretylium tosylate and amiodarone hydrochloride; as well as the Class IV agent verapamil. Adenosine, an unclassified antidysrhythmic indicated in the treatment of supraventricular tachycardia will also be discussed. Specific attention will be directed toward the use of these agents in patients with left ventricular dysfunction or history of congestive heart failure.

Coronary artery bypass surgery: outcome assessment

Improvement in quality of life following coronary artery bypass surgery is a function of a number of complex variables. This outcome, based on objective medical and subjective social criteria, must be assessed to determine the success of this financially expensive surgical intervention for management of patients with coronary artery disease. The majority of patients undergoing coronary artery bypass surgery demonstrate, at least early on, an improved quality of life. Subsets of patients have also been shown to have improved survival. With new surgical techniques aimed at improvement in flow to the areas of ischemic myocardium, even better results can be expected. Future studies will determine the extent of this improvement in quality of life over time and will serve to predict for which patients early surgical intervention will be most beneficial.

Distinguishing elation, gladness, and joy

On the basis of a structural analysis of the emotions, descriptive items were created that were postulated to discriminate between elation, gladness, and joy. The items described the situation of each emotion, the different ways in which the body was transformed, the propensity to behave in particular ways, and the different manner in which the emotions functioned to improve the person's life. In the first study, the items were given to subjects who had been asked to recall an instance of elation, gladness, or joy. Ss noted the extent to which each of the items pertained to their particular experience. Analyses of the data establish clear distinctions between elation and gladness and suggest that there may also be a distinct structure for joy. In the second study, the situations for elation and gladness were experimentally created, and objective measures of bodily transformation and behavioral propensity were taken while subjects were in the different emotional states. The results confirmed the structural differences suggested by the retrospective accounts.

Second generation antidysrhythmic agents

Several new antidysrhythmic agents have been or are about to be approved for the prevention and/or treatment of life-threatening or symptomatic ventricular arrhythmias. Prior to use in clinical practice, however, their relative risk/benefit ratio must be assessed. Whereas relief of bothersome symptoms of ventricular dysrhythmias may improve the patient's return to a more active role in society, one must be aware, at the same time, that these antidysrhythmics have adverse effects of their own that may significantly limit their effectiveness. None of these new antidysrhythmic agents has been shown to prevent suddent cardiac death in controlled trials. At the present time, studies are being conducted to assess the efficacy of these agents in preventing sudden cardiac death. The new antidysrhythmic agents are highly effective in treating a wide variety of ventricular, and in some cases, supraventricular dysrhythmias. These agents are orally effective and, because of their unique pharmacokinetic profile, can often be prescribed less often per day than first generation antidysrhythmics. Side effects, for the most part, are predictable and involve the gastrointestinal and central nervous systems. In most cases, such side effects are reversible with dosage reduction. Upon treating a patient for a potentially lethal dysrhythmia, a Class IC agent such as encainide, flecainide, or propafenone, may be considered as the first-line therapy. Class IB agents, although less effective when used alone, show augmented antidysrhythmic efficacy with a reduction in side effects when administered concomitantly with a Class IA agent, such as quinidine or procainamide.(ABSTRACT TRUNCATED AT 250 WORDS)