Evolution of appraisal tool usage preferences in PROSPERO records: a study of non-Cochrane systematic reviews

OBJECTIVES

This research-on-research substudy uses a data-driven approach to investigate the range of appraisal tools in non-Cochrane systematic reviews and meta-analyses registered in the International Prospective Register of Systematic Reviews (PROSPERO).

STUDY DESIGN AND SETTING

A comprehensive web scraping of all completed non-Cochrane registrations in PROSPERO from February 2011 to December 2017 was performed. The focus was classifying the appraisal tools based on study type, assessment aspects, and research topics.

RESULTS

After analyzing 17,708 complete records, we found a predominant use of methodological quality assessment tools compared to those for reporting quality or risk of bias (RoB). This indicates a greater emphasis on methodological rigor in the studied protocols. Various tools for assessing methodological quality were observed, reflecting the complexity of such evaluations. Instruments designed for evaluating methodological or reporting quality were mainly intended for non-randomized clinical trials or observational studies, unlike RoB tools more commonly used in randomized clinical trials. No distinct trends in tool usage were observed in specific research conditions or domains, suggesting that tool choice is influenced more by study design than research topic.

CONCLUSION

This study provides insights into the preferential use of various assessment tools in conducting non-Cochrane systematic reviews, as evidenced in PROSPERO records. The findings reveal various methodological assessment tools, underscoring their versatility across different study designs and research areas.

Relationships between abstract features and methodological quality explained variations of social media activity derived from systematic reviews about psoriasis interventions

OBJECTIVES

The aim of this study was to describe the relationship among abstract structure, readability, and completeness, and how these features may influence social media activity and bibliometric results, considering systematic reviews (SRs) about interventions in psoriasis classified by methodological quality.

STUDY DESIGN AND SETTING

Systematic literature searches about psoriasis interventions were undertaken on relevant databases. For each review, methodological quality was evaluated using the assessing the methodological quality of systematic reviews tool. Abstract extension, structure, readability, and quality and completeness of reporting were analyzed. Social media activity, which consider Twitter and Facebook mention counts, as well as Mendeley readers and Google scholar citations were obtained for each article. Analyses were conducted to describe any potential influence of abstract characteristics on review's social media diffusion.

RESULTS

We classified 139 intervention SRs as displaying high/moderate/low methodological quality. We observed that abstract readability of SRs has been maintained high for last 20 years, although there are some differences based on their methodological quality. Free format abstracts were most sensitive to the increase of text readability as compared with more structured abstracts (Introduction, Methods, Results, and Discussion or eight headings), yielding opposite effects on their quality and completeness depending on the methodological quality: a worsening in low quality reviews and an improvement in those of high quality. Both readability indices and preferred reporting items of systematic reviews and meta-analyses for Abstract total scores showed an inverse relationship with social media activity and bibliometric results in high methodological quality reviews but not in those of lower quality.

CONCLUSION

Our results suggest that increasing abstract readability must be specially considered when writing free format summaries of high-quality reviews because this fact correlates with an improvement of their completeness and quality, and this may help to achieve broader social media visibility and article usage.

Tricuspid but not Mitral Regurgitation Determines Mortality After TAVI in Patients With Nonsevere Mitral Regurgitation

INTRODUCTION AND OBJECTIVES

Many patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or less. The impact of coexistent tricuspid regurgitation (TR) remains to be determined. We sought to analyze the impact of moderate vs none-to-mild MR and its trend after TAVI, as well as the impact of concomitant TR and its interaction with MR.

METHODS

Multicenter retrospective study of 813 TAVI patients treated through the transfemoral approach with MR ≤ 2 between 2007 and 2015.

RESULTS

The mean age was 81 ± 7 years and the mean Society of Thoracic Surgeons score was 6.9% ± 5.1%. Moderate MR was present in 37.3% of the patients, with similar in-hospital outcomes and 6-month follow-up mortality to those with MR < 2 (11.9% vs 9.4%; P = .257). However, they experienced more rehospitalizations and worse New York Heart Association class (P = .008 and .001, respectively). Few patients (3.8%) showed an increase in the MR grade to > 2 post-TAVI. The presence of concomitant moderate/severe TR was associated with in-hospital and follow-up mortality rates of 13% and 34.1%, respectively, regardless of MR grade. Moderate-severe TR was independently associated with mortality (HR, 18.4; 95%CI, 10.2-33.3; P < .001).

CONCLUSIONS

The presence of moderate MR seemed not to impact short- and mid-term mortality post-TAVI, but was associated with more rehospitalizations. The presence of moderate or severe TR was associated with higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility.

Mitral Regurgitation After Transcatheter Aortic Valve Replacement: Prognosis, Imaging Predictors, and Potential Management

OBJECTIVES

This study sought to analyze the clinical impact of the degree and improvement of mitral regurgitation in TAVR recipients, validate the main imaging determinants of this improvement, and assess the potential candidates for double valve repair with percutaneous techniques.

BACKGROUND

Many patients with severe aortic stenosis present with concomitant mitral regurgitation (MR). Cardiac imaging plays a key role in identifying prognostic factors of MR persistence after transcatheter aortic valve replacement (TAVR) and for planning its treatment.

METHODS

A total of 1,110 patients with severe aortic stenosis from 6 centers who underwent TAVR were included. In-hospital to 6-month follow-up clinical outcomes according to the degree of baseline MR were evaluated. Off-line analysis of echocardiographic and multidetector computed tomography images was performed to determine predictors of improvement, clinical outcomes, and potential percutaneous alternatives to treat persistent MR.

RESULTS

Compared with patients without significant pre-TAVR MR, 177 patients (16%) presented with significant pre-TAVR MR, experiencing a 3-fold increase in 6-month mortality (35.0% vs. 10.2%; p < 0.001). After TAVR, the degree of MR improved in 60% of them. A mitral annular diameter of >35.5 mm (odds ratio: 9.0; 95% confidence interval: 3.2 to 25.3; p < 0.001) and calcification of the mitral apparatus by multidetector computed tomography (odds ratio: 11.2; 95% confidence interval: 4.03 to 31.3; p < 0.001) were independent predictors of persistent MR. At least 14 patients (1.3% of the entire cohort, 13.1% of patients with persistent MR) met criteria for percutaneous mitral repair with either MitraClip (9.3%) or a balloon-expandable valve (3.8%).

CONCLUSIONS

Significant MR is not uncommon in TAVR recipients and associates with greater mortality. In more than one-half of patients, the degree of MR improves after TAVR, which can be predicted by characterizing the mitral apparatus with multidetector computed tomography. According to standardized imaging criteria, at least 1 in 10 patients whose MR persists after TAVR could benefit from percutaneous mitral procedures, and even more could be treated with MitraClip after dedicated pre-imaging evaluation.

Short-term efficacy and safety of new biological agents targeting the interleukin-23-T helper 17 pathway for moderate-to-severe plaque psoriasis: a systematic review and network meta-analysis

A new generation of biologics targeting the interleukin-23-T helper 17 pathway has been developed. This study aimed to assess the short-term effectiveness and safety of these new agents using a network meta-analysis. Twenty-seven randomized clinical trials (10 629 patients) were identified by a comprehensive systematic literature review (PROSPERO 2015: CRD42015025472). Quality of evidence was assessed following Cochrane-compliant rules and the Grading of Recommendations, Assessment, Development and Evaluations approach. Efficacy and safety outcomes at weeks 10-16 were compared using a random-effects network meta-analysis within a frequentist framework to estimate pooled odds ratios (ORs) of direct and indirect comparisons among the therapeutic options. There were six direct drug-to-drug comparisons in the network, with a high degree of consistency between the direct and indirect evidence. From the available evidence, infliximab 5 mg kg^-1 every 8 weeks [OR 118·89, 95% confidence interval (CI) 60·91-232·04] and secukinumab 300 mg every 4 weeks (OR 87·07, 95% CI 55·01-137·82) are shown to be among the most effective short-term treatments, but are ranked as the biologics most likely to produce any adverse event or an infectious adverse event, respectively. Ustekinumab 90 mg every 12 weeks, the third most efficacious treatment (OR 73·67, 95% CI 46·97-115·56), was the only agent that did not show increased risk of adverse events compared with placebo. Treatment recommendations should also consider long-term outcomes and costs.

Facial Angiofibroma Severity Index (FASI): reliability assessment of a new tool developed to measure severity and responsiveness to therapy in tuberous sclerosis-associated facial angiofibroma

BACKGROUND

Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disorder characterized by the development of multisystem hamartomatous tumours. Topical sirolimus has recently been suggested as a potential treatment for TSC-associated facial angiofibroma (FA).

AIM

To validate a reproducible scale created for the assessment of clinical severity and treatment response in these patients.

METHODS

We developed a new tool, the Facial Angiofibroma Severity Index (FASI) to evaluate the grade of erythema and the size and extent of FAs. In total, 30 different photographs of patients with TSC were shown to 56 dermatologists at each evaluation. Three evaluations using the same photographs but in a different random order were performed 1 week apart. Test and retest reliability and interobserver reproducibility were determined.

RESULTS

There was good agreement between the investigators. Inter-rater reliability showed strong correlations (> 0.98; range 0.97-0.99) with inter-rater correlation coefficients (ICCs) for the FASI. The global estimated kappa coefficient for the degree of intra-rater agreement (test-retest) was 0.94 (range 0.91-0.97).

CONCLUSIONS

The FASI is a valid and reliable tool for measuring the clinical severity of TSC-associated FAs, which can be applied in clinical practice to evaluate the response to treatment in these patients.

Olive oil and health: summary of the II international conference on olive oil and health consensus report, Jaén and Córdoba (Spain) 2008

Olive oil (OO) is the most representative food of the traditional Mediterranean Diet (MedDiet). Increasing evidence suggests that monounsaturated fatty acids (MUFA) as a nutrient, OO as a food, and the MedDiet as a food pattern are associated with a decreased risk of cardiovascular disease, obesity, metabolic syndrome, type 2 diabetes and hypertension. A MedDiet rich in OO and OO per se has been shown to improve cardiovascular risk factors, such as lipid profiles, blood pressure, postprandial hyperlipidemia, endothelial dysfunction, oxidative stress, and antithrombotic profiles. Some of these beneficial effects can be attributed to the OO minor components. Therefore, the definition of the MedDiet should include OO. Phenolic compounds in OO have shown antioxidant and anti-inflammatory properties, prevent lipoperoxidation, induce favorable changes of lipid profile, improve endothelial function, and disclose antithrombotic properties. Observational studies from Mediterranean cohorts have suggested that dietary MUFA may be protective against age-related cognitive decline and Alzheimer's disease. Recent studies consistently support the concept that the OO-rich MedDiet is compatible with healthier aging and increased longevity. In countries where the population adheres to the MedDiet, such as Spain, Greece and Italy, and OO is the principal source of fat, rates of cancer incidence are lower than in northern European countries. Experimental and human cellular studies have provided new evidence on the potential protective effect of OO on cancer. Furthermore, results of case-control and cohort studies suggest that MUFA intake including OO is associated with a reduction in cancer risk (mainly breast, colorectal and prostate cancers).

Sirolimus in de novo heart transplant recipients with severe renal impairment

Two patients with end-stage heart failure and advanced renal dysfunction (under chronic dialysis therapy) underwent heart transplantation. In order to avoid further renal impairment, a calcineurine inhibitor-free immunosuppression regimen based on the sirolimus was used. Although temporary perioperative support with hemofiltration and dialysis was needed, both patients eventually regained a reasonable renal function with no episodes of clinical rejection and normal cardiac function at 13 and 11 months, respectively, after transplantation. Sirolimus-based immunosuppression might be an interesting alternative to calcineurine inhibitors in the management of patients with significant renal impairment.

Sirolimus as an Alternative to Anticalcineurin Therapy in Heart Transplantation: Experience of a Single Center

We report a series of 26 heart transplant recipients with renal impairment in which sirolimus was used as the basic immunosuppresive drug (without associated calcineurin inhibitors) to avoid further nephrotoxicity. Sirolimus (trough levels 10 to 12 ng/mL, average daily dose 3 mg) was used in two settings: de novo in 7 patients with significant preexistent renal impairment and as a chronic conversion in 19 stable patients with established renal failure (creatinine level >2 mg/dL). In all de novo patients (n = 7), the renal function significantly improved. Creatinine fell from 2.95 +/- 0.9 mg/dL to 1.41 +/- 0.4 mg/dL at follow-up (P = .0017). One patient died suddenly of a massive pulmonary embolism. Only one patient experienced histologic but reversible rejection. In one patient, anemia and diarrhea prompted sirolimus withdrawal. Five patients had infectious episodes: three bacterial pneumonias, one mediastinitis, and two CMV infections. In the chronic conversion group (n = 19), the improvement was mostly limited to patients with moderate renal failure (creatinine < or =2.5 mg/dL) in which creatinine fell from 2.24 +/- 0.2 to 1.9 +/- 0.27 mg/dL, P = .009). When basal creatinine was over 2.5 mg/dL, only one third of the patients improved after conversion. Two patients died: terminal renal failure and cerebrovascular accident. There were no clinical episodes of rejection. Secondary effects prompted the discontinuation of sirolimus in five patients: two definite and one possible interstitial pneumonitis and two cases of anemia). The symptoms resolved after sirolimus withdrawal. Six patients had infection: four pneumonias, one sepsis, and one cutaneous abscess. Sirolimus is an interesting alternative to calcineurin inhibitors in selected patients with renal impairment. It prevents renal failure in de novo recipients at high risk of catastrophic renal damage and ameliorates renal dysfunction in chronic patients with moderate renal dysfunction. Given the high incidence of secondary effects, the adequate dosage and the secondary effects profile needs further study.

Angioplasty of symptomatic high-grade internal carotid artery stenosis with intraluminal thrombus: therapeutic approach

Intraluminal thrombus in the internal carotid artery (ICA) is usually found in patients with severe atheromatous stenosis. Having reviewed 300 carotid angioplasties for symptomatic >70% ICA stenosis, we found three patients (1%) with intraluminal thrombus. Conservative treatment with anticoagulants and double antiplatelet coverage can result in lysis of the thrombus without severe risks. Percutaneous transluminal angioplasty and stenting, preferably with distal protection, can be an excellent alternative to carotid endarterectomy.

[Hyperperfusion syndrome as a complication of percutaneous transluminal angioplasty of the internal carotid artery]

INTRODUCTION

The hyperperfusion syndrome (HS) is described as an infrequent complication of carotid endarterectomy. It may also occur in percutaneous transluminal carotid angioplasty with a similar causal mechanism and clinical features to those seen in HS related to carotid endarterectomy.

CLINICAL CASE

We describe the case of a 69 year old man who developed HS at the time of transluminal carotid angioplasty and 'stenting' of symptomatic, pre-occlusive stenosis of the left internal carotid artery. This complication was not detected on the postoperative arteriography. On CT the presence of a hemispheric hematoma was confirmed. It is thought that HS is caused by a fault in autoregulation of the cerebral blood flow following correction of vascular stenosis in previously ischemic territory.

CONCLUSIONS

Most of the early complications of transluminal carotid angioplasty are ischemic. HS is rare but is a possible complication of transluminal carotid angioplasty and therefore meticulous control of the blood pressure is necessary. A CT scan after any atypical complication of angioplasty may be considered to be essential.

Percutaneous transluminal angioplasty of the symptomatic atherosclerotic carotid arteries. Results, complications, and follow-up

BACKGROUND AND PURPOSE

Carotid endarterectomy reduces stroke risk in patients with > 70% symptomatic stenosis. We present our results of percutaneous transluminal angioplasty (PTA) as an alternative treatment.

METHODS

Ninety-eight patients with symptomatic > 70% stenosis of the internal carotid artery were considered for PTA. Details of the procedure, complications, and 4-year follow-up were registered.

RESULTS

Eighty-five PTAs were performed in a 4-year period. Transient cardiovascular effects were frequent: hypotension (54.1%), bradycardia (67.1%), asystole (25.9%), and syncope (16.5%). Transient ischemic attack occurred in 3 of 82 patients (3.7%), and disabling stroke occurred in 4 (4.9%); mortality was 0%. After a mean follow-up period of 18.7 months, 4 patients died, 1 due to fatal stroke. The overall probability of surviving any stroke or death was 86.7%. Restenosis (> 70%) was seen in 6 cases (7.4%).

CONCLUSIONS

PTA may be a reasonable treatment for symptomatic atherosclerotic stenosis, at least in patients at high risk for carotid endarterectomy.

[The estimation of the severity of tricuspid insufficiency by Doppler color: the effects of gain, pulse repetition frequency and the echographic view]

INTRODUCTION AND OBJECTIVES

Regurgitant jet area is to date the most widely accepted color Doppler parameter for quantitation of atrium-ventricular regurgitations. In experimental studies, it has been demonstrated that color regurgitant jet area is greatly influenced by technical settings. The present study was aimed to analyze the effect of gain setting, pulse repetition frequency and echocardiographic plane on color jet area in patients with tricuspid regurgitation.

METHODS

We studied 64 patients with nontrivial (more than 1 cm2), rheumatic tricuspid regurgitation. Examinations were performed in apical four-chamber and right ventricle inflow-tract views, at two gain settings (subsaturation gain and 1/3 reduced gain) and at two pulse repetition frequencies (3.1 and 3.8 kHz). Therefore, every regurgitant jet was study under 8 different technical conditions. The remaining technical settings were held unchanged included throughout the studies. The traced area induced central varianced and aliased signals, as well as the immediately contiguous nonturbulent velocities that were moving in the same direction as the jet. Measurements were taken from 5 and 3 representative cycles in patients with atrial fibrillation and sinus rythm, respectively.

RESULTS

Globally, reduction in gain setting produced a color area decrease by 50%. This reduction was of greater extent for small jets (less than 5 cm2, 45 +/- 17%) with respect to larger jets (more than 5 cm2, 61 +/- 30%, p = 0.0009). Results were similar for both apical four-chamber and right ventricle inflow views and for the two pulse repetition frequencies. At a given color gain level and echocardiographic view, pulse repetition frequency at 3.1 kHz produced greater color areas (by 3-11%) than frequency at 3.8 kHz, but the difference was not significant. Overall, color jet area was significantly greater in right ventricle inflow view than in apical four-chamber view, but substantial individual variability was observed. Difference between both views was greater than 40% in 28% of patients, with the largest color area in right ventricle inflow view in most, especially in those patients with eccentric jets.

CONCLUSIONS

Gain setting and echocardiographic view greatly affect regurgitant jet area by color Doppler in patients with tricuspid regurgitation. Therefore, standardization of technical settings is mandatory in order to avoid diagnostic pitfalls.

Assessment of tricuspid regurgitation by Doppler color flow imaging: angiographic correlation

The correlation between data obtained by Doppler color flow imaging and angiographic severity has been investigated in mitral and aortic regurgitation. However, similar studies have not been performed for tricuspid regurgitation (TR). This study was performed to establish the correlation between measurements of regurgitant jet area by Doppler color flow imaging and the angiographic severity of TR. Fifty-four patients with rheumatic heart disease who underwent right ventriculography and transthoracic Doppler color flow imaging were studied. The regurgitant jet area was measured as the largest clearly definable flow disturbance in apical four-chamber and right ventricle inflow views, and expressed in both views as the absolute jet area or as the ratio of maximal jet area to right atrial area. Correlation of all Doppler color flow measurements with angiographic grades of TR were comparable, absolute jet area in apical four-chamber view being closest at r = 0.80. A regurgitant jet area in apical four-chamber view < 5 cm2 predicted minimal or mild TR by angiography with a sensitivity of 78% and a specificity of 100%, whereas a regurgitant jet area > 10 cm2 predicted severe TR with a sensitivity of 92% and a specificity of 91%. Values between 5 and 10 cm2 predicted moderate TR with a sensitivity of 89% and a specificity of 89%. Sensitivity and specificity were not improved with use of the ratio of jet area to right atrial area or with use of right ventricle inflow view. Thus, Doppler color flow jet measurements correlate closely with angiographic results in the evaluation of TR.(ABSTRACT TRUNCATED AT 250 WORDS)

[The acute and chronic effects of 10-mg nitroglycerin patches in stable angina of effort]

INTRODUCTION AND OBJECTIVES

To assess the anti-ischemic efficacy of nitroglycerin patches (10 mg/day), we studied, by means of serial exercise testing (Bruce protocol), 10 patients with stable effort angina in a randomized, placebo-controlled, cross-over, double-blind essay.

METHODS

Patients were exercised 1, 4, 12 and 24 hours after a single patch, and 4 and 12 hours after a 48 hours therapy course. Chronic therapy was assessed after both continuous and intermittent (intermission of 12 hours) patch application.

RESULTS

After single patch, time to angina and time to 1 mm ST depression were significantly increased with respect to placebo at 1-hour test (83 +/- 27 s and 119 +/- 39 s, respectively), 4-hour test (100 +/- 34 s and 87 +/- 29 s, respectively) and 12-hour test (46 +/- 15 s and 64 +/- 20 s, respectively). No effect was demonstrated at 24-hour test. After continuous treatment no differences with respect to placebo were found at any test. After intermittent treatment time to angina was prolonged (75 +/- 23 s) only at 4-hour test, and time to 1 mm ST depression at 4-hour test (61 +/- 19 s) and 12-hour test (41 +/- 14 s).

CONCLUSIONS

Nitroglycerin patches improve parameters of exercise ischemia for a 12 hours period. Tolerance is developed very early and provokes absolute lack of efficacy. Tolerance can be avoided with intermittent patch application. No treatment schedule shows 24 hours efficacy.

[Changes in the flow patterns of the hepatic veins obtained by pulsed Doppler during the postoperative follow-up of a patient with acute aortic insufficiency]

Blood flow pattern recording of hepatic veins using pulsed Doppler technique is a valid method for the assessment of hemodynamic changes in right atrium. We describe a patient with severe aortic regurgitation secondary to acute infective endocarditis who underwent surgical repair. Before surgery and during the postoperative period, several evolutive studies (including conventional echo and hepatic veins pulsed Doppler recordings) were performed. The different central blood flow patterns were correlated with changing hemodynamic conditions during follow-up of the patient. These central flow velocities reflect changes in right atrial pressure contours, and are easily obtained non-invasively with pulsed wave Doppler ultrasound of the hepatic veins. They could be an useful method for assessing right heart filling dynamics, reporting characteristic patterns in other cardiac disease states.

[The importance of the echocardiographic diagnosis of a mycotic aneurysm of the mitral septal leaflet in infectious endocarditis of the aortic valve: the surgical implications]

Mycotic aneurysm of the septal leaflet of the mitral valve is an infrequent complication associated with aortic infective endocarditis. The most probable mechanisms implicated on its formation are two: the lesion induced by regurgitant jet striking on septal mitral leaflet and the direct spreading of infection through the fibrosa inter-valvular. We describe the preoperative diagnosis of mycotic aneurysms of the septal mitral leaflet by two-dimensional echocardiography and color flow mapping in 2 patients. Surgical management will depend on the anatomic characteristics of the aneurysm and its hemodynamic repercussion. Careful echocardiographic search for mycotic mitral aneurysms should be performed in cases of aortic valve endocarditis, in view of its important prognostic implications.

Differences in response to single dose and steady-state therapy with verapamil in stable angina

Ten patients with stable effort angina were studied in a randomized double-blind and placebo-controlled trial to compare the antianginal efficacy of "acute" and "chronic" (after reaching a steady-state level) treatment with verapamil. Efficacy was assessed by exercise testing after a 120 mg single-dose and at the end of a seven-dose course of 120 mg of verapamil given thrice daily. Three daily exercise tests were performed the first, second and fifth day of the study protocol at 8, 12 and 16 hours. Eight hours after the last dose was given, exercise time increased by 54 +/- 30 sec after a single-dose of verapamil and by 156 +/- 31 sec after seven-doses of verapamil (P less than 0.05 as compared to single-dose verapamil). The time to 1 mm depression of the ST segment increased by 30 +/- 20 sec after a single-dose of verapamil and by 66 +/- 28 sec after seven-doses of verapamil (P less than 0.01 as compared to single dose verapamil). Six of the ten patients became free from angina on treadmill exercise after a seven-dose course of verapamil, but only one patient became free from angina after acute testing with a single-dose of verapamil. It is concluded that several doses of verapamil are required to achieve an optimal anti-ischemic effect, as suggested by the pharmacodynamic properties of this drug. Once steady-state is achieved, the effects of verapamil remain for at least 8 hours, so that an administration schedule of three times daily protects the patient for a 24-hour period.

Prevention of early aortocoronary bypass occlusion by low-dose aspirin and dipyridamole. Grupo Español para el Seguimiento del Injerto Coronario (GESIC)

To analyze the efficacy of low-dose aspirin in preventing early aortocoronary vein graft occlusion, 1,112 consecutive patients were enrolled in a multicenter, randomized, double-blind, placebo-controlled trial comparing 50 mg t.i.d. aspirin, 50 mg aspirin plus 75 mg t.i.d. dipyridamole, and placebo. All patients received 100 mg q.i.d. dipyridamole for 48 hours before surgery, and assigned treatment was started 7 hours after surgery. Vein graft angiography was performed in 927 patients (83%) within 28 days of surgery (mean, 10 days). Aspirin plus dipyridamole significantly (p = 0.017) reduced the occlusion rate of distal anastomoses from 18% (placebo) to 12.9%. Occlusion rate in the aspirin group was 14%, which approached statistical significance (p = 0.058). Furthermore, only aspirin plus dipyridamole reduced (p = 0.01) the number of patients with occluded grafts (placebo, 33%; aspirin, 27.1%; aspirin plus dipyridamole, 24.3%). Mediastinal drainage was slightly higher (p = 0.04) in the aspirin plus dipyridamole group (713 +/- 456 ml) than in the other two groups (placebo, 670 +/- 437 ml; aspirin, 629 +/- 337 ml), but hospital mortality (average, 4.6%) and early reoperation (average, 3.9%) rates were similar among the three groups. Thus, low-dose aspirin plus dipyridamole safely improves early saphenous vein aortocoronary graft patency; this effect is an added benefit to a preoperative regimen of dipyridamole.

[Evaluation using serial exercise tests of verapamil alone and combined with isosorbide dinitrate in exertional angina]

The response to verapamil alone and combined with isosorbide dinitrate in a group of 12 patients with severe ischemic heart disease and stable effort angina was assessed by means of serial treadmill testing. The study was randomized, of a square latin design and double-blind. The tested drugs and dosages were 120 mg of verapamil, 120 mg of verapamil plus 20 mg of isosorbide dinitrate and placebo. Patients were serially tested (Bruce protocol) over three consecutive days at 8-9-12 and 16 hours. A significative improvement was observed in several ischemic parameters both with verapamil alone and combined with isosorbide dinitrate, but this improvement was remarkably enhanced with the combination of drugs. The mean exercise time to produce angina improved from 268 +/- 18 sec (basal) to 379 +/- 19 sec (verapamil plus isosorbide dinitrate) and the time for 1 mm ST segment depression from 163 +/- 22 sec (basal) to 257 +/- 19 sec (verapamil plus isosorbide dinitrate) when measured at the last daily test (8 hours after drug administration). It is concluded that both verapamil alone and combined with isosorbide dinitrate at the chosen doses are clinically efficient, significantly improving the ischemic parameters. The combination of verapamil and isosorbide dinitrate resulted in a remarkably better improvement in this group of patients with stable effort angina.

[Traumatic tricuspid insufficiency]

Isolated tricuspid valve regurgitation is a rare finding after nonpenetrating chest trauma. The clinical course is usually benign and the time of surgery can be delayed for many years. Two-dimensional Doppler echocardiography is an essential procedure in the diagnosis of chordae tendineae or papillary muscle traumatic injury. We present two cases of traumatic tricuspid regurgitation with mild symptoms undiagnosed for sixteen and forty-three years, respectively.

An assessment of single doses of 8 mg sustained-release molsidomine using serial exercise tests

The effectiveness and duration of the anti-anginal action of two sustained-release preparations, molsidomine (8 mg) and isosorbide dinitrate (20 mg), were assessed by means of serial exercise tests in 12 patients with angina of effort. The tests, which were limited by the symptoms, were carried out on three consecutive days using the Bruce protocol. Each patient was tested four times each day: the first test was performed before treatment and the others were carried out 1, 4 and 8 h after administration of the drug or placebo. One hour after administration of molsidomine, the appearance of signs of ischaemia in the ECG were considerably delayed and they were reduced in magnitude. Furthermore, the length of time during which the patients were free of angina increased. After 4 h both drugs significantly delayed the onset of angina and depression of the ST segment by 1 mm. The conclusion is that at the doses used both drugs prolong the length of time in which there is no angina, but that they have no significant effect at 8 h.

Noninvasive determination of pulmonary arterial systolic pressure by continuous wave Doppler

We evaluated the accuracy of continuous wave Doppler for estimating pulmonary arterial systolic pressure in patients with tricuspid regurgitation. Of 44 patients with a variety of cardiac disorders, 39 (89%) had Doppler-detected tricuspid regurgitation. Adequate spectral profiles of the flow signals were obtained in 34 of them (87%), representing 77% of the entire group. Continuous wave Doppler ultrasound was used to measure the maximum velocity of the regurgitant jet, and by applying the modified Bernoulli equation, the systolic pressure gradient between the right ventricle and the right atrium was calculated. Pulmonary arterial systolic pressure was estimated by adding the transtricuspid gradient to the mean right atrial pressure, and correlated well with catheterization values (r = 0.96). The correlation coefficient was not significantly modified if mean right atrial pressures were excluded in the calculations (r = 0.91). Continuous wave Doppler constitutes a sensitive method for the detection of tricuspid regurgitation. The method using the tricuspid gradient provides an accurate estimation of pulmonary arterial systolic pressure. Combined with other available methods (pulsed wave Doppler), this noninvasive technique can yield information comparable with that obtained at catheterization.

Comparison of Doppler-determined elevated pulmonary arterial pressure with pressure measured at cardiac catheterization

This study assesses use of pulsed Doppler echocardiography to measure pulmonary artery (PA) pressure. PA flow at the right ventricular (RV) outflow tract was analyzed in 51 patients. Attention was focused on PA flow morphologic pattern, RV systolic intervals, time to peak flow and acceleration time index. Correlation was made with PA pressure and total pulmonary resistance. Three morphologic patterns of PA flow were found: type I indicates normal PA pressure (sensitivity 85%, specificity 100%) and types II and III indicate PA hypertension (sensitivity 100%, specificity 85%). The RV preejection/RV ejection ratio, time to peak flow and acceleration time index show a good correlation coefficient improved when a logarithmic function was applied. The best correlation was achieved with time to peak flow (r = -0.77 with PA pressure, r = -0.79 with total pulmonary resistance), and especially with acceleration time index (r = -0.84 with PA pressure, r = -0.87 with total pulmonary resistance). Analysis of pulmonary flow is a reliable new tool for evaluating PA pressure and is even better for evaluating total pulmonary resistance. Acceleration time index is the parameter that correlates best with these 2 variables.