Palpation for muscular tenderness in the anterior chest wall: an observer reliability study

OBJECTIVE

To asses the interobserver and intraobserver reliability (in terms of day-to-day and hour-to-hour reliability) of palpation for muscular tenderness in the anterior chest wall.

DESIGN

A repeated measures designs was used.

SETTING

Department of Nuclear Medicine, Odense University Hospital, Denmark.

PARTICIPANTS

Two experienced chiropractors examined 29 patients and 27 subjects in the interobserver part, and 1 of the 2 chiropractors examined 14 patients and 15 subjects in the intraobserver studies.

INTERVENTION

Palpation for muscular tenderness was done in 14 predetermined areas of the anterior chest wall with all subjects sitting. Each dimension was rated as absent or present for tenderness or pain for each location. All examinations were carried out according to a standard written procedure.

RESULTS

Based on a pooled analysis of data from palpation of the anterior chest wall, we found kappa values of 0.22 to 0.31 for the interobserver reliability. For the intraobserver reliability, we found kappa values of 0.21 to 0.28 for the day-to-day reliability and 0.44 to 0.49 for the hour-to-hour reliability.

CONCLUSION

Our results indicated great variations between experienced chiropractors palpating for intercostal tenderness or tenderness in the minor and major pectoral muscles in a population of patients with and without chest pain. This may hamper the ability of clinicians to diagnose and classify the musculoskeletal component of chest pain if based exclusively on palpation of the anterior chest wall.

Patient delay from onset of chest pain suggesting acute coronary syndrome to hospital admission

OBJECTIVE

The aim of the study was to examine patient delay (time from onset of chest pain to patient seeking medical care) among patients who were admitted to hospital with suspected acute coronary syndrome (ACS).

DESIGN AND RESULTS

For 337 patients acutely admitted to the Cardiology Department, Odense University Hospital, during a 3-month period in 1998 with suspected ACS, patient delay and the total pre-hospital delay were registered. In addition, information on patient characteristics, patient behaviour and symptom perception was obtained. The median patient delay was 2.85 h (range 0.2-91 h), of this the "silent" patient delay represented 1 h (range 1 min-11.3 h). The total pre-hospital delay was median 3.88 h. Thirty-one per cent of the patients had confirmed acute myocardial infarction (AMI), and this patient group had a significantly shorter patient delay compared with the group without AMI, 2.05 h vs 3.12 h, p = 0.01. Patient delay of more than 2 h was associated with the factors "self-medication" and "wanted to wait and see if the symptoms went away". A smaller than average risk of patient delay was found in the case of "suspicion of heart attack" and "suspicion of a serious condition".

CONCLUSION

Patient delay is considered to be a serious impediment to markedly improving the prognosis in the case of ACS.

A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction

BACKGROUND

For the treatment of myocardial infarction with ST-segment elevation, primary angioplasty is considered superior to fibrinolysis for patients who are admitted to hospitals with angioplasty facilities. Whether this benefit is maintained for patients who require transportation from a community hospital to a center where invasive treatment is available is uncertain.

METHODS

We randomly assigned 1572 patients with acute myocardial infarction to treatment with angioplasty or accelerated treatment with intravenous alteplase; 1129 patients were enrolled at 24 referral hospitals and 443 patients at 5 invasive-treatment centers. The primary study end point was a composite of death, clinical evidence of reinfarction, or disabling stroke at 30 days.

RESULTS

Among patients who underwent randomization at referral hospitals, the primary end point was reached in 8.5 percent of the patients in the angioplasty group, as compared with 14.2 percent of those in the fibrinolysis group (P=0.002). The results were similar among patients who were enrolled at invasive-treatment centers: 6.7 percent of the patients in the angioplasty group reached the primary end point, as compared with 12.3 percent in the fibrinolysis group (P=0.05). Among all patients, the better outcome after angioplasty was driven primarily by a reduction in the rate of reinfarction (1.6 percent in the angioplasty group vs. 6.3 percent in the fibrinolysis group, P<0.001); no significant differences were observed in the rate of death (6.6 percent vs. 7.8 percent, P=0.35) or the rate of stroke (1.1 percent vs. 2.0 percent, P=0.15). Ninety-six percent of patients were transferred from referral hospitals to an invasive-treatment center within two hours.

CONCLUSIONS

A strategy for reperfusion involving the transfer of patients to an invasive-treatment center for primary angioplasty is superior to on-site fibrinolysis, provided that the transfer takes two hours or less.

Palpation of the upper thoracic spine: an observer reliability study

OBJECTIVE

To assess the intraobserver reliability (in terms of hour-to-hour and day-to-day reliability) and the interobserver reliability with 3 palpation procedures for the detection of spinal biomechanic dysfunction in the upper 8 segments of the thoracic spine.

DESIGN

A repeated-measures design was used in all substudies.

SETTING

Department of Nuclear Medicine, Odense University Hospital, Denmark.

PARTICIPANTS

Two chiropractors examined 29 patients and 27 subjects in the interobserver part and 1 chiropractor examined 14 patients and 15 subjects in the intraobserver studies.

INTERVENTION

Three types of palpation were performed: Sitting motion palpation and prone motion palpation for biomechanic dysfunction and paraspinal palpation for tenderness. Each dimension was rated as "absent" or "present" for each segment. All examinations were performed according to a standard written procedure.

RESULTS

Using an "expanded" definition of agreement that accepts small inaccuracies (+/-1 segment) in the numbering of spinal segments, we found--based on the pooled data from the thoracic spine--kappa values of 0.59 to 0.77 for the hour-to-hour and the day-to-day intraobserver reliability with all 3 palpation procedures. Kappa coefficients were 0.24 and 0.22 for the interobserver reliability with prone and sitting motion palpation and 0.67 and 0.70, respectively, with paraspinal palpation for tenderness.

CONCLUSION

With expanded agreement we found good hour-to-hour and day-to-day intraobserver reliability with all 3 palpation procedures and good interobserver reliability for paraspinal tenderness. The interobserver reliability was unacceptably poor with prone and sitting motion palpation.

Continuous vectorcardiography is superior to standard electrocardiography in the prediction of long-term outcome after thrombolysis in patients with acute myocardial infarction

BACKGROUND

Thrombolytic therapy results in reperfusion of the occluded coronary vessel in approximately 75% of treated patients with acute myocardial infarction (AMI). Unsuccessful thrombolysis results in impaired outcome. This study was undertaken to evaluate reperfusion assessments with 12-lead standard static electrocardiography (ECG) and continuous vectorcardiography (VCG) in AMI patients treated with thrombolytic therapy, with particular emphasis on the value of these assessments in relation to long-term outcome.

METHODS

ST-recovery analysis 90 and 180 min after the start of thrombolytic therapy was performed by repeated ECG and by VCG in 63 AMI patients. Median follow-up was 255 days.

RESULTS

No significant differences in long-term outcome were found between patients with or without obtained reperfusion, as assessed by ECG. For VCG, we found significant elevated relative risks for experiencing death (relative risk = 11.00, confidence interval = 2.70-44.90); P = 0.0008 for the group with ST-vector magnitude recovery of less than 50% at 90 min from start of thrombolytic therapy.

CONCLUSION

We demonstrated that early reperfusion assessment with VCG enables the prediction of long-term outcome and is superior to reperfusion assessment with standard static ECG in this regard. We therefore recommend continuous ischemia monitoring of AMI patients treated with thrombolytic therapy as a routine procedure.

Saturated fat intake is reduced in patients with ischemic heart disease 1 year after comprehensive counseling but not after brief counseling

OBJECTIVE

To examine the dietary habits of patients with ischemic heart disease 1 year after they received either dietary advice on using the Plate Model and how to increase intakes of fruits and vegetables in a 10-minute session (brief counseling group, BCG) or dietary advice primarily based on the National Cholesterol Education Program Step I diet provided in 2 individually tailored 50-minute sessions held 3 months apart (comprehensive counseling group, CCG).

DESIGN

A randomized study that included dietary intake evaluation on basis of 7-day weighed food records completed at 3 occasions: immediately before counseling (week zero), 12 weeks after counseling, and 52 weeks after counseling.

SUBJECTS

BCG was composed of 15 men and 2 women and CCG was composed of 16 men and 3 women with ischemic heart disease age 70 years or younger recruited from the Department of Cardiology, Odense University Hospital, Odense, Denmark.

STATISTICAL ANALYSES PERFORMED

ANOVA, unpaired t tests, and multiple regression analysis, as well as nonparametric statistical analyses were carried out.

RESULTS

The comprehensive counseling resulted in significant improvements from week 0 to 52 in the percent of energy from fat (33% to 28%), saturated fat (12% to 9%) and carbohydrate (51% to 54%) consumed by the subjects. The corresponding values in BCG did not differ significantly (31% to 32%, 11% to 12%, 53% to 52% respectively). Differences from week 0 to 52 between groups were significant for fat, saturated fat, and carbohydrate intake. In CCG, median intakes of fish, fruits, and vegetables were 44 g/day, 172 g/day, and 315 g/day, respectively, at week 52. The corresponding values in BCG were 44 g/day, 129 g/day, and 224 g/day. There was no significant difference either within or between the groups.

CONCLUSION

This study suggests that sustained improvements in dietary behavior require individualized and reinforced counseling in patients with ischemic heart disease. Changes in intakes of fish, fruits, and vegetables need to be specifically targeted.

Biochemical markers of ischaemia for the early identification of acute myocardial infarction without St segment elevation

Blood was collected on admission and after 1-2 h in 130 consecutive patients admitted with typical chest pain in order to assess the capacity of myoglobin, fatty-acid-binding protein (FABP), CK-MB mass, and troponin I (TnI) in the early identification of acute myocardial infarction (AMI) without ST elevation. Using the maximum value within 6 h of onset of symptoms, AMI was detected with a 90-95% sensitivity and a 81-94% specificity by FABP at a cut-off level 8-12 midrog/l, or 81-86% and 89-93%, respectively, by myoglobin at a cut-off level 70-90 microg/l. CK-MB mass and TnI had low sensitivity, albeit very high specificity. As almost all AMI patients were identified within 6 h, serial measurements of FABP or myoglobin ruled out AMI with a very high degree of certainty. Due to the low prevalence of AMI (16%), the positive predictive values were modest (47-73%), yet increasing the probability of AMI by a factor 3-4. Myoglobin and FABP are very useful markers in the early triage of chest pain patients.

Interpretive intra- and interobserver reproducibility of rest/stress 99Tcm-sestamibi myocardial perfusion SPECT in a consecutive group of male patients with stable angina pectoris before and after percutaneous transluminal angioplasty

BACKGROUND

Observer variability of 99Tcm-sestamibi myocardial perfusion imaging (MPI) has rarely been investigated. The aim of our study was to evaluate the interpretive reproducibility with this technique.

PATIENTS

We report on 108 consecutive male patients with stable angina pectoris, investigated before and after percutaneous transluminal angioplasty (PTCA).

METHODS

A 2-day rest/stress 99Tcm-sestamibi gated single photon emission computed tomography (SPECT) protocol was used. MPI was interpreted by two independent observers without knowledge of clinical data, using a 20-segment scoring model.

RESULTS

Intra- and interobserver agreement was found to be good to excellent (kappa = 0.71-0.85) with regard to the overall diagnosis as well as the individual vessel diagnosis (kappa = 0.60-0.87). However, agreement was higher for left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCX) vascular territories than for the right coronary artery (RCA) territory. Moderate to good intraobserver agreement (kappa = 00.54-0.68) and slightly lower interobserver agreement (kappa = 0.52-0.56) was found for segmental score interpretation. When comparing the interpretive reproducibility before and after PTCA intra- and interobserver agreement was better after PTCA, probably reflecting the increase in normal scans after revascularization.

CONCLUSIONS

In a group of consecutive male patients with stable angina pectoris interpretive reproducibility (overall and individual vessel diagnosis) was good to excellent. However, segmental scoring reproducibility was moderate to good.

Cost-effectiveness analysis of intravascular ultrasound guided percutaneous coronary intervention versus conventional percutaneous coronary intervention

OBJECTIVE

Investigation of the cost-effectiveness of intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) compared to PCI guided by coronary angiography (CAG).

METHODS

One hundred and eight men referred for PCI, were randomized to IVUS or CAG guided PCI. After 6 months, the patients were subjected to a study related clinical and invasive follow-up investigation by CAG, IVUS and intracoronary Doppler flow measurements. Incremental costs of IVUS guided procedures and costs of re-interventions were estimated using the Activity Based Costing (ABC) method.

RESULTS

Patients randomized to IVUS guided PCI experienced an improved clinical outcome, with lower angina levels than patients in the CAG guided group. The initial cost of performing IVUS guidance was increased due to extra procedure time, IVUS catheters and slightly more balloons and stents, but fewer patients in the IVUS guided group needed re-intervention. Overall, these savings outweighed the initial cost increase.

CONCLUSION

Our data suggest that when performing IVUS guided PCI, costs as well as benefits increase. The increased benefits measured as cost savings resulting from less restenosis outweigh the cost increase from performing the IVUS guided PCI as opposed to CAG guided PCI.

Early reperfusion assessment and repeated thrombolysis in acute myocardial infarction estimated by repeated standard electrocardiography. A randomised, double-blind, placebo-controlled pilot study

Thrombolytic therapy with streptokinase (SK) in acute myocardial infarction (AMI) does not result in early reperfusion in approximately 25% of patients. We hypothesized that early repeated thrombolysis with rt-PA in patients with early failed reperfusion would result in myocardial reperfusion. Fifty-nine AMI patients with a symptom delay of <6 h, treated with SK were included. ECG was taken on admission and after 90 and 180 min. An ST recovery of > or =25% at 90 min was interpreted as successful reperfusion. Sixteen patients had failed reperfusion at 90 min and were randomized to repeated thrombolysis with rt-PA or placebo. At 180 min from SK start, ST recovery was higher in the placebo group than in the rt-PA group (71 vs. 40%, p = 0.05). No serious bleeding complications were observed. Due to the limited sample size it was not possible to draw prominent conclusions.

Health related quality of life after conservative or invasive treatment of inducible postinfarction ischaemia. DANAMI study group

OBJECTIVE

To assess health related quality of life in patients with inducible postinfarction ischaemia.

DESIGN

A questionnaire based follow up study on patients randomised to conservative or invasive treatment because of postinfarction ischaemia.

SETTING

Seven county hospitals in eastern Denmark and the Heart Centre, National University Hospital, Copenhagen, Denmark.

PATIENTS

113 patients with inducible postinfarction ischaemia: 51 were randomised to conservative treatment and 62 to invasive treatment. Average follow up time was three years (19-57 months).

MAIN OUTCOME MEASURES

SF-36, Rose angina and dyspnoea questionnaire, drug use, lifestyle, and cognitive function.

RESULTS

Invasively treated patients scored better on the SF-36 scales of physical functioning (p = 0.03) and on role-physical (p = 0.04) and physical component scales (p = 0.05) and took significantly less anti-ischaemic drug treatment. Angina occurred in 18% of the invasively treated patients and 31% of the conservatively treated patients (p = 0.09). However, more invasively treated patients suffered from concentration difficulties (18% v 4%; p = 0.04).

CONCLUSIONS

Patients who were treated invasively had better health related quality of life scores in the physical variables compared with conservatively treated patients. However, a larger proportion of invasively treated patients had concentration difficulties.

Follow-up study of patients randomized in the Scandinavian simvastatin survival study (4S) of cholesterol lowering

The Scandinavian Simvastatin Survival Study (4S) and other randomized clinical trials have demonstrated that cholesterol-lowering treatment with statins improves prognosis in patients with coronary atherosclerosis compared with placebo. The effect of therapy with statins beyond the typical 5 to 6 years' duration of the trials, in particular regarding the risk of cancer, has not been investigated. This study examines the long-term effects of simvastatin for up to 8 years on cause-specific mortality in patients with coronary heart disease (CHD). We performed an observational, government registry-based study of mortality in the groups originally randomized to simvastatin or placebo in the 4S over an additional 2-year follow-up period, so that the median total follow-up period was 7.4 years (range 6.9 to 8.3 in surviving patients). Randomization took place at outpatient clinics at 94 clinical centers in Denmark, Finland, Iceland, Norway, and Sweden from 1988 to 1989. Of 4,444 patients with CHD, 2,223 and 2,221 were randomized to treatment with placebo or simvastatin therapy, respectively. Patients received treatment with simvastatin, starting at 20 mg/day, with titration to 40 mg/day at 12 or 24 weeks if total cholesterol was >5.2 mmol/L (200 mg/dl), or placebo. After the double-blind period, most patients in both treatment groups received simvastatin as open-label prescription. Of the 1,967 patients originally treated with placebo and surviving the double-blind period, 97 (4.9%) died during the following 2 years. In the group randomized to simvastatin the corresponding number was 74 of the 2, 039 survivors (3.6%). Adding these deaths to those occurring during the original trial, the total was 353 (15.9%) and 256 (11.5%) deaths in the groups originally randomized to placebo and simvastatin, respectively. The relative risk was 0.70 (95% confidence interval 0. 60 to 0.82, p = 0.00002). The total number of cancer deaths was 68 (3.1%) in the placebo group and 52 (2.3%) in the simvastatin group (relative risk 0.73, 95% confidence interval 0.51 to 0.05, p = 0. 087), and the numbers of noncardiovascular and other deaths were similar in both groups. We therefore conclude that treatment with simvastatin for up to 8 years in patients with CHD is safe and yields continued survival benefit.

Correlation between serial changes in left-sided heart chambers and atrial natriuretic peptide and N-terminal pro atrial natriuretic peptide after a first myocardial infarction. An echocardiographic study

Dilatation of the left ventricle predicts morbidity and mortality after acute myocardial infarction. We compared serial echocardiographic examinations of the left atrium and ventricle with measurements of plasma atrial natriuretic peptide (ANP) and plasma N-terminal pro atrial natriuretic peptide (NT-proANP) in 22 patients during the first 6 months following a first myocardial infarction. ANP, but not NT-proANP, was found to be significantly correlated to the diastolic/systolic size of the left atrium (r = 0.58/0.60) and the systolic size of the left ventricle (r = 0.43) in the acute phase 2-4 days after infarction. At 10-12 days after the infarction, we found a significant correlation between all sizes of the left-sided chambers and ANP, whereas NT-proANP only correlated with the left atrial sizes. Three months after the infarction, all sizes of the left-sided chambers correlated with both ANP and NT-proANP, with the exception of a non-significant correlation between NT-proANP and the left atrial diastolic size. After 6 months only the area of the diastolic and systolic left atrium correlated with plasma ANP and only the systolic size of the left atrium correlated with NT-proANP. The percentage change in the size of the left atrium, but not the left ventricle, correlated significantly with the percentage change in both ANP (r = 0.57) and NT-proANP (r = 0.70). We conclude that the distension of the left atrium rather than the dilatation of the left ventricle is related to the concentration of ANP and NT-proANP after an acute myocardial infarction.

Lipoprotein changes and reduction in the incidence of major coronary heart disease events in the Scandinavian Simvastatin Survival Study (4S)

BACKGROUND

The Scandinavian Simvastatin Survival Study (4S) randomized 4444 patients with coronary heart disease (CHD) and serum cholesterol 5.5 to 8.0 mmol/L (213 to 310 mg/dL) with triglycerides < or =2.5 mmol/L (220 mg/dL) to simvastatin 20 to 40 mg or placebo once daily. Over the median follow-up period of 5.4 years, one or more major coronary events (MCEs) occurred in 622 (28%) of the 2223 patients in the placebo group and 431 (19%) of the 2221 patients in the simvastatin group (34% risk reduction, P<.00001). Simvastatin produced substantial changes in several lipoprotein components, which we have attempted to relate to the beneficial effects observed.

METHODS AND RESULTS

The Cox proportional hazards model was used to assess the relationship between lipid values (baseline, year 1, and percent change from baseline at year 1) and MCEs. The reduction in MCEs within the simvastatin group was highly correlated with on-treatment levels and changes from baseline in total and LDL cholesterol, apolipoprotein B, and less so with HDL cholesterol, but there was no clear relationship with triglycerides. We estimate that each additional 1% reduction in LDL cholesterol reduces MCE risk by 1.7% (95% CI, 1.0% to 2.4%; P<.00001).

CONCLUSIONS

These analyses suggest that the beneficial effect of simvastatin in individual patients in 4S was determined mainly by the magnitude of the change in LDL cholesterol, and they are consistent with current guidelines that emphasize aggressive reduction of this lipid in CHD patients.

Effect of simvastatin on ischemic signs and symptoms in the Scandinavian simvastatin survival study (4S)

In patients participating in the Scandinavian Simvastatin Survival Study, cholesterol lowering with simvastatin reduced the incidence of carotid bruits and cerebrovascular events as well as new-onset or worsening of angina pectoris and intermittent claudication. These effects suggest that simvastatin may have a general antiatherosclerotic effect not limited to the coronary bed.

Effects of amlodipine and isosorbide dinitrate on exercise-induced and ambulatory ischemia in patients with chronic stable angina pectoris

This study was designed to compare once-daily administration of 5-10 mg amlodipine with two daily doses of 40 mg sustained-release isosorbide dinitrate in 59 patients with stable angina using a randomized, double-blind, crossover study design. Anginal episodes, nitroglycerin consumption, and possible adverse events were recorded in a diary. A maximal symptom-limited bicycle exercise test and 48-hour ambulatory ECG monitoring were performed at baseline and at the end of each 5-week period of therapy. Exercise time, time to angina, time to ST depression, and maximal ST depression were measured during exercise. During ambulatory monitoring, the number of ischemic episodes and the duration per hour of ST depression were assessed. Amlodipine significantly reduced anginal episodes (P < 0.001) when compared with isosorbide dinitrate. Furthermore, amlodipine prolonged time to ST depression (P < 0.001) and time to angina (P < 0.05) when compared with isosorbide dinitrate. The number and duration of ischemic episodes during ambulatory monitoring were significantly reduced with amlodipine when compared with baseline values (P < 0.05), whereas no differences were found between isosorbide dinitrate and baseline. Adverse events were reported more frequently with isosorbide dinitrate than with amlodipine (P < 0.02). Amlodipine appears to be more effective and tolerable than sustained-release isosorbide dinitrate as monotherapy for chronic stable angina.