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Dyer MTD, Goldsmith KA, Sharples LS, Buxton MJ. A review of health utilities using the EQ-5D in studies of cardiovascular disease. Health Qual Life Outcomes 2010; 8:13. [PMID: 20109189 PMCID: PMC2824714 DOI: 10.1186/1477-7525-8-13] [Citation(s) in RCA: 285] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 01/28/2010] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The EQ-5D has been extensively used to assess patient utility in trials of new treatments within the cardiovascular field. The aims of this study were to review evidence of the validity and reliability of the EQ-5D, and to summarise utility scores based on the use of the EQ-5D in clinical trials and in studies of patients with cardiovascular disease. METHODS A structured literature search was conducted using keywords related to cardiovascular disease and EQ-5D. Original research studies of patients with cardiovascular disease that reported EQ-5D results and its measurement properties were included. RESULTS Of 147 identified papers, 66 met the selection criteria, with 10 studies reporting evidence on validity or reliability and 60 reporting EQ-5D responses (VAS or self-classification). Mean EQ-5D index-based scores ranged from 0.24 (SD 0.39) to 0.90 (SD 0.16), while VAS scores ranged from 37 (SD 21) to 89 (no SD reported). Stratification of EQ-5D index scores by disease severity revealed that scores decreased from a mean of 0.78 (SD 0.18) to 0.51 (SD 0.21) for mild to severe disease in heart failure patients and from 0.80 (SD 0.05) to 0.45 (SD 0.22) for mild to severe disease in angina patients. CONCLUSIONS The published evidence generally supports the validity and reliability of the EQ-5D as an outcome measure within the cardiovascular area. This review provides utility estimates across a range of cardiovascular subgroups and treatments that may be useful for future modelling of utilities and QALYs in economic evaluations within the cardiovascular area.
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Affiliation(s)
- Matthew TD Dyer
- Health Economics Research Group, Brunel University, Uxbridge, UK
- National Collaborating Centre for Mental Health, The Royal College of Psychiatrists, London, UK
| | - Kimberley A Goldsmith
- Papworth Hospital NHS Trust, Cambridge UK
- MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
| | - Linda S Sharples
- Papworth Hospital NHS Trust, Cambridge UK
- MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
| | - Martin J Buxton
- Health Economics Research Group, Brunel University, Uxbridge, UK
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Cross P, Edwards RT, Opondo M, Nyeko P, Edwards-Jones G. Does farm worker health vary between localised and globalised food supply systems? ENVIRONMENT INTERNATIONAL 2009; 35:1004-1014. [PMID: 19482357 DOI: 10.1016/j.envint.2009.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Revised: 04/24/2009] [Accepted: 04/29/2009] [Indexed: 05/27/2023]
Abstract
Significant environmental benefits are claimed for local food systems, but these biophysical indicators are increasingly recognised as inadequate descriptors of supply chain ethics. Social factors such as health are also important indicators of good practice, and are recognised by the organic and local food movements as important to the development of rounded sustainable agricultural practices. This study compared the self-reported health status of farm workers in the United Kingdom, Spain, Kenya and Uganda who were supplying distant markets with fresh vegetables. Workers on Kenyan export horticulture farms reported significantly higher levels of physical health than did Kenyan non-export farm workers and workers in the other study countries. Mean health levels for farm workers in the United Kingdom were significantly lower than relevant population norms, indicating widespread levels of poor health amongst these workers. These results suggest that globalised supply chains can provide social benefits to workers, while local food systems do not always provide desirable social outcomes. The causal mechanisms of these observations probably relate more to the social conditions of workers than directly to income.
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Affiliation(s)
- Paul Cross
- School of the Environment and Natural Resources, Bangor University, Bangor, Gwynedd LL57 2UW, UK.
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53
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Arnold SV, Morrow DA, Lei Y, Cohen DJ, Mahoney EM, Braunwald E, Chan PS. Economic impact of angina after an acute coronary syndrome: insights from the MERLIN-TIMI 36 trial. Circ Cardiovasc Qual Outcomes 2009; 2:344-53. [PMID: 20031860 DOI: 10.1161/circoutcomes.108.829523] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Angina in patients with coronary artery disease is associated with worse quality of life; however, the relationship between angina frequency and resource utilization is unknown. METHODS AND RESULTS Using data from the MERLIN-TIMI 36 trial, we assessed the association between the extent of angina after an acute coronary syndrome (ACS) and subsequent cardiovascular resource utilization among 5460 stable outpatients who completed the Seattle Angina Questionnaire at 4 months after an ACS and who were then followed for an additional 8 months. Angina frequency was categorized as none (score, 100; 2739 patients), monthly (score, 61 to 99; 1608 patients), weekly (score, 31 to 60; 854 patients), and daily (score, 0 to 30; 259 patients). Multivariable regression models evaluated the association between angina frequency and overall costs attributable to cardiovascular hospitalizations, outpatient visits and procedures, and medications. As compared with no angina, overall costs increased in a graded fashion with higher angina frequency-no angina, $2928 (reference); monthly angina, $3909 (adjusted relative cost ratio, 1.29; 95% CI, 1.21 to 1.39); weekly angina, $4558 (adjusted relative cost ratio, 1.52; 95% CI, 1.48 to 1.67); and daily angina, $6949 (adjusted relative cost ratio, 2.32; 95% CI, 2.01 to 2.69; P for trend <0.001). Differences in costs were attributable primarily to higher rates of ACS hospitalization and coronary revascularization among patients with more severe angina. CONCLUSIONS Among stable outpatients after ACS, a direct graded relationship was found between higher angina frequency and healthcare costs. As compared with patients without angina, patients with daily angina had a >2-fold increase in resource utilization and incremental costs of $4000 after 8 months of follow-up.
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Affiliation(s)
- Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, Kansas City, MO 64111, USA
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Ara R, Pandor A, Tumur I, Paisley S, Duenas A, Williams R, Rees A, Wilkinson A, Durrington P, Chilcott J. Cost effectiveness of ezetimibe in patients with cardiovascular disease and statin intolerance or contraindications: a Markov model. Am J Cardiovasc Drugs 2009; 8:419-27. [PMID: 19159125 DOI: 10.2165/0129784-200808060-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the cost effectiveness of long-term ezetimibe monotherapy in patients with established cardiovascular disease (CVD) who do not tolerate statins or in whom they are contraindicated. METHODS A Markov model was used to estimate the potential costs and benefits associated with ezetimibe monotherapy compared with no treatment. The benefits associated with ezetimibe treatment were informed by a systematic review of clinical evidence and a published relationship linking changes in low-density lipoprotein cholesterol (LDL-C) levels to cardiovascular events. RESULTS In the absence of data from clinical outcome trials, surrogate endpoints such as changes in lipid levels were used as indicators of clinical outcomes. A meta-analysis of seven placebo-controlled trials included in the review showed that ezetimibe was associated with a statistically significant mean reduction (from baseline to endpoint) in LDL-C of 18.56% (95% CI -19.68, -17.44; p < 0.00001) compared with placebo. Using 10,000 Monte Carlo simulations, it is estimated that ezetimibe monotherapy would prevent an average of 49 nonfatal myocardial infarctions, 11 nonfatal strokes, and 37 cardiovascular deaths in a cohort of 1,000 patients aged 55 years with a baseline LDL-C concentration of 4.0 mmol/L. Events avoided provide an additional 211 quality-adjusted life-years (QALYs) over the 45 years modeled. With a mean incremental cost of pound 4,861,000 (year 2006 value), the discounted cost per QALY is pound 23,026 (Jackknife CI 22 979, 23 074). The model is reasonably robust to variations in key parameters. Incremental cost-effectiveness ratios fall below pound 20,000 per QALY for cohorts with baseline LDL-C values >4.5 mmol/L. CONCLUSION Ezetimibe monotherapy compared with no treatment is a cost-effective alternative for individuals with a history of CVD and high LDL-C levels, who do not tolerate statins or in whom they are contraindicated.
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Affiliation(s)
- Roberta Ara
- Health Economics and Decision Science, ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
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Arnold SV, Morrow DA, Wang K, Lei Y, Mahoney EM, Scirica BM, Braunwald E, Cohen DJ. Effects of Ranolazine on Disease-Specific Health Status and Quality of Life Among Patients With Acute Coronary Syndromes. Circ Cardiovasc Qual Outcomes 2008; 1:107-15. [PMID: 20031797 DOI: 10.1161/circoutcomes.108.798009] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background—
Ranolazine has been shown to reduce myocardial ischemia and symptom severity among selected patients with chronic angina. However, data regarding the effect of ranolazine on health status/quality of life (QOL) are limited.
Methods and Results—
We performed a prospective QOL analysis alongside the Metabolic Efficiency with Ranolazine for Less Ischemia in Non–ST-elevation acute coronary syndromes (MERLIN)-TIMI 36 trial, a randomized, double-blind, placebo-controlled trial of ranolazine in 6560 patients with non–ST-elevation acute coronary syndromes. Health status/QOL was evaluated at baseline and 4, 8, and 12 months after index hospitalization using the Seattle Angina Questionnaire, Rose dyspnea scale, SF-12, and EuroQol-5D. Health status/QOL scores improved significantly at all follow-up time points for both treatment arms. In the overall population, randomization to ranolazine was associated with minimal 12-month improvements in angina frequency and Seattle Angina Questionnaire-QOL (
P
<0.05). In subsequent exploratory analyses, there was a significant interaction between the benefits of ranolazine and anginal status before the index event. Among patients with prior angina (n=3565), treatment with ranolazine was associated with modest benefits across the full range of QOL domains, with the greatest benefits observed in angina frequency (mean effect=3.4;
P
<0.001) and Seattle Angina Questionnaire-QOL (mean effect=2.7;
P
<0.001). There were no significant benefits among patients without prior angina, however.
Conclusion—
Among a broad population of patients with unstable coronary disease, ranolazine had a minimal effect on disease-specific health status and QOL over ≈12 months of follow-up. Posthoc subgroup analysis, however, suggested a modest benefit among the subgroup of patients with angina before their acute coronary syndromes event.
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Affiliation(s)
- Suzanne V. Arnold
- From the Saint Luke’s Mid America Heart Institute (S.V.A., K.W., Y.L., E.M., D.J.C.), Kansas City, Mo; and TIMI Study Group (D.A.M., B.M.S., E.B.), Brigham and Women’s Hospital, Boston, Mass
| | - David A. Morrow
- From the Saint Luke’s Mid America Heart Institute (S.V.A., K.W., Y.L., E.M., D.J.C.), Kansas City, Mo; and TIMI Study Group (D.A.M., B.M.S., E.B.), Brigham and Women’s Hospital, Boston, Mass
| | - Kaijun Wang
- From the Saint Luke’s Mid America Heart Institute (S.V.A., K.W., Y.L., E.M., D.J.C.), Kansas City, Mo; and TIMI Study Group (D.A.M., B.M.S., E.B.), Brigham and Women’s Hospital, Boston, Mass
| | - Yang Lei
- From the Saint Luke’s Mid America Heart Institute (S.V.A., K.W., Y.L., E.M., D.J.C.), Kansas City, Mo; and TIMI Study Group (D.A.M., B.M.S., E.B.), Brigham and Women’s Hospital, Boston, Mass
| | - Elizabeth M. Mahoney
- From the Saint Luke’s Mid America Heart Institute (S.V.A., K.W., Y.L., E.M., D.J.C.), Kansas City, Mo; and TIMI Study Group (D.A.M., B.M.S., E.B.), Brigham and Women’s Hospital, Boston, Mass
| | - Benjamin M. Scirica
- From the Saint Luke’s Mid America Heart Institute (S.V.A., K.W., Y.L., E.M., D.J.C.), Kansas City, Mo; and TIMI Study Group (D.A.M., B.M.S., E.B.), Brigham and Women’s Hospital, Boston, Mass
| | - Eugene Braunwald
- From the Saint Luke’s Mid America Heart Institute (S.V.A., K.W., Y.L., E.M., D.J.C.), Kansas City, Mo; and TIMI Study Group (D.A.M., B.M.S., E.B.), Brigham and Women’s Hospital, Boston, Mass
| | - David J. Cohen
- From the Saint Luke’s Mid America Heart Institute (S.V.A., K.W., Y.L., E.M., D.J.C.), Kansas City, Mo; and TIMI Study Group (D.A.M., B.M.S., E.B.), Brigham and Women’s Hospital, Boston, Mass
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Epstein DM, Sculpher MJ, Clayton TC, Henderson RA, Pocock SJ, Buxton MJ, Fox KAA. Costs of an early intervention versus a conservative strategy in acute coronary syndrome. Int J Cardiol 2008; 127:240-6. [PMID: 17707103 DOI: 10.1016/j.ijcard.2007.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Revised: 05/11/2007] [Accepted: 06/23/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Randomised Intervention Treatment of unstable Angina (RITA-3) found that non-ST-elevation myocardial infarction and unstable angina patients randomised to routine early arteriography experienced a lower rate of death or myocardial infarction than patients randomised to conservative therapy over a five year period of follow up. This paper uses data from the RITA-3 trial to compare the health service costs of the two strategies. METHODS The resource use data included initial arteriography and revascularisation procedures in the early intervention group and subsequently in both groups; in-patient days in hospital for any reason in the first year of follow-up; incidence of myocardial infarction; and cardiac medication. RESULTS After five years, the early intervention arm accrued a total mean cost of pound sterling 11,340 (euro 15,592) and the conservative arm a mean of pound sterling 9749(euro 13,405), an additional mean cost in the intervention arm of pound sterling 1591 (95% CI pound sterling 851 to pound sterling 2276) (euro 2188; 95%CI euro 1160 to euro 3228). On average, costs increased with age and were higher in male patients and in patients with severe angina. However, the incremental cost of the intervention strategy was consistent across different patient sub-groups. CONCLUSION Over a period of 5 years, the initial additional cost of a strategy of early intervention is only partially offset by subsequent interventions in patients managed conservatively.
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Affiliation(s)
- David M Epstein
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK.
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Plomondon ME, Magid DJ, Masoudi FA, Jones PG, Barry LC, Havranek E, Peterson ED, Krumholz HM, Spertus JA, Rumsfeld JS. Association between angina and treatment satisfaction after myocardial infarction. J Gen Intern Med 2008; 23:1-6. [PMID: 17955303 PMCID: PMC2173926 DOI: 10.1007/s11606-007-0430-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Revised: 07/06/2007] [Accepted: 10/02/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patient satisfaction is increasingly recognized as a quality indicator and important outcome of care. Little is known about the clinical factors associated with satisfaction after myocardial infarction (MI). OBJECTIVE To assess the hypothesis that angina after MI is independently associated with lower treatment satisfaction. METHODS We evaluated 1,815 MI patients from 19 U.S. centers. Angina was measured at 1 and 6 months after MI using the Seattle Angina Questionnaire (SAQ). Treatment satisfaction was measured using the SAQ at 6 months. Multivariable regression was used to evaluate the association between 1- and 6-month angina and 6-month treatment satisfaction. RESULTS Sixty-two percent of patients had no angina at 1 and 6 months after MI, 14% had transient angina (angina at 1 month, no angina at 6 months), 11% had new angina (angina at 6 months only), and 13% had persistent angina (angina at both 1 and 6 months). In unadjusted analysis, the presence of angina at 6 months, whether new or persistent, was associated with lower treatment satisfaction (p < 0.001). In multivariable analysis, angina was associated with lower treatment satisfaction [relative risk (RR) 2.9, 95% confidence interval (CI) 2.4-3.5 patients with new angina; RR 3.1, 95% CI 2.5-3.9 patients with persistent angina, vs patients with no angina]. CONCLUSIONS In conclusion, angina in the 6 months following MI is present in almost 1 in 4 patients and is strongly associated with lower treatment satisfaction. This suggests the importance of angina surveillance and management after MI as a possible target to improve treatment satisfaction and, thereby, quality of care.
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Affiliation(s)
- Mary E Plomondon
- Cardiovascular Outcomes Research, Eastern Colorado Health Care System, Denver VA Medical Center, Denver, CO, USA.
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Denvir MA, Lee AJ, Rysdale J, Walker A, Eteiba H, Starkey IR, Pell JP. Influence of socioeconomic status on clinical outcomes and quality of life after percutaneous coronary intervention. J Epidemiol Community Health 2007; 60:1085-8. [PMID: 17108307 PMCID: PMC2465496 DOI: 10.1136/jech.2005.044255] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine whether socioeconomic status (SES) influences clinical outcomes and quality of life after percutaneous coronary intervention (PCI). DESIGN Prospective observational study. SETTING Two interventional cardiac centres. PARTICIPANTS 1346 consecutive patients undergoing PCI over a 12-month period. OUTCOMES Self reported health-related quality of life (HRQoL; EuroQol-5 Dimensions (EQ-5D); EuroQol Visual Analogue Scale (EQ-VAS)), repeat angiography, revascularisation, hospital admission, myocardial infarction and death within 12 months, by SES derived using postal address code. MAIN RESULTS No significant differences were found between patients with high and low SES in the occurrence of repeat angiography (p = 0.55), repeat revascularisation (PCI, p = 0.81, CAEG, p = 0.27), total cardiac hospitalisation (p = 0.10), myocardial infarction (p = 0.97) or death 12 months after PCI (p = 0.88). Non-procedure-related readmissions were higher in patients with low SES (18.6% v 13.7%; p = 0.025). After adjustment for confounding factors, patients with low SES had lower HRQoL scores at baseline (95% CI for difference 0.01 to 0.14; p = 0.003) and at 12 months (95% CI 0.07 to 0.17; p<0.001) compared with those with high SES. CONCLUSIONS Clinical outcomes were similar for patients in different SES groups. Patients with low SES had considerably more non-procedure-related readmissions and lower quality-of-life scores. Future studies on HRQoL after coronary revascularisation should take account of these important differences related to SES.
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Affiliation(s)
- M A Denvir
- Centre for Cardiovascular Research, University of Edinburgh, Edinburgh, UK.
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Maddox TM, Reid KJ, Rumsfeld JS, Spertus JA. One-year health status outcomes of unstable angina versus myocardial infarction: a prospective, observational cohort study of ACS survivors. BMC Cardiovasc Disord 2007; 7:28. [PMID: 17850662 PMCID: PMC2014769 DOI: 10.1186/1471-2261-7-28] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Accepted: 09/12/2007] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Unstable angina (UA) patients have lower mortality and reinfarction risks than ST-elevation (STEMI) or non-ST elevation myocardial infarction (NSTEMI) patients and, accordingly, receive less aggressive treatment. Little is known, however, about the health status outcomes (angina, physical function, and quality of life) of UA versus MI patients among survivors of an ACS hospitalization. METHODS In a cohort of 1,192 consecutively enrolled ACS survivors from two Kansas City hospitals, we evaluated the associations between ACS presentation (UA, NSTEMI, and STEMI) and one-year health status (angina, physical functioning and quality of life), one-year cardiac rehospitalization rates, and two-year mortality outcomes, using multivariable regression modeling. RESULTS After multivariable adjustment for demographic, hospital, co-morbidity, baseline health status, and treatment characteristics, UA patients had a greater prevalence of angina at 1 year than STEMI patients (adjusted relative risk [RR] = 1.42; 95% CI [1.06, 1.90]) and similar rates as NSTEMI patients (adjusted RR = 1.1; 95% CI [0.85, 1.42]). In addition, UA patients fared no better than MI patients in Short Form-12 physical component scores (UA vs. STEMI score difference -0.05 points; 95% CI [-2.41, 2.3]; UA vs. NSTEMI score difference -1.91 points; 95% CI [-4.01, 0.18]) or Seattle Angina Questionnaire quality of life scores (UA vs. STEMI score difference -1.39 points; 95% CI [-5.63, 2.85]; UA vs. NSTEMI score difference -0.24 points 95% CI [-4.01, 3.54]). Finally, UA patients had similar rehospitalization rates as MI patients (UA vs. STEMI adjusted hazard ratio [HR] = 1.31; 95% CI [0.86, 1.99]; UA vs. NSTEMI adjusted HR = 1.03; 95% CI [0.73, 1.47]), despite better 2-year survival (UA vs. STEMI adjusted HR = 0.51; 95% confidence interval (CI) [0.28, 0.95]; UA vs. NSTEMI adjusted HR = 0.40; 95% CI [0.24, 0.65]). CONCLUSION Although UA patients have better survival rates, they have similar or worse one-year health status outcomes and cardiac rehospitalization rates as compared with MI patients. Clinicians should be aware of the adverse health status outcome risks for UA patients and consider close monitoring for the opportunity to improve their health status and minimize the need for subsequent rehospitalization.
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Affiliation(s)
- Thomas M Maddox
- Denver VAMC/University of Colorado Health Science Center, Denver, CO, USA
| | - Kimberly J Reid
- Mid America Heart Institute of Saint Luke's Hospital, Kansas City, MO, USA
| | - John S Rumsfeld
- Denver VAMC/University of Colorado Health Science Center, Denver, CO, USA
| | - John A Spertus
- Mid America Heart Institute of Saint Luke's Hospital, Kansas City, MO, USA
- University of Missouri – Kansas City, Kansas City, MO, USA
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Budzyński J, Kłopocka M, Pulkowski G, Suppan K, Fabisiak J, Majer M, Swiatkowski M. The effect of double dose of omeprazole on the course of angina pectoris and treadmill stress test in patients with coronary artery disease--a randomised, double-blind, placebo controlled, crossover trial. Int J Cardiol 2007; 127:233-9. [PMID: 17689732 DOI: 10.1016/j.ijcard.2007.04.079] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2006] [Revised: 01/28/2007] [Accepted: 04/23/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Gastroesophageal reflux (GER) and coronary artery disease (CAD) frequently overlap, making the proper diagnosis of chest pain more difficult. GER symptoms may mistake anginal chest pain, and oesophageal acidification may induce myocardial ischaemia both in the rest and in the effort. Increase of oesophageal pH should prevent these conditions. AIM To estimate the effect of double omeprazole dose on the course of angina pectoris and treadmill stress test in patients with coronary artery disease (CAD), using double-blind, crossover randomised, placebo-controlled study design. METHODS We studied 48 patients with angina pectoris symptoms and significant narrowing of coronary vessels in angiography. After baseline examination and treadmill stress test all subjects were randomised to treat either with omeprazole (20 mg b.i.d.) or placebo for 14 days, using a double-blind, crossover placebo controlled design. RESULTS Seventeen (35%) subjects reported more than by half decrease in symptoms severity after omeprazole and 6 (12%) after placebo (p=0,01). Omeprazole significantly decreased the number of chest pain episodes and number of nitroglycerin doses taken in the second week of both study phases, as well as the percentage of subjects with significant decrease of ST interval during the stress test (64% vs. 73%, p<0,05). However majority of other stress test parameters (i.e. test duration, DUKE index) have improved both after omeprazole and placebo administration (by 9-38%). CONCLUSION Double dose of omeprazole significantly decreased symptoms severity in 35% of patients with CAD, as well as frequency of some electrocardiographic signs of myocardial ischaemia during stress test.
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Affiliation(s)
- Jacek Budzyński
- Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Department of Gastroenterology, Vascular Diseases and Internal Medicine, Ujejskiego 75 Street, PL85-168 Bydgoszcz, Poland.
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Hravnak M, Whittle J, Kelley ME, Sereika S, Good CB, Ibrahim SA, Conigliaro J. Symptom expression in coronary heart disease and revascularization recommendations for black and white patients. Am J Public Health 2007; 97:1701-8. [PMID: 17329655 PMCID: PMC1963307 DOI: 10.2105/ajph.2005.084103] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined whether symptoms of coronary heart disease vary between Black and White patients with coronary heart disease, whether presenting symptoms affect physicians' revascularization recommendations, and whether the effect of symptoms upon recommendations differs in Black and White patients. METHODS We interviewed Black and White patients in Pittsburgh in 1997 to 1999 who were undergoing elective coronary catheterization. We interviewed them regarding their symptoms, and we interviewed their cardiologist decision-makers regarding revascularization recommendations. We obtained coronary catheterization results by chart review. RESULTS Black and White patients (N=1196; 9.7% Black) expressed similar prevalence of chest pain, angina equivalent, fatigue, and other symptoms, but Black patients had more shortness of breath (87% vs 72%, P=.001). When we considered only those patients with significant stenosis (n=737, 7.1% Black) and controlled for race, age, gender, and number of stenotic vessels, those who expressed shortness of breath were less likely to be recommended for revascularization (odds ratio=0.535; 95% confidence interval=0.375, 0.762; P<.001), but there was no significant interaction with race. CONCLUSIONS Black patients reported shortness of breath more frequently than did White subjects. Shortness of breath was a negative predictor for revascularization for all patients with significant stenosis, but there was no difference in the recommendations by symptom by race.
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Affiliation(s)
- Marilyn Hravnak
- Center for Health Equity Research and Promotion, Pittsburgh Veterans Affairs Health System, University of Pittsburgh, Pittsburgh, Pa 15261, USA.
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Huber S, Muthupillai R, Lambert B, Pereyra M, Napoli A, Flamm SD. Tissue characterization of myocardial infarction using T1rho: influence of contrast dose and time of imaging after contrast administration. J Magn Reson Imaging 2007; 24:1040-6. [PMID: 16972231 DOI: 10.1002/jmri.20720] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To determine whether contrast between acutely infarcted and normal myocardia in T1-rho-weighted cine TFE (T1rho-TFE) and delayed-enhancement (DE) images (measured using a metric percent enhancement (PE)) varied with the dose or time of imaging after contrast administration. MATERIALS AND METHODS Eighteen patients with acute myocardial infarction (AMI) were randomly divided into three groups according to the dose of gadoversetamide (0.1, 0.2, or 0.3 mmol/kg) administered. After contrast administration, T1rho-TFE images were acquired at five and 40 minutes, and DE images were acquired at 10 and 30 minutes. RESULTS For T1rho-TFE imaging the PE values at 40 minutes were 70+/-14, 98+/-14, and 105+/-41 at 0.1, 0.2, and 0.3 mmol/kg dose levels, which were significantly greater than the corresponding PEs at five minutes after contrast administration (44+/-12, 71+/-14, and 36+/-13). For DE and T1rho-TFE imaging the dose of contrast agent did not significantly affect the PE. However, with DE the PE tended to increase with the dose. At all dose levels, irreversible injury was more conspicuous in T1rho-TFE images acquired at 40 minutes than at five minutes after contrast. CONCLUSION In T1rho-TFE, acute infarction was more conspicuous in images acquired at a later time point, and the PE did not vary with the contrast dose.
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Affiliation(s)
- Steffen Huber
- Department of Radiology, St. Luke's Episcopal Hospital/Texas Heart Institute, and Baylor College of Medicine, Houston, Texas 77030, USA
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Wilson JM, Ferguson JJ, Hall RJ. Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Peterson PN, Spertus JA, Magid DJ, Masoudi FA, Reid K, Hamman RF, Rumsfeld JS. The impact of diabetes on one-year health status outcomes following acute coronary syndromes. BMC Cardiovasc Disord 2006; 6:41. [PMID: 17062160 PMCID: PMC1635061 DOI: 10.1186/1471-2261-6-41] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2006] [Accepted: 10/24/2006] [Indexed: 11/25/2022] Open
Abstract
Background Diabetes is an important predictor of mortality patients with ACS. However, little is known about the association between diabetes and health status after ACS. The objective of this study was to examine the association between diabetes and patients' health status outcomes one year after an acute coronary syndrome (ACS). Methods This was a prospective cohort study of patients hospitalized with ACS. Patients were evaluated at baseline and one year with the Seattle Angina Questionnaire (SAQ). Socio-demographic and clinical characteristics were ascertained during index ACS hospitalization. One year SAQ Angina Frequency, Physical Limitation, and Health-Related Quality of Life (HRQoL) scales were the primary outcomes of the study. Results Of 1199 patients, 326 (37%) had diabetes. Patients with diabetes were more likely to present with unstable angina (52% vs. 40%; p < 0.001), less likely to present with STEMI (20% vs. 31%; p < 0.001), and less likely to undergo coronary angiography (68% vs. 82%; p < 0.001). In multivariable analyses, the presence of diabetes was associated with significantly more angina (OR 1.36; 95% CI 1.01–1.38), cardiac-related physical limitation (OR 1.94; 95% CI 1.57–3.24) and HRQoL deficits (OR 1.43; 95% CI 1.01–2.04) at one year. Conclusion Diabetes is associated with more angina, worse physical limitation, and worse HRQoL one year after an ACS. Future studies should assess whether health status outcomes of patients with diabetes could be improved through more aggressive ACS treatment or post-discharge surveillance and angina management.
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Affiliation(s)
- Pamela N Peterson
- Department of Medicine, University of Colorado at Denver and Health Sciences Center, Denver Colorado, USA
- Department of Medicine, Denver Health Medical Center, Denver Colorado, USA
| | - John A Spertus
- Cardiovascular Research, Mid America Heart Institute of Saint Luke's Hospital, Kansas City Missouri, USA
- School of Medicine, University of Missouri – Kansas City, Kansas City Missouri, USA
| | - David J Magid
- Clinical Research Unit, Kaiser Permanente, Denver Colorado, USA
- Department of Preventive Medicine and Biometrics, University of Colorado at Denver and Health Sciences Center, Denver Colorado, USA
| | - Fredrick A Masoudi
- Department of Medicine, University of Colorado at Denver and Health Sciences Center, Denver Colorado, USA
- Department of Medicine, Denver Health Medical Center, Denver Colorado, USA
| | - Kimberly Reid
- Cardiovascular Research, Mid America Heart Institute of Saint Luke's Hospital, Kansas City Missouri, USA
| | - Richard F Hamman
- Department of Preventive Medicine and Biometrics, University of Colorado at Denver and Health Sciences Center, Denver Colorado, USA
| | - John S Rumsfeld
- Department of Medicine, VA Medical Center, Denver Colorado, USA
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Dickens CM, McGowan L, Percival C, Tomenson B, Cotter L, Heagerty A, Creed FH. Contribution of depression and anxiety to impaired health-related quality of life following first myocardial infarction. Br J Psychiatry 2006; 189:367-72. [PMID: 17012661 DOI: 10.1192/bjp.bp.105.018234] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The extent to which depression impairs health-related quality of life (HRQoL) in the physically ill has not been clearly established. AIMS To quantify the adverse influence of depression and anxiety, assessed at the time of first myocardial infarction and 6 months later, on the physical aspect of HRQoL 12 months after the infarction. METHOD In all, 260 in-patients, admitted following first myocardial infarction, completed the Hospital Anxiety and Depression Scale and the Medical Outcomes Study SF-36 assessment before discharge and at 6- and 12-month follow-up. RESULTS Depression and anxiety 6 months after myocardial infarction predicted subsequent impairment in the physical aspects of HRQoL (attributable adjusted R(2)=9%, P<0.0005). These negative effects of depression and anxiety on outcome were mediated by feelings of fatigue. Depression and anxiety present before myocardial infarction did not predict HRQoL 12 months after myocardial infarction. CONCLUSIONS Detection and treatment of depression and anxiety following myocardial infarction improve the patient's health-related quality of life.
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Affiliation(s)
- C M Dickens
- Department of Psychiatry, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.
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Kennedy DJ, Burket MW, Khuder SA, Shapiro JI, Topp RV, Cooper CJ. Quality of life improves after renal artery stenting. Biol Res Nurs 2006; 8:129-37. [PMID: 17003252 DOI: 10.1177/1099800406291459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although treatment of renal artery stenosis (RAS) with stents has been shown to improve blood pressure (BP) and renal function in some patients, little is known about the effect on health-related quality of life. A composite quality of life survey was administered in a cross-sectional cohort fashion to 149 patients presenting with angiographically and hemodynamically confirmed RAS either before (baseline, n = 37) or after (follow-up, n = 112) stent revascularization. BP, renal function, and antihypertensive medication use were also assessed. Systolic BP was lower in the revascularized patients (166 +/- 23 vs. 153 +/- 26, p < .01). The Short Form-36 Physical Component Summary (PCS) scores were higher (better) in revascularized patients (37 +/- 9 vs. 31 +/- 9, p < .01), whereas Mental Component Summary scores were equivalent (49 +/- 13 vs. 51 +/- 11, p = ns). Sleep dysfunction scores were lower (better) in the revascularized patients (32 +/- 26 vs. 48 +/- 32, p < .001), whereas self-reported appetite was higher (better; 62% +/- 29% vs. 73% +/- 27%,p < .05). After matching for age and gender, Short Form-36 PCS remained higher in the revascularized cohort (37 +/- 8 vs. 32 +/- 8, p < .05). Importantly, in multivariate analysis, revascularization was the most significant determinant of a higher PCS score (r2 = .07, beta = 5.21, p < .01). The current data suggest that renal artery stenting may improve health-related quality of life in patients with renovascular disease.
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Affiliation(s)
- David J Kennedy
- Department of Medicine, University of Toledo College of Medicine, Toledo, OH 43614-2598, USA
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Perers E, From Attebring M, Caidahl K, Herlitz J, Karlsson T, Wahrborg P, Hartford M. Low risk is associated with poorer quality of life than high risk following acute coronary syndrome. Coron Artery Dis 2006; 17:501-10. [PMID: 16905961 DOI: 10.1097/00019501-200609000-00002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Morbidity after acute coronary syndromes includes both physical and mental disorders affecting quality of life. The aim of this investigation was to study quality of life at a 3-month follow-up in patients with acute coronary syndrome, with the main objective of exploring whether unstable angina pectoris and myocardial infarction (MI) patients differ in this respect. METHODS This investigation was part of a prospective risk stratification study of consecutive patients with acute coronary syndrome of whom 814 below the age of 75 years (278 diagnosed with unstable angina pectoris and 536 with myocardial infarction) accepted an invitation to a follow-up visit 3 months after discharge. At follow-up, the patients completed the Cardiac Health Profile, a disease-specific quality of life questionnaire, designed to evaluate perceived cognitive, emotional, social and physical function. RESULTS Quality of life was mainly influenced by patient characteristics and previous history. The Cardiac Health Profile scores in unstable angina pectoris patients were significantly higher (i.e. poorer quality of life) than myocardial infarction patients at the 3-month visit (34, 22, 50; median, 25th, 75th percentile and 30, 19, 44; median, 25th, 75th percentile, respectively, P=0.006). The adjusted odds ratio for a poorer quality of life in unstable angina pectoris patients in relation to myocardial infarction patients was 1.39 (95% confidence interval 1.03, 1.87; P=0.03). The highest Cardiac Health Profile scores were seen in the unstable angina pectoris patients without electrocardiogram signs of ongoing ischemia and/or elevated markers of myocardial necrosis. CONCLUSION Patients with unstable angina pectoris, especially of the low-risk type, and therefore treated accordingly, are more likely to experience poorer quality of life following an acute hospitalization than patients with other types of acute coronary syndrome. Once myocardial infarction or high-risk unstable angina pectoris has been ruled out, these patients still require a careful and systematic follow-up.
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Affiliation(s)
- Elisabeth Perers
- Department of Cardiology, Sahlgrenska University Hospital, Göteborg, Sweden.
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Spertus JA, Dawson J, Masoudi FA, Krumholz HM, Reid KJ, Peterson ED, Rumsfeld JS. Prevalence and predictors of angina pectoris one month after myocardial infarction. Am J Cardiol 2006; 98:282-8. [PMID: 16860010 DOI: 10.1016/j.amjcard.2006.01.099] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Revised: 01/31/2006] [Accepted: 01/31/2006] [Indexed: 11/22/2022]
Abstract
Angina pectoris (AP) is a treatable symptom that is associated with mortality and decreased quality of life. The prevalence and predictors of AP 1 month after a myocardial infarction (MI), a time when additional treatments might be offered, have not been described. We prospectively enrolled 2,094 patients with MI from 19 centers in the United States and evaluated angina symptoms 1 month after discharge with the Seattle Angina Questionnaire. Multivariable logistic regression analysis was performed to identify patient and treatment characteristics associated with 1-month AP. At 1 month, 571 patients (27.3%) had AP. Women (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.09 to 1.74), younger patients (OR 1.33 per 10-year increment, 95% CI 1.20 to 1.47), those with previous coronary artery bypass (OR 1.47, 95% CI 1.05 to 2.05), smokers (OR 1.35, 95% CI 1.09 to 1.77), and those who developed postinfarct AP during the index hospitalization (OR 1.85, 95% CI 1.20 to 2.65) were more likely to have AP at follow-up. In contrast, patients who were treated with coronary artery bypass surgery during their index admission were less likely to have AP at 1 month (OR 0.5, 95% CI 0.33 to 0.77). The strongest correlate was the frequency of AP before patients' MI. Compared with those without AP before MI, those with AP < 1 time per week (OR 1.86, 95% CI 1.45 to 2.41), weekly (OR 4.24, 95% CI 3.09 to 5.82), and daily (OR 6.12, 95% CI 3.62 to 10.3) were more likely to have AP 1 month later. In conclusion, > 1 in 4 patients reported AP 1 month after an MI.
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Affiliation(s)
- John A Spertus
- Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri, USA.
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Cairns JA. Ranolazine: Augmenting the Antianginal Armamentarium⁎⁎Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology. J Am Coll Cardiol 2006; 48:576-8. [PMID: 16875986 DOI: 10.1016/j.jacc.2006.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Poole-Wilson PA, Pocock SJ, Fox KAA, Henderson RA, Wheatley DJ, Chamberlain DA, Shaw TRD, Clayton TC. Interventional versus conservative treatment in acute non-ST elevation coronary syndrome: time course of patient management and disease events over one year in the RITA 3 trial. Heart 2006; 92:1473-9. [PMID: 16621882 PMCID: PMC1861054 DOI: 10.1136/hrt.2005.060541] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To determine whether, in acute non-ST elevation coronary syndrome, the benefit from early invasive coronary intervention compared with a conservative strategy of later symptom-guided intervention varies over time. METHODS In RITA 3 (Randomised Intervention Trial of unstable Angina 3) patients were randomly assigned to coronary angiography (median 2 days after randomisation) and appropriate intervention (n = 895) or to a symptom-guided conservative strategy (n = 915). RESULTS In the first week patients in both groups were at highest risk of death, myocardial infarction (MI) or refractory angina (incidence rate 40 times higher than in months 5-12 of follow up). There were 22 MIs and 6 deaths in the intervention group (largely due to procedure-related events, 14 MIs and 3 deaths) versus 17 MIs and 3 deaths in the conservative group. In the rest of the year there were an additional 12 versus 27 MIs, respectively (treatment-time interaction p = 0.021). Over one year in the intervention group there was a 43% reduction in refractory angina; 22% of patients underwent coronary artery bypass surgery and 35% underwent percutaneous coronary intervention only, which reduced refractory angina but provoked some early MIs; and 43% were still treated medically, mostly because of a favourable initial angiogram. CONCLUSION Any intervention policy needs to recognise the high risk of events in the first week and the substantial minority of patients not needing intervention. Intervention may be best targeted at higher risk patients, as the early hazards of the procedure are then offset by reduced subsequent events.
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Affiliation(s)
- P A Poole-Wilson
- Department of Cardiac Medicine, National Heart and Lung Institute, Imperial College London, London, UK.
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Panhofer P, Zacherl J, Jakesz R, Bischof G, Neumayer C. Improved quality of life after sympathetic block for upper limb hyperhidrosis. Br J Surg 2006; 93:582-6. [PMID: 16607680 DOI: 10.1002/bjs.5304] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abstract
Background
The aim of the study was to assess two disease-specific quality of life (QoL) instruments after limited endoscopic thoracic sympathetic block (TS) at T4 for upper limb hyperhidrosis.
Methods
Between 2001 and 2005, 112 patients underwent 223 TS procedures in a prospective study. Some 103 patients (92·0 per cent) had palmar, 87 (77·7 per cent) had axillary and 75 (67·0 per cent) had combined hyperhidrosis. QoL questionnaires devised by Keller et al. and Milanez de Campos et al. were employed before and after treatment. Mean(s.d.) follow-up was 21·9(10·1) months.
Results
A total of 106 patients (94·6 per cent) were evaluated. All patients with palmar hyperhidrosis were completely or almost dry after surgery. Side-effects of compensatory sweating and gustatory sweating were observed in 17·0 and 28·3 per cent of patients respectively. QoL improved after TS in 100 per cent (Keller) and 97·3 per cent (Milanez de Campos) of patients illustrated by ameliorated scores of 78·7 and 67·8 per cent, respectively (both P < 0·001). Both questionnaires showed that compensatory sweating resulted in reduced postoperative QoL (P = 0·011, Keller; P = 0·032, Milanez de Campos).
Conclusion
Endoscopic sympathetic block at T4 leads to improved QoL. Both current questionnaires fulfilled validation criteria for disease-specific QoL instruments in upper limb hyperhidrosis.
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Affiliation(s)
- P Panhofer
- Department of General Surgery, University Clinic of Surgery, Medical University of Vienna, Austria
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Dixon SR, Grines CL, O'Neill WW. The Year in Interventional Cardiology. J Am Coll Cardiol 2006; 47:1689-706. [PMID: 16631010 DOI: 10.1016/j.jacc.2006.02.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2006] [Revised: 01/23/2006] [Accepted: 02/08/2006] [Indexed: 01/14/2023]
Affiliation(s)
- Simon R Dixon
- William Beaumont Hospital, Royal Oak, Michigan 48073, USA
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Krumholz HM. The Year in Epidemiology, Health Services, and Outcomes Research. J Am Coll Cardiol 2005; 46:1362-70. [PMID: 16198857 DOI: 10.1016/j.jacc.2005.06.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2005] [Accepted: 06/14/2005] [Indexed: 01/19/2023]
Affiliation(s)
- Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, Connecticut 06520-8088, USA.
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Ohman EM, Chang PP. Improving Quality ofLife After Cardiogenic Shock: Do More Revascularization!**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology. J Am Coll Cardiol 2005; 46:274-6. [PMID: 16022954 DOI: 10.1016/j.jacc.2005.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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