Inclusion of older women in randomized clinical trials: factors associated with taking study medication in the fracture intervention trial

OBJECTIVES

The purpose of this study is to describe the early study medication discontinuation (SMD) experience during the first year of follow-up in a randomized clinical trial in older women and to determine the associations between various baseline characteristics and risk of SMD. DESIGH, SETTING, AND PARTICIPANTS: The authors studied 6,459 postmenopausal women aged 55 to 80 from 11 clinical settings during their first year of participation in the Fracture Intervention Trial (FIT). This trial was designed to test the efficacy of alendronate (Fosamax) on fracture prevention among women with low bone mass.

RESULTS

Study medication discontinuation was greatest in the first month post-randomization (2.2%) and declined thereafter. Cumulative rates of study medication discontinuation were 4.8% (n = 311) at 3 months and 11.1% (n = 717) at 12 months. SMD was not associated with age, marital status, alcohol consumption, regular exercise, past estrogen replacement therapy use, bone mineral density, or personal or maternal fracture history. After adjusting for covariates and markers of comorbidity, the strongest predictor of SMD was fair-to-poor self-rated health (relative risk (RR) 2.10; 95% confidence interval (CI) 1.47, 2.99). Having four or more depressive symptoms was also a significant predictor and had a risk associated with SMD (RR vs none 1.34; 95% CI 1.05, 1.71) similar to that seen for individuals with good self-rated health (RR 1.49; 95% CI 1.16, 1.91).

CONCLUSIONS

Results from this cohort emphasize that clinical trials in older women with multiple concomitant conditions can achieve high levels of adherence. Thought should be given to measuring self-rated health and depressive symptoms before randomization to help identify individuals to be targeted for special assistance programs that focus on encouraging adherence.

Recovery from hip fracture in eight areas of function

BACKGROUND

This report describes changes in eight areas of functioning after a hip fracture, identifies the point at which maximal levels of recovery are reached in each area, and evaluates the sequence of recuperation across multiple functional domains. METHODS. Community-residing hip fracture patients (n = 674) admitted to eight hospitals in Baltimore, Maryland, 1990-1991 were followed prospectively for 2 years from the time of hospitalization. Eight areas of function (i.e., upper and lower extremity physical and instrumental activities of daily living; gait and balance; social, cognitive, and affective function) were measured by personal interview and direct observation during hospitalization at 2, 6, 12, 18, and 24 months. Levels of recovery are described in each area, and time to reach maximal recovery was estimated using Generalized Estimating Equations and longitudinal data.

RESULTS

Most areas of functioning showed progressive lessening of dependence over the first postfracture year, with different levels of recovery and time to maximum levels observed for each area. New dependency in physical and instrumental tasks for those not requiring equipment or human assistance prefracture ranged from as low as 20.3% for putting on pants to as high as 89.9% for climbing five stairs. Recuperation times were specific to area of function, ranging from approximately 4 months for depressive symptoms (3.9 months), upper extremity function (4.3 months), and cognition (4.4 months) to almost a year for lower extremity function (11.2 months).

CONCLUSIONS

Functional disability following hip fracture is significant, patterns of recovery differ by area of function, and there appears to be an orderly sequence by which areas of function reach their maximal levels.

Change in muscle mass and muscle strength after a hip fracture: relationship to mobility recovery

BACKGROUND

Hip fracture in elderly persons has a serious impact on long-term physical function. This study determines the change in muscle strength and muscle mass after a hip fracture, and the associations between these changes and mobility recovery.

METHODS

Ninety community-dwelling women aged 65 years and older who had recently experienced a fracture of the proximal femur were included in the study. At 2 to 10 days after hospital admission, the women's grip strength, ankle dorsiflexion strength, and regional muscle mass (by dual-energy x-ray absorptiometry) were measured, and the prefracture level of independence for five mobility function items was assessed. All measurements were repeated at 12 months.

RESULTS

At follow-up, only 17.8% of the women had returned to their prefracture level of mobility function for all five items. Mobility function recovery was not related to change in skeletal muscle mass of the nonfractured leg or the arms. However, women who lost grip strength (mean loss of -28.7%, SD = 16.9%), or who lost ankle strength of the nonfractured leg (mean loss of -21.5%, SD = 14.7%), had a worse mobility recovery compared with those who gained strength (p = .04 and p = .09, respectively). In addition, chronic disease (p = .03), days hospitalized (p = .04), and self-reported hip pain (p = .07) were independent predictors of decline in mobility function.

CONCLUSIONS

The results suggest that loss of muscle strength, but not loss of muscle mass, is an independent predictor of poorer mobility recovery 12 months after a hip fracture. When confirmed by other studies, these findings may have implications for rehabilitation strategies after a hip fracture.

Diltiazem in acute myocardial infarction treated with thrombolytic agents: a randomised placebo-controlled trial. Incomplete Infarction Trial of European Research Collaborators Evaluating Prognosis post-Thrombolysis (INTERCEPT)

BACKGROUND

Diltiazem reduces non-fatal reinfarction and refractory ischaemia after non-Q-wave myocardial infarction, an acute coronary syndrome similar to the incomplete infarction that occurs after successful reperfusion. We postulated that this agent would reduce cardiac events in patients after acute myocardial infarction treated initially with thrombolytic agents-a clinical application previously unexplored with heart-rate-lowering calcium antagonists.

METHODS

A prospective, randomised, double-blind, sequential trial was done in 874 patients with acute myocardial infarction, but without congestive heart failure, who first received thrombolytic agents. Patients received either 300 mg oral diltiazem once daily, or placebo, initiated within 36-96 h of infarct onset, and given for up to 6 months. The trial primary endpoint was the cumulative first event rate of cardiac death, non-fatal reinfarction, or refractory ischaemia. Additional prespecified endpoints included several composites of non-fatal cardiac events (non-fatal reinfarction combined with refractory ischaemia, all recurrent ischaemia, or the need for myocardial revascularisation). The diagnosis of ischaemia, whether refractory or recurrent, and the need for myocardial revascularisation, was always based on objective electrocardiographical evidence of ischaemia, either at rest or on exertion.

RESULTS

For the trial primary endpoint, 131 events occurred in the 444 placebo patients and 97 events in the 430 diltiazem patients (hazard ratio 0.79; 95% CI, 0.61-1.02; p=0.07). For non-fatal cardiac events, diltiazem treatment was associated with a relative decrease (0.76; 0.58-1.00) in the combined event rate of non-fatal reinfarction and refractory ischaemia. There was a similar decrease in the composite non-fatal endpoints of non-fatal reinfarction combined with all recurrent ischaemia (0.80; 0.64-1.00) and non-fatal reinfarction combined with the need for myocardial revascularisation (0.67; 0.46-0.96). The need for myocardial revascularisation alone was significantly reduced by 42% (0.61; 0.39-0.96). No major safety issues were encountered.

CONCLUSIONS

Diltiazem did not reduce the cumulative occurrence of cardiac death, non-fatal reinfarction, or refractory ischaemia during a 6-month follow-up, but did reduce all composite endpoints of non-fatal cardiac events, especially the need for myocardial revascularisation.

Guidelines for the diagnosis and management of unstable angina and non-Q-wave myocardial infarction: proposed revisions. International Cardiology Forum

BACKGROUND

In 1994, the United States Agency for Health Care Policy and Research issued clinical practice guidelines for the diagnosis and management of unstable angina and non-Q-wave myocardial infarction. In the past 5 years, rapid progress has been made in the management of patients with unstable coronary syndromes, yet current guidelines do not necessarily reflect these advances.

METHODS AND RESULTS

An international forum of cardiology investigators reviewed existing guidelines and discussed areas in which the diagnosis and treatment of unstable angina and non-Q-wave myocardial infarction should be modified. It was agreed that there is sufficient evidence to recommend the following changes: (1) use of serum cardiac markers should be expanded to include troponin I and T levels as diagnostic and prognostic tools; (2) low-molecular-weight heparins should replace unfractionated heparin as antithrombotic agents; (3) new classes of antiplatelet agents are recommended in addition to aspirin; and (4) the use of cholesterol-lowering drugs is appropriate in the long-term management of these patients.

CONCLUSIONS

Evidence from clinical trials within the last 5 years requires that significant changes be made to existing guidelines for the diagnosis and management of unstable angina and non-Q-wave myocardial infarction. The recommendations detailed should be considered in the creation and implementation of updated guidelines.

Are there gender differences in patients presenting with unstable angina?

BACKGROUND

There are limited studies on gender differences in patients with unstable angina. We investigated the influence of gender in these patients in a tertiary referral centre.

METHODS AND RESULTS

Three hundred and thirteen consecutive patients (210 men and 103 women) with unstable angina were studied over a 42-month period. Patient characteristics, cardiovascular risk factors and subsequent management including coronary artery bypass graft (CABG) operation and percutaneous transluminal coronary angioplasty (PTCA) were investigated. There was no difference in age [61.6 (11.0) (S.D.) years for men vs. 63.5 (10.5) years for women]. Diabetes mellitus and hypertension were more common in women (diabetes, 11% vs. 23%, P = 0.007; hypertension, 32% vs. 52%; P = 0.001). The number of smokers was greater in men (73% vs. 46%, P = 0.00001). There was no difference in the prevalence of hypercholesterolaemia or in the incidence of previous myocardial infarction, previous history of angina and family history of ischaemic heart disease. The duration of unstable angina before presentation to the referring hospital was similar in both sexes. The use of aspirin, intravenous heparin and antianginal drugs was also comparable in the two genders. The number of coronary arteries involved in men and women appeared similar (one vessel, 22% vs. 27%; two vessels, 26% vs. 21%; three vessels, 52% vs. 52% in men and women, respectively). The proportion of men and women who underwent subsequent revascularisation was also similar (CABG, 31% vs. 33%; PTCA, 42% vs. 40%). The overall in-hospital mortality was higher in women (6.8% vs. 2.8%), but was not statistically significant (P = 0.18).

CONCLUSIONS

Gender differences in unstable angina manifest in the preponderance of selected risk factors including diabetes mellitus and hypertension in women and smoking in men. There is no difference in age, the degree of coronary artery involvement and the subsequent management in a tertiary referral centre.

Antianginal and anti-ischaemic efficacy of tedisamil, a potassium channel blocker

OBJECTIVE

To determine the efficacy and safety of the potassium channel blocker tedisamil versus placebo in the treatment of patients with stable angina.

DESIGN

Prospective, double blind, placebo controlled study. 203 patients first completed a seven day placebo run in. They were then randomised to receive 50 mg, 100 mg or 150 mg tedisamil twice daily, or placebo. Treadmill exercise testing was carried out at baseline and after 14 days of double blind treatment.

MAIN OUTCOME MEASURES

Primary efficacy parameters were an increase in total exercise duration and a reduction of the sum of ST segment depression using six ECG leads at maximum workload at trough (12 hours after last medication). Secondary aims included increase in exercise time to onset of 0.1 mV ST segment depression, increase in exercise time to onset of any anginal pain, and reduction in ST segment depression in any of the six specified leads at maximum workload. These were all at trough. The same parameters were also assessed at peak concentrations (two hours after administration). Overall attacks of angina and the use of short acting nitrates were assessed from patient diaries.

RESULTS

Tedisamil led to a dose dependent prolongation of exercise duration (significant at all concentrations), an effect that was greater at peak than at trough. Treatment also led to a significant dose dependent reduction in the sum of ST segment depression at both trough and peak concentrations. Tedisamil also decreased (in a dose dependent way) the frequency of anginal attacks and the consumption of short acting nitrates, an improvement that became significant for all doses in the second treatment week. Adverse events with tedisamil were few. There was a pronounced rise in the incidence of diarrhoea with the 150 mg twice daily regimen. Bradycardic effects and increases in QT interval were dose dependent, but were no more evident at exercise than at rest.

CONCLUSIONS

Tedisamil, at doses of 50-100 mg twice daily, was found to be an effective antianginal and anti-ischaemic agent. At doses above 100 mg twice daily its main side effect, diarrhoea, becomes pronounced; therefore the 50-100 mg twice daily regimen appears to be appropriate.

Loss of bone density and lean body mass after hip fracture

Few studies of bone loss have assessed the amount of loss directly after a hip fracture. The present prospective study was conducted to determine changes in bone mineral density (BMD) and muscle mass shortly after fracture and through 1 year to assess short-term loss and related factors. The setting was two acute care teaching hospitals in Baltimore, Maryland, and subjects were 205 community-dwelling women with a new fracture of the proximal femur between 1992 and 1995. Bone density of the nonfractured hip and whole-body and body composition were measured by dual-energy X-ray absorptiometry at 3 and 10 days and 2, 6 and 12 months after admission. Mean BMD of the femoral neck was 0.546 +/- 0.007 g/cm(2) at baseline. Average loss of femoral neck BMD from baseline was 2.1% at 2 months, 2.5% at 6 months and 4.6% at 12 months. The average loss of BMD in the intertrochanteric region was 2.1% at 12 months. Total lean body mass decreased by 6% while fat mass increased by 3. 6% by 1 year after the fracture. These findings indicate that significant loss in BMD and lean body mass occur shortly after hip fracture while body fat increases. Continued loss was evident throughout the 1 year of follow-up. This loss of both bone density and muscle mass may lead to new fractures.

Femoral neck and intertrochanteric fractures have different risk factors: a prospective study

The aim of this study was to determine whether both types of hip fracture, femoral neck and intertrochanteric, have similar risk factors. A prospective cohort study was carried out on community-dwelling elderly women in four areas of the United States: Baltimore, MD; Pittsburgh, PA; Minneapolis, MN and Portland, OR. The participants were 9704 Caucasian women, 65 years and older, of whom 279 had fractured their femoral neck and 222 had fractured their trochanteric region of the proximal femur. The predictors used were the bone mass of the calcaneus and proximal femur, anthropometry, history of fracture (family and personal), medication use, functional status, physical activity and visual function. The main outcome measures were femoral neck and intertrochanteric fractures occurring during an average of 8 years of follow-up. In multivariate proportional hazards models, several risk factors increased the risk of both types of hip fracture; including femoral neck bone density and increased functional difficulty. In hazard regression models that directly compared risk factors for the two types of hip fracture, calcaneal bone mineral density (BMD) predicted femoral neck fractures more strongly than intertrochanteric fractures (OR = 1.16; 95% CI = 1.02-1.31). Steroid use and impaired functional status also predicted femoral neck fractures instead of intertrochanteric fractures. Poor health status (OR = 0.74; 95% CI = 0.55-1.00) predicted intertrochanteric fractures more strongly than femoral neck fractures. We conclude that femoral neck fractures are largely predicted by BMD and poor functional ability while aging and poor health status predispose to intertrochanteric fractures.

Stent implantation reduces restenosis in patients with suboptimal results following coronary angioplasty

BACKGROUND

Primary intracoronary stenting reduces the rate of restenosis when compared with balloon angioplasty (PTCA) in selected patients. The strategy of PTCA followed by provisional stent placement for suboptimal PTCA results may be preferable to universal stenting but has not yet been tested in a randomized trial.

METHODS

An attempt was made to obtain an optimal result with PTCA alone in 143 patients. Stenting was required in 50 patients (35%) for significant coronary dissection or PTCA failure. In the remaining 93 patients, the angiographic result was assessed immediately using on-line quantitative coronary angiography and classified as either optimal (<15% residual stenosis) or suboptimal (>/=15% residual stenosis). Sixteen patients (11%) had an optimal result from PTCA. The remaining 77 (54%) patients had a suboptimal result and were immediately randomized either to no further treatment or to the placement of a stent. The primary end-point was the rate of restenosis (>50% stenosis), assessed by quantitative coronary angiography, at 6 months.

RESULTS

Angiographic follow-up was completed in 132 patients. Restenosis occurred in 53 (36,69)% of patients with a suboptimal result randomized to PTCA alone compared with 24 (12,41)% of patients randomized to stent (P=0.023). There was no significant difference in minimal luminal diameter at follow-up between the randomized groups. The rate of restenosis was 14 (2,43)% in patients with an optimal PTCA result and 14 (5,28)% in those that required stenting.

CONCLUSIONS

Optimal angiographic results following conventional PTCA are rare and the restenosis rate following suboptimal results is high. The strategy of stenting suboptimal results is associated with a significant reduction in the rate of stenosis.

Intertrochanteric versus femoral neck hip fractures: differential characteristics, treatment, and sequelae

BACKGROUND

More than 220,000 persons 65 years and older fracture a hip every year in the United States. Although hip fractures have been considered as a single, homogeneous condition, there are two major anatomic types of proximal femoral fractures: intertrochanteric and femoral neck. The present study's objective was to determine if the two types of hip fracture have different patient characteristics and sequelae.

METHODS

A prospective study of 923 elderly patients admitted to seven Baltimore hospitals for a hip fracture between 1984 and 1986.

RESULTS

Patients with intertrochanteric fractures were slightly older, sicker on hospital admission, had longer hospital stays, and were less likely at 2 months postfracture to have recovered activities of daily living than femoral neck fracture patients. Intertrochanteric fracture patients also had higher mortality rates at 2 and 6 months after fracturing. Long-term recovery (1 year) did not differ between fracture type.

CONCLUSIONS

It appears that intertrochanteric fracture patients have intrinsic factors (older age, poor health) impacting upon their risk of fracture and ability to recover. Differences in patient characteristics and sequelae do exist between femoral neck and intertrochanteric hip fracture patients that impact upon recovery.

Serum concentrations of steroids, parathyroid hormone, and calcitonin in postmenopausal women during the year following hip fracture: effect of location of fracture and age

BACKGROUND

Hip fracture in the aged is a major health problem, especially considering the increasing proportion of the elderly in the population. This study examines changes in circulating levels of hormones, which are purported to affect bone metabolism, in response to hip fracture in postmenopausal women.

METHODS

Patients consisted of women ages 65 and older who had surgery within 2 days of fracture. Serum samples were obtained at 3, 10, 60, 180, and 360 days postfracture. Healthy women without hip fractures from the same age range served as a control group (n = 17). Hormones were determined by radioimmunoassay. Subjects with fractures in the neck region of the femur (n = 78) were compared to subjects with fractures in the trochanteric region (n = 88).

RESULTS

Estrone concentration (47.6 +/- 5.7 pg/mL; mean +/- SEM) at 3 days postfracture was elevated (p < .001) compared to control levels of 20.7 +/- 4.6 pg/mL. By 2 months, levels had declined to control levels. Androstenedione and the adrenal hormones, DHEAS and cortisol, displayed similar responses. Parathyroid hormone (PTH) levels were not significantly different from the control concentration at 3 days following fracture, but increased (p < .001) during the year following fracture. Calcitonin concentrations were much higher (p < .001) 3 days postfracture (42.1 +/- 3.7 pg/mL) compared to controls without fracture (9.8 +/- 3 pg/mL). Except for testosterone, no differences could be attributed to fracture location. Only PTH, with concentrations higher in the older age groups (p < .001), showed an age-related response.

CONCLUSIONS

Following hip fracture, there are some dramatic responses in hormones that purportedly are mechanistically important in bone metabolism. These changes include transient increases in steroid hormones, chronic elevations in calcitonin, and rising levels of PTH during the year after fracture.

Increased binding of fibrinogen to glycoprotein IIIa-proline33 (HPA-1b, PlA2, Zwb) positive platelets in patients with cardiovascular disease

AIMS

The GPIIb-IIIa complex on the platelet membrane plays an important part in thrombosis as it is the receptor for fibrinogen. The gene for platelet membrane glyco-protein IIIa has multiple alleles one of which, the GPIIIa-Proline33 (HPA-1b, PlA2, Zwb) allele has been reported in some, but not all studies, to be associated with an increased risk of myocardial infarction. We investigated whether the presence of the Pro33 form of GPIIIa on the platelet membrane is associated with increased fibrinogen binding.

METHODS AND RESULTS

Blood samples from 70 patients (54 male) with stable angina of whom 22 (18 male) had a history of previous myocardial infarction, were analysed for the GPIIIa-Leu-Pro33 polymorphism at the genomic level, and for whole blood flow cytometric measurement of platelet fibrinogen binding. The GPIIIa-Pro33 form was present in 20 (28.6%) patients (1 homozygous) representing an allele frequency of 0.85 and 0.15 (GPIIIa-Leu33:Pro33). The incidence of myocardial infarction was higher (40.0%) in patients positive for GPIIIa-Pro33 than in those without (32.0%) but this was not significant (P=0.58). Fibrinogen binding to ADP-stimulated platelets was significantly higher in the GPIIIa-Pro33 positive group at all ADP concentrations (<0.0001; two way ANOVA). There was no association between fibrinogen binding and the level of expression of the GPIIb-IIIa complex, platelet volume or platelet count. Fibrinogen binding in response to thrombin stimulation was not different between the groups (P>0.05).

CONCLUSIONS

The increased tendency of platelets from patients with the Pro33 form of GPIIIa may predispose patients with this allele to a higher risk of acute thrombotic events, and argues for selective use of therapeutic agents that inhibit ADP-mediated platelet activation in occlusive vascular disease states.

The flavin environment in old yellow enzyme. An evaluation of insights from spectroscopic and artificial flavin studies

Spectroscopic and chemical modification studies of modified flavins bound to old yellow enzyme have led to predictions about the flavin environment of this enzyme. These studies analyzed solvent accessibility and hydrogen bonding patterns of particular flavin atoms, in addition to suggesting amino acid residues that are in close proximity to those atoms. Here, these studies are evaluated in the light of the crystal structure of old yellow enzyme to reveal that the spectroscopic and modified flavin results are generally consistent with the crystal structure. This highlights the fact that these are useful methods for studying flavin binding site structure. Although several of the inferred properties of the flavin environment are not consistent with the crystal structure, these discrepancies occurred in cases where an incorrect choice was made from among multiple plausible explanations for an experimental result. We conclude that modified flavin studies are powerful probes of flavin environment; however, it is risky to specify details of interactions, especially because of uncertainties due to induced charge delocalization in the flavin.

Crystal structure of thymidylate synthase A from Bacillus subtilis

Thymidylate synthase (TS) converts dUMP to dTMP by reductive methylation, where 5,10-methylenetetrahydrofolate is the source of both the methylene group and reducing equivalents. The mechanism of this reaction has been extensively studied, mainly using the enzyme from Escherichia coli. Bacillus subtilis contains two genes for TSs, ThyA and ThyB. The ThyB enzyme is very similar to other bacterial TSs, but the ThyA enzyme is quite different, both in sequence and activity. In ThyA TS, the active site histidine is replaced by valine. In addition, the B. subtilis enzyme has a 2.4-fold greater k(cat) than the E. coli enzyme. The structure of B. subtilis thymidylate synthase in a ternary complex with 5-fluoro-dUMP and 5,10-methylenetetrahydrofolate has been determined to 2.5 A resolution. Overall, the structure of B. subtilis TS (ThyA) is similar to that of the E. coli enzyme. However, there are significant differences in the structures of two loops, the dimer interface and the details of the active site. The effects of the replacement of histidine by valine and a serine to glutamine substitution in the active site area, and the addition of a loop over the carboxy terminus may account for the differences in k(cat) found between the two enzymes.

Simultaneous assessment of myocardial viability and function for the detection of hibernating myocardium using ECG-gated 99Tcm-tetrofosmin emission tomography: a comparison with 201Tl emission tomography combined with cine magnetic resonance imaging

The aims of this study were to evaluate the simultaneous assessment of myocardial viability and function for the detection of hibernating myocardium using ECG-gated 99Tcm-tetrofosmin single photon emission tomography (SPET), and to compare the technique with 201Tl SPET in combination with cine magnetic resonance imaging (MRI). Fifteen patients aged 41-70 years with impaired left ventricular function (mean LVEF 23.4 +/- 8.1%) and three-vessel coronary artery disease were studied before and after coronary artery bypass grafting (CABG). The following investigations were performed within the 3 months before surgery: stress/redistribution and separate-day rest 201Tl SPET with early and late imaging, stress and ECG-gated rest 99Tcm-tetrofosmin SPET, and resting cine MRI. Between 3 and 6 months post-surgery, stress/redistribution 201Tl SPET and cine MRI were repeated. Tracer uptake in nine segments of the left ventricle was graded visually and by quantitative analysis. Myocardial motion and thickening were graded visually from cine MRI and from gated 99Tcm-tetrofosmin SPET images. Segments were defined as hibernating pre-operatively if tracer uptake was moderately reduced or better but myocardial motion was severely hypokinetic or worse. The accuracy of pre-operative assessment was assessed by comparison with post-operative function assessed by MRI. The sensitivity and specificity for the prediction of functional improvement were 69% and 60% for late rest 201Tl uptake combined with MRI; 58% and 62% for rest 99Tcm-tetrofosmin uptake combined with MRI; and 62% and 45% when gated 99Tcm-tetrofosmin SPET was used to assess both tracer uptake and wall motion. In 21 of 135 segments, contractile function could not be assessed by gated 99Tcm-tetrofosmin SPET because of inadequate tracer uptake; function was improved in 5 (25%) of these segments after CABG. In conclusion, the combined assessment of viability and function using ECG-gated 99Tcm-tetrofosmin SPET is feasible and it allows the assessment of hibernating myocardium with similar accuracy to the combination of ungated 99Tcm-tetrofosmin SPET with MRI. Where tracer uptake is too poor for assessment of function, there is a low incidence of myocardial hibernation. However, ECG-gated 99Tcm-tetrofosmin SPET is not superior to 201Tl SPET combined with cine MRI in the identification of hibernation.

Cardioprotection by opening of the K(ATP) channel in unstable angina. Is this a clinical manifestation of myocardial preconditioning? Results of a randomized study with nicorandil. CESAR 2 investigation. Clinical European studies in angina and revascularization

AIMS

To assess the anti-ischaemic and anti-arrhythmic effects and overall safety of nicorandil, an ATP sensitive potassium (K+) channel opener, with 'cardioprotective' effects, in patients with unstable angina.

METHODS

In a multicentre, randomized, double-blind, parallel-group, placebo-controlled study, oral nicorandil 20 mg twice daily or a matching placebo was administered for a minimum of 48 h to patients admitted with unstable angina. Treatment was standardized to include, where tolerated, oral aspirin, a beta-blocker and diltiazem. Continuous Holter ECG monitoring was performed for 48 h to assess the frequency and duration of transient myocardial ischaemia and any tachyarrhythmia, as the predefined end-points of the study. A pain chart recorded the incidence and severity of chest pain throughout the study period. Patients with myocardial infarction identified retrospectively from troponin-T analysis were excluded.

RESULTS

Two hundred and forty-five patients were recruited into the study. Forty-three patients were excluded with an index diagnosis of myocardial infarction, two were not randomized and 12 had unsatisfactory tape data. In the remaining 188 patients, six out of 89 patients (6.7%) on nicorandil experienced an arrhythmia, compared with 17 out of 99 patients (17.2%) on placebo (P=0.04). Three nicorandil patients experienced three runs of non-sustained ventricular tachycardia compared to 31 runs in 10 patients on placebo (P=0.087 patients; P<0.0001 runs). Three nicorandil patients had four runs of supraventricular tachycardia, compared to 15 runs in nine patients on placebo (P=0.14 patients; P=0.017 runs). Eleven (12.4%) patients on nicorandil had 37 episodes of transient myocardial ischaemia (mostly silent) compared with 74 episodes in 21 (21.2%) patients on placebo (P=0.12 patients; P=0.0028 episodes). In the overall safety analysis, which included all patients who received at least one dose of study medication, there were no significant differences in the rates of myocardial infarction or death between the nicorandil or placebo-treated groups.

CONCLUSIONS

Nicorandil, added to aggressive anti-anginal treatment for unstable angina, reduces transient myocardial ischaemia, non-sustained ventricular, and supraventricular arrhythmia compared to placebo. The anti-arrhythmic activity with nicorandil is probably a secondary effect resulting from its anti-ischaemic action and we suggest that this may be related to its effect on the ATP sensitive potassium channel causing pharmacological preconditioning.

The management of hypercholesterolaemia in patients with coronary artery disease referred for coronary angiography

There are clear benefits in treating hypercholesterolaemia in patients with ischaemic heart disease, especially those with previous myocardial infarction. Following publication of trial evidence and treatment guidelines for hypercholesterolaemia, we investigated the current practice of the management of hypercholesterolaemia in patients with coronary artery disease referred for coronary angiography by general physicians. We prospectively reviewed 156 consecutive patients (117 men; mean age 61.5+/-9.6 [S.D.] years) with a history of angina pectoris who attended the day case unit for coronary angiography in a 10 week period. Nearly a tenth of these patients had not been screened for hypercholesterolaemia in this study. Of those patients with a cholesterol level > or =5.5 mmol/l, almost a quarter were not on a statin or any other cholesterol-lowering therapy. Continued effort should be given to the screening and effective management of hypercholesterolaemia in patients with coronary artery disease.

Comparison of 201Tl, 99mTc-tetrofosmin, and dobutamine magnetic resonance imaging for identifying hibernating myocardium

BACKGROUND

Both radionuclide perfusion tracers and contractile response to dobutamine have been used to identify hibernating myocardium. The aim was to compare 201Tl (thallium) single photon emission CT (SPECT), 99mTc-tetrofosmin (tetrofosmin) SPECT, and dobutamine cine MRI for identifying regions of reversible myocardial dysfunction.

METHODS AND RESULTS

Thirty patients with 3-vessel coronary artery disease and impaired left ventricular function (mean LVEF, 24.0%; SD, 8.3%) scheduled for coronary bypass grafting were recruited. All underwent rest/dobutamine stress (5 to 10 microg . kg-1 . min-1) cine MRI, stress/rest tetrofosmin SPECT, and stress/redistribution and separate-day rest/redistribution thallium SPECT before surgery. Stress/redistribution thallium SPECT and resting MRI were repeated after surgery. In a 9-segment model, SPECT images were scored visually for tracer uptake, which was also measured from a polar plot of myocardial counts. MRI was scored visually for endocardial motion, myocardial thickening, and thickness. Five patients died before follow-up, and 2 declined postoperative investigation. In the remaining 23 patients, mean LVEF increased from 24.0% (SD, 8.3%) to 29.7% (SD, 11.1%) (P<0.05). Of 207 segments analyzed, 145 had significantly abnormal wall motion before surgery, and 82 of these improved function after revascularization. The criteria for predicting recovery of severely hypokinetic segments on preoperative imaging were tracer uptake graded "moderately reduced" or better, or positive inotropic response on dobutamine MRI. Late-rest thallium images showed the highest sensitivity (76%), compared with stress-redistribution thallium (68%) and rest tetrofosmin (66%) (P<0.05). All 3 tracer techniques were nonspecific (44%, 51%, and 49%, respectively). Redistribution of thallium after the resting injection was insensitive (18%) but highly specific (83%). Inotropic response to dobutamine was also insensitive (50%) but specific (81%).

CONCLUSIONS

Radionuclide uptake is a sensitive but nonspecific predictor of myocardial functional recovery, whereas dobutamine MRI is specific but insensitive.

The use of an implantable left ventricular assist device in a patient with cardiogenic shock following acute myocardial infarction

We report the successful long-term use of an implantable left ventricular assist device in a 42-year old patient who suffered cardiogenic shock after an acute anterior myocardial infarction unresponsive to recanalisation of the infarct-related artery and intra-aortic balloon counterpulsation. Attempts to wean our patient from the assist device were not successful and the patient underwent cardiac transplantation after 35 weeks on device assistance. The intermediate and long-term use of an implantable left ventricular assist device may be lifesaving in post-myocardial infarction cardiogenic shock and may allow sufficient time for any stunned myocardium to recover. Should there be no recovery, the device acts as a bridge to cardiac transplantation.

EUROPA substudies, confirmation of pathophysiological concepts. European trial on reduction of cardiac events with perindopril in stable coronary artery disease

In patients with coronary disease, ACE inhibitors may improve endothelial function in the coronary arteries as well as peripheral arteries, and may have anti-proliferative effects which might result in retardation of progression of coronary artery disease. In order to verify these pathophysiological concepts, a series of substudies will be conducted as part of the EUROPA programme. Angiographic and intravascular ultrasound examination of coronary arteries will be performed in approximately 400 patients before and after 3 years' treatment with either perindopril or placebo, in order to assess progression and possible regression of coronary lesions. B-mode ultrasonography of the brachial artery will be used as a model for changes in the coronary arteries, to assess endothelial function in response to ischaemia (reactive hyperaemia) and to vasoconstriction (cold pressor test). Three hundred patients will be investigated before and at different intervals after initiation of study treatment. In addition genetic characterization will be performed of patients participating in EUROPA in order to assess whether specific genotypes do respond more or less favourably to perindopril. In addition, the effect of perindopril will be investigated in patients with diabetes type II, since ACE inhibition in such patients may improve microvascular function and renal function. Integration of these substudies, as well as detailed analysis of other specific subgroups in EUROPA, will help us understand the effects of treatment with perindopril in patients with stable coronary artery disease.

Current roles and future possibilities for low-molecular-weight heparins in unstable angina

Intravenous unfractionated heparin (UFH) is associated with several limitations, including short duration of action, poor bioavailability, unpredictable anticoagulant response, a risk of heparin-induced thrombocytopenia (HIT), and disease reactivation following early discontinuation. Because of these limitations, there is interest in the development of newer antithrombotic strategies. Low-molecular-weight heparins (LMWHs) offer potential benefits over standard heparin and allow the opportunity for subcutaneous self-administration for longer periods. In the acute phase of unstable angina, LMWHs have been shown to be superior to placebo and at least as effective as UFH in reducing death, myocardial infarction and recurrent angina. Trials of longer-term therapy with LMWHs are in progress. Although animal studies have suggested that LMWHs, by reducing neo-intimal proliferation, may prevent restenosis following coronary angioplasty, clinical trials have been disappointing. However, an initial study with the LMWH enoxaparin (Lovenox/Clexane) and ticlopidine after elective stenting (ENTICES) showed a reduction in stent thrombosis and ischaemic events. This has led to a further trial of antiplatelet therapy versus Lovenox plus antiplatelet therapy for patients with an increased risk of stent thrombosis (ATLAST). Further studies are assessing the role of diffusion and pressure-driven and mechanical devices to deliver high and sustained local intravascular concentrations of heparin.

The European trial on reduction of cardiac events with perindopril in stable coronary artery disease (EUROPA)

BACKGROUND

Angiotensin-converting enzyme (ACE) inhibitors have an accepted place in the treatment of hypertension and heart failure. However, at present they have no specific role in the prevention or treatment of coronary artery disease: evidence from animal experiments and some of the large ACE inhibitor cardiac studies makes this effect well worth testing.

OBJECTIVE

The objective of EUROPA is to assess the effects of perindopril (an ACE inhibitor) on outcome in patients with stable coronary artery disease, but no clinical heart failure.

METHODS

This is a double-blind, placebo-controlled, multicentre study with a duration of 3.5 years. It is proposed to recruit 10500 patients from 24 countries in Europe. The primary end-point is a combined one: total mortality, non-fatal acute myocardial infarction, unstable angina pectoris and cardiac arrest with successful resuscitation are included; the outcome is studied in patients with proven coronary artery disease and no clinical heart failure. Secondary end-points consist of these events individually calculated. The first patient was recruited in October 1997, and it is planned to finish recruitment by the end of 1998.

Can C reactive protein or troponins T and I predict outcome in patients with intractable unstable angina?

OBJECTIVE

To determine whether a single blood test for the measurement of C reactive protein, or troponin I or T concentrations could be used to stratify patients with intractable unstable angina awaiting transfer for coronary angiography by correlating these values with coronary anatomy and transient myocardial ischaemia.

DESIGN

Prospective study.

SETTING

Tertiary cardiac unit.

PATIENTS

All patients admitted to their local hospital with ischaemic chest pain, uncontrolled by medical treatment, in whom acute myocardial infarction had been excluded by serial measurement of creatine kinase and lack of Q waves on ECG.

INTERVENTION

Coronary angiography and ST segment monitoring for 24 hours.

MAIN OUTCOME MEASURES

Concentrations of C reactive protein, troponins T and I, coronary anatomy, presence of transient myocardial ischaemia.

RESULTS

Median C reactive protein, troponin I, and troponin T concentrations were 17.1 mg/dl (4.8 to 203.9), 0.05 microgram/l (0 to 7.8), and 0.0 microgram/l (0 to 2.51), respectively. Seven patients (10%) had normal coronaries and 14, 20, and 31 had one, two, or three vessel coronary disease, respectively. Nineteen (26%) had transient myocardial ischaemia, 33 (46%) had complex lesion morphology, and six (8%) had intracoronary thrombus. Of the three markers, troponin T alone was higher in patients with multivessel disease (p < 0.05) and in those with transient myocardial ischaemia (p < 0.05), but there was no significant relation between C reactive protein, troponin T or I and lesion morphology or thrombus.

CONCLUSIONS

In patients transferred to a tertiary centre with intractable chest pain, C reactive protein and troponin I are not predictive of transient myocardial ischaemia or lesion morphology, both of which are surrogate markers of outcome. Troponin T is, however, raised in patients with multivessel disease or transient myocardial ischaemia. These serum protein assays cannot be used to stratify the risk of patients with unstable angina who are awaiting transfer to the tertiary centre.

Accuracy of medical records in hip fracture

OBJECTIVE

To determine the accuracy of diagnoses and procedure codes in medical records for hip fracture patients.

DESIGN

A validation sample of hip fracture medical records was used to compare the facesheet data with progress notes, operative reports, and discharge summaries for patients in a prospective study of functional recovery.

SETTING

Eight Baltimore hospitals with the highest volume of older hip fracture patients.

PATIENTS

Study subjects were 343 community-dwelling patients, 65 years of age and older, admitted to one of eight Baltimore hospitals between January 1990 and June 1991 with a diagnosis of hip fracture.

MAIN OUTCOME MEASURES

Facesheet diagnosis codes were compared with admitting notes, discharge summary, and/or progress notes. The abstracted surgical procedure was compared with postoperative radiographs.

RESULTS

Excess coding of diagnoses on the hospital facesheet was evident in 12% of charts. In 17% of charts, a complication identified in the chart was not coded on the facesheet. More complications with low severity were omitted. Agreement between the abstractor's procedure review and radiograph readings for arthroplasty was 84%. In 15% of patients, the abstractor coded total arthroplasty when hemiarthroplasty was done.

CONCLUSIONS

Discrepancy between the hospital facesheet and the medical record and between the abstracted surgical procedure and radiographs was found for hip fracture patients. This may make findings from health outcomes research relying on administrative databases uncertain and reimbursement inaccurate.

Ultrasound-guided compression of femoral pseudoaneurysm: an audit of practice

OBJECTIVE

To audit the practice of ultrasound-guided compression of femoral pseudoaneurysm in a specialist cardiac hospital.

BACKGROUND

Femoral pseudoaneurysm is an important complication of invasive cardiac procedures. This may require surgical repair but more recently ultrasound-guided compression for ablating pseudoaneurysms has been described. We investigated the success of such a procedure.

METHODS AND RESULTS

In a 26-month period, 56 patients were referred for ultrasound scanning to exclude the formation of a femoral pseudoaneurysm following transfemoral cardiac procedures. During this period, 5756 diagnostic cardiac catherisations and 1165 coronary angioplasties were performed in our hospital (total of 6921 procedures). Of the 56 patients, 20 patients (0.3% of 6921) were found to have a pseudoaneurysm. Ultrasound-guided compression was attempted in 11 patients and was successful in 7 patients (64%). Of the patients who had failed ultrasound-guided compression, 2 proceeded to surgical closure and 2 were treated conservatively with compression stockings to facilitate thrombosis of the pseudoaneurysm. Of those who did not have an attempted ultrasound-guided compression of the pseudoaneurysm (n=9), a conservative approach consisting of resting the leg was adopted to facilitate spontaneous thrombosis of the pseudoaneurysm; repeat ultrasound scanning was needed for follow-up and 1 patient required surgical closure in this group.

CONCLUSIONS

In patients with a femoral pseudoaneurysm following an invasive cardiac procedure, ultrasound-guided compression may be useful as an immediate step to ablate the pseudoaneurysm. This avoids either prolonged leg rest and repeated ultrasound scanning or surgical intervention. However, ultrasound-guided compression is not always successful; in these patients, a period of conservative management with repeat ultrasound scanning is appropriate to allow for the possible spontaneous thrombosis of the pseudoaneurysm. Surgical closure is needed in those patients whose pseudoaneurysm is enlarging, painful or remain patent.

Long-term prognosis in unstable angina. The importance of early risk stratification using continuous ST segment monitoring

AIMS

To assess the ability of clinical characteristics, admission ECG and continuous ST segment monitoring in determining long-term prognosis in unstable angina.

METHODS

Two hundred and twelve patients with unstable angina (mean age 59 years), presenting within 24 h of an acute episode of angina were recruited at three hospitals and treated with standardized medical therapy. All patients kept chest pain charts and underwent ST segment monitoring for 48 h. The occurrence of death, myocardial infarction, and need for revascularization was assessed over a median follow-up of 2.6 years.

RESULTS

The risk of death of myocardial infarction was greatest in the first 6-8 weeks after admission. Admission ECG ST depression and the presence of transient ischaemia predicted increased risk of subsequent death or myocardial infarction, whereas a normal ECG predicted a good prognosis. In 14 patients, ST segment monitoring provided the only evidence of recurrent ischaemia, and 72% of this group suffered an adverse event. Transient ischaemia and a history of hypertension were the most powerful independent predictors of death or myocardial infarction.

CONCLUSIONS

Adverse events in unstable angina occur early after admission and can be predicted by clinical and ECG characteristics, and by the presence of transient ischaemia during ST segment monitoring. Risk stratification by these simple assessments can identify patients with unstable angina at high risk.

Mobility after hip fracture predicts health outcomes

OBJECTIVES

Balance and gait are essential to physical functioning and the performance of activities of daily living. The objective of this study was to determine the predictive value of a balance and gait test on subsequent mortality, morbidity, and healthcare utilization among older hip fracture patients.

DESIGN

A prospective study of hip fracture recovery.

SETTING

Patients with a new hip fracture admitted from the community to one of eight Baltimore hospitals and followed in their homes for 2 years postfracture.

PARTICIPANTS

A total of 306 patients with hip fracture, 65 years of age and older, who completed a gait and balance assessment at 2 months postfracture.

MEASUREMENTS

The relationship between gait and balance test performance at 2 months postfracture and mortality, physician visits, rehospitalizations, nursing home placement, and falls up to 24 months postfracture was assessed by Cox proportional hazards and least squares regression.

RESULTS

After adjusting for age, sex, race, and comorbidity, the balance score and the summary mobility score predicted mortality. A 17% increase in the risk of mortality was demonstrated for each unit decrease in the balance score (range 0-17), and a 10% increase was demonstrated for each decrease in the summary score (range 0-26). Unsteady balance during immediate standing, turning, sitting down, and rising from a chair were associated significantly with increased mortality. Poor balance, but not poor gait, was associated with an increase in hospitalizations up to 24 months postfracture. Both poor balance and poor gait were associated with nursing home placement, with 20% and 17% increased odds, respectively. Mobility did not predict future physician visits or falls.

CONCLUSIONS

These findings demonstrate that balance and gait are predictive of future health outcomes for older hip fracture patients.

Amlodipine versus diltiazem as additional antianginal treatment to atenolol. Centralised European Studies in Angina Research (CESAR) Investigators

The antianginal efficacy and tolerability of amlodipine and diltiazem were compared in a double-blind randomized trial of 97 patients with angina resistant to atenolol alone. Both amlodipine and diltiazem significantly reduced the frequency of angina attacks (p <0.001) and glyceryl trinitrate consumption (p <0.05 to p <0.01). During Holter monitoring, both treatments reduced the overall frequency of ambulatory myocardial ischemia, although changes did not reach statistical significance. Exercise test parameters (total exercise time, time to angina, time to ST depression, and maximum ST depression) tended to improve with both treatments, but changes did not achieve statistical significance relative to baseline or to each other. Both drugs were generally well tolerated. Adverse events occurred in 15 patients in the amlodipine group (30%) and in 17 patients in the diltiazem group (36%), but patients taking diltiazem reported almost twice as many adverse events (30) patients taking amlodipine (18). Quality of life, as assessed by total Nottingham Health Profile Scores, was not significantly different between treatments. The addition of either once-daily amlodipine or twice-daily sustained release diltiazem improved symptoms in patients with angina resistant to atenolol alone, but diltiazem was associated with more frequent and more serious adverse events.

Family history and risk of osteoporotic fracture. Study of Osteoporotic Fractures Research Group

The importance of family history of fractures as a risk factor for fractures is unclear. The aim of this study was to test the hypothesis that family history of fracture increased a woman's risk of hip, wrist and other osteoporotic fracture and determine whether the influence of family history is independent of low bone density. We tested this hypothesis in a prospective study of 9704 Caucasian women, age 65 years or older, by assessing family history and bone density of the radius and calcaneus at baseline; 7963 women had femoral bone density measurements two years later. Fractures occurring during an average of 7.1 years of follow-up since baseline and 5.2 years since the second examination were confirmed by radiographic report. After adjusting for age, risk of hip fracture was increased in those with a maternal (1.48; 95% CI = 1.03-2.11); sister's (1.83; 1.20-2.80) or brother's history of hip fracture (2.26; 1.16-4.42). Risk of wrist fracture was increased by maternal (1.52; 1.10-2.11) and paternal (2.41; 1.14-5.07) history of wrist fracture. Adjustment for bone density did not consistently and substantially affect the strength of the associations. Family history of hip fracture was not associated with an increased risk of wrist fracture and family history of wrist fracture did not increase the risk of hip fracture. We conclude that family history is an important risk factor for fracture that may act, at least in part, through means besides bone density. Furthermore, the effect of family history is not a general but site-specific predisposition to fracture.

An intergenerational program for persons with dementia using Montessori methods

An intergenerational program bringing together older adults with dementia and preschool children in one-on-one interactions is described. Montessori activities, which have strong ties to physical and occupational therapy, as well as to theories of developmental and cognitive psychology, are used as the context for these interactions. Our experience indicates that older adults with dementia can still serve as effective mentors and teachers to children in an appropriately structured setting.

Do ACE inhibitors modulate atherosclerosis?

The ACE/angiotensin II/bradykinin system is inextricably linked to some of the processes that contribute to the generation of atherosclerosis at genetic, molecular, biochemical and pharmacological levels. There is a large body of laboratory-derived experimental data that suggests that inhibition of ACE activity has antiproliferative, anti-inflammatory and vasodilatory effects that can modulate this atherosclerotic process from the earliest form of endothelial dysfunction, to delay of lesion formation in primary atherosclerosis or in myointimal proliferation after PTCA. The clinical evidence for these potential benefits is so far sparse. There are several possible explanations for these discrepancies. Firstly, the role of the ACE/bradykinin/angiotensin II system in the local vascular response to either the primary process of atherosclerosis, or to the injury induced by balloon angioplasty is likely to vary between species and models. Secondly, there is a tendency to ensure the presence of ACE inhibitor in high concentration before or during the vascular insult in animal models, whereas this has not been the case in the clinical studies of post-PTCA restenosis. Whilst the animal studies therefore offer potentially valuable insights into the mechanics of local vascular response, the ability of ACE inhibitors to interfere with such mechanisms now needs to be tested in clinical trials that are each aimed at precisely answering specific questions. The experimental data so far lend considerable support to the fact that drugs acting solely by interference with the angiotensin II-receptor complex are at a theoretical disadvantage, when compared with ACE inhibitors, since the former would be expected to have little effect on bradykinin-mediated activities. To the established benefits of ACE inhibitors in left ventricular dysfunction, and the interesting possibility that there may be an anti-ischaemic action in these circumstances, we may add the promise of the TREND study. In the coming years, there is an urgent requirement for intensive investigation into the ability of ACE inhibitors to modulate the various stages of the atherosclerotic spectrum. For now though, the jury remains out.

Excess mortality attributable to hip fracture in white women aged 70 years and older

OBJECTIVE

The purpose of this study was to estimate the excess mortality attributable to hip fracture.

METHODS

The 6-year survival rate of community-dwelling White female hip fracture patients aged 70 years and older entering one of seven hospitals from 1984 to 1986 (n = 578) was compared with that of White female respondents aged 70 years and older interviewed in 1984 for the Longitudinal Study on Aging (n = 3773).

RESULTS

After age, education, comorbidity, and functional impairment were controlled, the mortality differential between the two groups accumulated to an excess among hip fracture patients of 9 deaths per 100 women 5 years postfracture. Among those with three or more functional impairments or one or more comorbidities, the excess was 7 deaths per 100: the effect of the fracture had disappeared in these groups by 4 years. In contrast, those with two or fewer impairments and those with no comorbidities had a continuing trend of increased mortality, with an excess of 14 deaths per 100 by 5 years.

CONCLUSIONS

There is an immediate increase in mortality following a hip fracture in medically ill and functionally impaired patients, whereas among those with no comorbidities and few impairments, there is a gradual increase in mortality that continues for 5 years postfracture.

Proxy reporting in five areas of functional status. Comparison with self-reports and observations of performance

Proxy ratings of functional status were compared with subject self-reports in five domains relevant to the study of older persons and with observations of subject performance in two areas (physical and instrumental functioning). Data were derived from 233 proxy-subject pairs evaluated in a prospective study of hip fracture patients aged 65 years or more in Baltimore, Maryland (1990-1991). Agreement between proxy and subject reports was highest for a summary measure of instrumental functioning and lowest for a measure of depression. Proxies tended to report more disability than did subjects, although bias varied by function. Patterns of agreement for proxy reports versus observations of performance compared with patterns for proxy reports versus subject reports were lower for measures of instrumental functioning, and bias was generally more extreme for instrumental and physical functioning measures. The authors conclude that agreement and bias differ by functional domain, by the way summary measures are created and scored, and by the criterion against which proxy reports are compared.

Pathophysiology of transient myocardial ischemia in acute coronary syndromes. Characterization by continuous ST-segment monitoring

BACKGROUND

Transient ischemia in stable coronary disease peaks in the morning, reflecting increased myocardial oxygen demand and coronary vasomotor tone after walking. In acute coronary syndromes, however, ischemia may result from transient thrombus formation or coronary spasm at the site of a ruptured plaque. We report on the pathophysiological mechanisms underlying transient ischemia in acute coronary syndromes despite optimal therapy, on the basis of analysis of heart rate changes preceding ischemia and its circadian variation.

METHODS AND RESULTS

Two hundred fifty-six patients with unstable angina or non-Q-wave myocardial infarction underwent continuous ST-segment monitoring for 48 hours while receiving maximal medical therapy. All ischemic episodes were characterized by their timing, duration, association with pain, and heart rate changes before the onset of ischemia. During 10,629 hours of monitoring, 44 patients (17.2%) had 176 episodes of transient ischemia. The mean heart rate at onset of ischemia was 68 +/- 12.8 bpm, and > 55% of ischemic episodes were not preceded by a significant increase in heart rate. Ischemic activity had a single nocturnal peak, with 64% of all episodes occurring between 10 PM and 8 AM, this nocturnal preponderance being evident for episodes with or without a preceding increase in heart rate. The characteristics and timing of transient ischemia were similar in unstable angina and non-Q-wave myocardial infarction, but transient ischemia was more frequent (27.3% versus 15.1%; P < .05) and prolonged (median, 20 versus 13.5 minutes; P < .01) in non-Q-wave myocardial infarction.

CONCLUSIONS

In acute coronary syndromes, transient ischemia has a low threshold, occurs predominantly without an increase in myocardial oxygen demand, and is present mainly at night rather than in the morning. These findings in patients receiving maximal medical therapy suggest significant pathophysiological differences underlying transient ischemia compared with stable coronary disease.

The economic cost of hip fractures in community-dwelling older adults: a prospective study

OBJECTIVES

To evaluate the incremental cost in the year after hip fracture.

DESIGN

Prospective cohort study.

SETTING

Baltimore, Maryland.

PARTICIPANTS

759 community dwelling older patients who sustained a hip fracture and participated in the Baltimore Hip Fracture Study.

MEASUREMENTS

Resource use for direct medical care, formal nonmedical care, and informal care in the 6 months before and the year after fracture was estimated from interviews with patients or proxy respondents. Costs in 1993 dollars were estimated by multiplying resources times national unit cost estimates.

RESULTS

The annualized costs in the year before the fracture ranged between $18,523 and $20,928. The costs in the year after the fracture equaled $37,250. The incremental costs in the year after the fracture, compared with the costs in the year before the fracture, ranged between $16,322 and $18,727. The largest cost differences were attributable to hospitalizations, nursing home stays, and rehabilitation services.

CONCLUSIONS

Because we compared the costs after a fracture with costs before, our estimates of the incremental cost of a hip fracture are lower than others in the literature. These results, obtained from interviews with patients enrolled in a cohort study, or their proxies, provide the best data available to date on the economic cost of hip fractures among community-dwelling older persons.

Asynchronous left ventricular wall motion in unstable angina

The objective of the study was to assess the nature of left ventricular wall motion disturbances in patients with unstable angina and the relative contributions of the severity of symptoms and the severity of coronary artery disease (CAD) to their genesis. A prospective examination was performed on 30 patients with unstable angina (UA) with triple CAD, 34 matched patients with chronic stable angina (CSA) (20 with triple CAD and 14 with isolated left anterior descending (LAD) artery disease), and compared to 21 normals. LV cavity size was normal in all three groups. Twenty-two of 30 patients with UA had marked (>3 mm) abnormal long axis shortening during isovolumic relaxation time (IVRT), 65% of LV sites being abnormal. In CSA, minor (<3 mm) shortening during IVRT occurred in 7 patients with triple CAD, and in 5 with LAD disease, with 12% of LV sites involved in both groups, P<0.001 vs. UA. The incidence of other long axis abnormalities, including reduced extent and peak rate of shortening and lengthening as well as the delay in the onset of shortening and lengthening was increased between patients with CSA and triple CAD compared with LAD but not between the two groups of patients with triple CAD, CSA and UA. Transmitral E/A ratio was also reduced in the two groups with triple vessel disease, CSA and UA. Thus, the incidence of minor long axis abnormalities is similar in CSA and UA and is related to the severity of CAD. However, abnormal shortening during IVRT is more severe and generalised in UA but not in CSA with triple vessel disease. We suggest that these abnormalities of wall motion bear a close relation to the development of instability within the setting of CAD.

How European cardiologists perceive the role of calcium antagonists in the treatment of stable angina

Some 100 European cardiologists discussed calcium antagonists' role in the management of stable angina. Sixty-two percent of those involved used calcium antagonists rather than beta-blockers as first line therapy; 46% were prepared to use calcium antagonists in patients who had had a myocardial infarction more than 6 months previously. Only one tenth would use calcium antagonists in angina patients with left ventricular dysfunction. There was a broad preference for the use of heart rate-moderating calcium antagonists in most forms of stable angina. The discussions also underlined the diagnostic importance of angiography, exercise testing and lipid profile analysis.

Natural variability of transient myocardial ischaemia during daily life: an obstacle when assessing efficacy of anti-ischaemic agents?

OBJECTIVE

To assess the degree of variability of transient myocardial ischaemia during daily life in patients with coronary artery disease, which could confound the interpretation of trials of the therapeutic effects of anti-ischaemic agents.

DESIGN

Prospective method evaluation.

SETTING

Tertiary referral centre, outpatient clinic.

PATIENTS

Patients with stable angina, confirmed coronary artery disease, and a positive treadmill exercise test for ischaemia. Patients were not preselected on the basis of prior documented transient ischaemia during ambulatory ST segment monitoring.

INTERVENTIONS

A simulated drug-study with 4 monitoring phases in 16 subjects. To minimise variability in ischaemic activity, patients underwent weekly 48 hour ambulatory ST segment monitoring outside hospital off all prophylactic therapy on the same weekdays for 4 weeks.

MAIN OUTCOME MEASURE

Variability in the frequency and duration of transient myocardial ischaemia.

RESULTS

There was marked variability in both ischaemic activity and mean duration of ischaemia in patients with confirmed ischaemia, the greatest degree of variability being between patients and from day to day within weeks within patients, with a further contribution to variability being noted between fortnights within patients.

CONCLUSIONS

Despite assessment off all therapy and an adequate period of monitoring (48 hours) with small intervals between monitoring periods (5 days), marked variability in ischaemic activity was noted, and regression towards the mean was clearly shown. Ambulatory ST segment monitoring outside hospital is not a reliable method for assessing the therapeutic effects of anti-ischaemic agents.

Markers of failure to thrive among older hip fracture patients

OBJECTIVES

To determine whether there is a group of recent hip fracture patients who exhibit the signs of failure to thrive and to identify potential precursors to their decline in physical functioning.

DESIGN

Prospective (nonintervention) study of hip fracture recovery; patients were assessed in the hospital and at 2, 6, 12, 18, and 24 months post-fracture.

SETTING

Hip fracture patients admitted to one of eight Baltimore area hospitals from the community with a new fracture of the proximal femur between January 1, 1990, and June 15, 1991.

PARTICIPANTS

Patients were 65 years of age and older and lived in the community before the fracture. A total of 804 patients were eligible for the study; the present study analyses were restricted to the 252 patients who survived 1 year and had a self-report assessment at 6 and 12 months post-fracture.

MEASUREMENTS

A questionnaire administered during hospitalization assessed pre-fracture functional and health status and current affective and cognitive status. In-home interviews post-fracture ascertained dependence and difficulty with physical and instrumental activities of daily living. Abstraction of the medical records provided information about comorbidities, surgical procedure, and hospital length of stay.

RESULTS

Patients who declined in ability to walk from 6 to 12 months post-fracture had greater use of health resources (more hospitalizations) and poorer physical functioning up to 2 years post-fracture. Impaired function in physical activities of daily living at 6 months, high glucose, calcium, and CO2 at admission, and low BUN and creatinine at admission were more prevalent among decliners than among non-decliners.

CONCLUSIONS

Findings indicate that certain older hip fracture patients begin to exhibit signs and symptoms of failure to thrive. About 10% of patients who survived at least 1 year after fracture could not retain their recovery level of functioning after 6 months and began to decline further. High glucose and CO2 and low BUN and creatinine on hospital admission were associated with later functional decline among hip fracture patients, but their clinical significance is uncertain.

Severity of radiographic findings in hip osteoarthritis associated with total hip arthroplasty

OBJECTIVE

The decision to perform total hip arthroplasty (THA) in patients with osteoarthritis (OA) of the hip is based largely on patients' reports of pain and disability and not on radiographic findings of OA. We determine the severity of radiographic OA and its association with disability in patients undergoing THA.

METHODS

Individual radiographic features (osteophytes, joint space narrowing, sclerosis, cysts, deformity) and global severity of hip OA were assessed in 95 consecutive elderly patients with hip OA undergoing THA who were enrolled in a Patient Outcome Research Team (PORT) project.

RESULTS

Eighty-seven patients (91.5%) had either severe or moderate OA in the hip to be replaced; 17% of these had a previous contralateral THA. Only 8 patients (8.4%) had mild or no signs of OA in the hip to be replaced and 4 (50%) of these patients had their opposite hip replaced previously.

CONCLUSION

These data indicate that radiographic features of moderate to severe hip OA are associated with clinical findings and the necessity to perform THA in the majority of patients. Patients who have had a prior hip replacement, however, may be more likely to have a contralateral replacement done earlier (p = 0.03), before radiographic signs are evident.

A portable neuromuscular function assessment for studying recovery from hip fracture

OBJECTIVE

To determine the reliability and applicability of a portable, performance-based assessment of balance and gait in characterizing recovery after hip fracture in elderly persons.

DESIGN

The assessment was developed as part of a prospective, observational study of hip fracture recovery among elderly persons. Reliability was assessed in 24 subjects by administering the tasks twice within 1 week.

SETTING

In-home assessments were performed on community-dwelling elderly.

PATIENTS

Randomly selected subset of hip fracture patients, 65 years and older, admitted to 1 of 8 Baltimore hospitals between January 1990 and June 1991. Twenty-four patients were asked to repeat the gait and balance assessment at the 6-month follow-up visit.

MAIN OUTCOME MEASURES

The evaluations included: (1) sitting balance, (2) arising from an armless chair, (3) standing balance, eyes open and closed, (4) one leg standing balance, (5) sitting down, (6) gait, and (7) range of motion in the knee and hip.

RESULTS

The assessment took 15 to 20 minutes to complete and was feasible to perform for recent hip fracture patients, except for single leg standing. Interrater reliability was good for most tasks, with agreement between evaluators being 74% to 100% for tasks involving standing balance, chair rise, gait, and range of motion; kappas = 0.4 to 0.9. Single leg standing, knee extension, and balance while sitting were the least reliable tasks; 59% to 73% agreement, kappas = 0.1 to 0.4.

CONCLUSIONS

We conclude that this instrument is a reliable measure of physical ability that will provide a clear indication of mobility impairment in patients recovering from a hip fracture. This instrument should prove useful in assessing patients with lower extremity difficulties.

Axial bone mass in older women. Study of Osteoporotic Fractures Research Group

OBJECTIVE

To determine the anthropometric, historical, and lifestyle factors associated with bone mineral density (BMD) of the spine and proximal femur in older women.

DESIGN

Cross-sectional analyses.

SETTING

Four clinical centers in Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, Pennsylvania.

PARTICIPANTS

7963 ambulatory, nonblack women 65 year of age or older.

MEASUREMENTS

Medical history was obtained by questionnaire and interview, and physical and anthropometric data were obtained by examination. Lumbar spine and proximal femoral BMDs were measured using dual-energy x-ray absorptiometry.

RESULTS

The multivariable models could predict 21% and 25% of the difference between participants in BMD at the femoral neck and lumbar spine, respectively. Weight was most highly associated with BMD. Postmenopausal estrogen use and other indicators of total estrogen exposure were strongly associated with increased BMD. Use of diuretics (both thiazide and nonthiazide), activity levels and muscle strength, alcohol intake, and dietary calcium intake were associated with higher BMD. A family history of osteoporotic fracture was strongly associated with low BMD. European ancestry and blond hair, childbirth or breast feeding, a history of hyperthyroidism, and progestin use were not associated with axial BMD.

CONCLUSIONS

Weight is strongly associated with BMD. Estrogen exposure, physical activity, and calcium intake are also positively associated with BMD, whereas a family history of osteoporosis is associated with reduced BMD. These associations suggest ways to better identify risk for fracture.