Decisional needs in people with kidney failure, their relatives and health professionals about end-of-life care options: A qualitative interview study

AIM

To investigate the decisional needs in Denmark of people with kidney failure, relatives, and health professionals when planning end-of-life care.

DESIGN

A qualitative interview study.

METHODS

Individual semi-structured interviews were carried out with people with kidney failure, relatives and health professionals from November 2021 to June 2022. Malterud's systematic text condensation was used to analyse transcripts.

RESULTS

A total of 13 patients, 10 relatives, and 12 health professionals were interviewed. Overall, four concepts were agreed on: (1) Talking about end of life is difficult, (2) Patients and relatives need more knowledge and information, (3) Health professionals need more tools and training, and (4) Experiencing busyness as a barrier to conversations about end of life.

CONCLUSION

People with kidney failure, relatives, and health professionals shared certain decisional needs while also having some different decisional needs about end-of-life care. To meet these various needs, end-of-life conversations should be systematic and organized according to the patients' needs and wishes.

IMPACT

Non-systematic end-of-life care decision-making processes limit patients' involvement. Patients and relatives need more knowledge about end-of-life care, and health professionals need more competences and time to discuss decisional needs. A shared decision-making intervention for people with kidney failure when making end-of-life care decisions will be developed.

REPORTING METHOD

This empirical qualitative research is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

PATIENT OR PUBLIC CONTRIBUTION

Patients, relatives, and health professionals have been involved throughout the research process as part of the research team and advisory board. The patients are people with kidney failure and the relatives are relatives of a person with kidney failure. For this study, the advisory board has particularly contributed to the validation of the invitation letter for participation, the interview guides and the preparation of the manuscript.

Patient involvement interventions for patients with kidney failure making end-of-life care decisions: a scoping review

OBJECTIVE

The objective of this review was to investigate and map empirical evidence of patient involvement interventions to support patients with kidney failure making end-of-life care decisions in kidney services.

INTRODUCTION

Clinical guidance integrating end-of-life care within kidney failure management pathways varies. Advance care planning interventions aimed at involving patients with kidney failure in their end-of-life care planning are established in some countries. However, there is limited evidence of the other types of patient involvement interventions integrated within services to support patients with kidney failure in making decisions about their end-of-life care.

INCLUSION CRITERIA

This scoping review included studies exploring patient involvement interventions evaluated for patients with kidney failure considering end-of-life care, their relatives, and/or health professionals in kidney services. Studies of children under the age of 18 years were excluded.

METHODS

The review was informed by JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review guidelines. MEDLINE, Scopus, Embase, and CINAHL were searched for full-text studies in English, Danish, German, Norwegian, or Swedish. Two independent reviewers assessed the literature against the inclusion criteria. A relational analysis framework was used to synthesize the data extracted from the included studies, and to investigate and map different patient involvement interventions.

RESULTS

The search identified 1628 articles, of which 33 articles met the inclusion criteria. A total of 23 interventions were described. Interventions targeted patients (n=3); health professionals (n=8); patients and health professionals (n=5); and patients, relatives, and health professionals (n=7). Intervention components included patient resources (eg, information, patient decision aids), consultation resources (eg, advance care planning, shared decision-making), and practitioner resources (eg, communication training). Patient involvement interventions were delivered within hospital-based kidney services.

CONCLUSIONS

The review identified several ways to support patients with kidney failure to be involved in end-of-life care decisions. Future interventions may benefit from adopting a complex intervention framework to engage multiple stakeholders in the research and design of an intervention for shared decision-making between patients with kidney failure, their relatives, and health professionals about integrating end-of-life care options into their kidney disease management pathway.

Shared decision-making and planning end-of-life care for patients with end-stage kidney disease: a protocol for developing and testing a complex intervention

Background

Internationally, it has been stressed that advance care planning integrated within kidney services can lead to more patients being involved in decisions for end-of-life care. In Denmark, there is no systematic approach to advance care planning and end-of-life care interventions within kidney services. A shared decision-making intervention for planning end-of-life care may support more effective treatment management between patients with end-stage kidney disease, their relatives and the health professionals. The purpose of this research is to find evidence to design a shared decision-making intervention and test its acceptability to patients with end-stage kidney disease, their relatives, and health professionals in Danish kidney services.

Methods

This research project will be conducted from November 2020 to November 2023 and is structured according to the UK Medical Research Council framework for complex intervention design and evaluation research. The development phase research includes mixed method surveys. First, a systematic literature review synthesising primary empirical evidence of patient-involvement interventions for patients with end-stage kidney disease making end-of-life care decisions will be conducted. Second, interview methods will be carried out with patients with end-stage kidney disease, relatives, and health professionals to identify experiences of involvement in decision-making and decisional needs when planning end-of-life care. Findings will inform the co-design of the shared decision-making intervention using an iterative process with our multiple-stakeholder steering committee. A pilot test across five kidney units assessing if the shared decision-making intervention is acceptable and feasible to patients, relatives, and health professionals providing services to support delivery of care in kidney services.

Discussion

This research will provide evidence informing the content and design of a shared decision-making intervention supporting patient-professional planning of end-of-life care for patients with end-stage kidney disease, and assessing its acceptability and feasibility when integrated within Danish kidney units. This research is the first step to innovating the involvement of patients in end-of-life care planning with kidney professionals.

Mapping the empirical evidence on patient involvement interventions in patients with end-stage kidney disease making end-of-life care decisions: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to investigate and map existing empirical evidence on patient involvement interventions helping patients with end-stage kidney disease to make end-of-life care decisions about kidney services.

INTRODUCTION

Patients with end-stage kidney disease have a high disease burden and mortality rate. Despite this, kidney services differ in how they offer and integrate end-of-life care, if it is offered at all. Some countries have established advance care planning protocols to encourage patient involvement when offering end-of-life care options as part of end-stage kidney disease care. However, there is a limited understanding of the components of patient involvement interventions designed to support patients with end-stage kidney disease making decisions about end-of-life care.

INCLUSION CRITERIA

The review will consider studies on patient involvement interventions concerning end-of-life care decisions for patients with end-stage kidney disease. A broad definition of patient involvement interventions will be used. Studies on interventions that do not involve patients or relatives will be excluded. The review will focus on interventions applied to kidney health care and other services, such as community-based health care.

METHODS

MEDLINE, Embase, Scopus, and CINAHL will be searched. The literature will be screened for inclusion by two independent reviewers. Data synthesis will be conducted through relational analysis investigating patient involvement interventions and relevant information in line with the review objective and questions. Data will be extracted and listed in the data extraction instruments, accompanied by a narrative summary describing how the results relate to the review objective.

Palliative care needs experienced by Danish patients with end-stage kidney disease

BACKGROUND

Patients with end-stage kidney disease (ESKD) may have palliative care needs. A tool validated in a Danish context to identify such needs is lacking. The Integrated Palliative Outcome Scale-Renal (IPOS-Renal) aims to identify patients' palliative care needs. The current study is the first phase of a research project translating and validating the IPOS-Renal into Danish.

OBJECTIVES

To investigate palliative care needs among Danish patients with ESKD.

DESIGN

A literature review was conducted using meta-ethnography inspired by Noblit and Hare. A focus group with health care professionals (HCPs) and semi-structured individual patient interviews were conducted and analysed using Malterud's principles of systematic text condensation.

RESULTS

A synthesis of 15 studies, a focus group with 13 HCPs, and interviews with nine patients were conducted. We found that patients with ESKD experienced several symptoms related to physical, social, mental and existential and practical needs. The most prominent findings were fatigue, reduced physical functioning, dizziness, impaired memory, dependency on relatives or HCPs, social isolation and loss of identity.

CONCLUSION

The palliative care needs identified in the Danish patient population are substantiated by the IPOS-Renal questionnaire. However, some Danish patients also appear to struggle with dizziness and impaired memory. These symptoms do not appear specifically in the IPOS-Renal questionnaire but may have to be included in a Danish version.

[Palliative care is for everyone, even for patients with life-threatening medical organ failure]

Healthcare authorities have emphasised the need to develop palliative care for everybody suffering from life-threatening diseases, including people suffering from medical organ failure. In 2011, the Danish Health Authority requested that all medical associations developed guidelines for palliative care. Until now, this has been fulfilled by only four associations. The aim of this review is to summarise the status of the palliative care needs and palliative care across diagnosis for patients suffering from life-threatening medical organ failure and to draw attention to the lack of care and the importance of guidelines.

Renal Haemodynamics are not Related to Genotypes in Offspring of Parents with Essential Hypertension

Introduction. The pathogenesis of essential hypertension (EH) has a major genetic component and is associated with renal abnormalities. Normotensive offspring of hypertensive parents are likely to develop EH and are a suitable population for identifying possible relations between genetic and renal abnormalities.

Methods. We investigated if renin-angiotensin-aldosterone system associated genotypes (angiotensinogen [M235T] and ACE [I/D]) are related to blood pressure (BP), renal haemodynamics and sodium excretion in sex and age-matched (18—35 years) healthy Caucasian offspring of either two parents with EH (n=101, EH-offspring) or two normotensive parents (n=50, controls). The alpha-adducin polymorphism (G460W) was also investigated.

Results. Compared to controls, BP, heart rate, renal vascular resistance (RVR) and urinary sodium excretion were, respectively, 5%, 7%, 15% and 20% higher in EH-offspring. In controls, the TT-genotype of the M235T angiotensinogen polymorphism was associated with higher BP and higher plasma angiotensinogen. By contrast, in EHoffspring the TT-genotype was associated with lower BP and unchanged plasma angiotensinogen. Plasma angiotensinogen correlated positively with BP in EH-offspring, with a similar tendency (p=0.08) in controls. The distributions of the three candidate polymorphisms were similar in EH-offspring and controls. There were no associations between any of the polymorphisms and any of the renal parameters measured.

Conclusion. The markedly greater RVR, proportionally larger than the greater BP, supports a role for RVR in the pathogenesis of EH. The lack of association between the candidate polymorphisms and the investigated parameters, even in this homogenous and for hypertension strongly predisposed group, suggests that the polymorphisms investigated do not play important roles in the pathogenesis of hypertension.

Developments in the invasive diagnostic-therapeutic cascade of women and men with acute coronary syndromes from 2005 to 2011: a nationwide cohort study

OBJECTIVES

To investigate for trends in sex-related differences in the invasive diagnostic-therapeutic cascade in a population of patients with acute coronary syndromes (ACS).

DESIGN

A nationwide cohort study.

SETTING

Administrative and clinical registries covering all hospitalisations, invasive cardiac procedures and deaths in the Danish population of 5.6 million inhabitants.

PARTICIPANTS

We included 52,565 patients aged 30-90 years who were hospitalised with a first ACS from January 2005 to November 2011. Follow-up was 60 days from the day of index admission.

MAIN OUTCOME MEASURES

Diagnostic coronary angiography, percutaneous coronary intervention or coronary artery bypass within 60 days of index admission.

RESULTS

Women constituted 36%, were older, had more comorbidity and were less likely to be admitted to a hospital with cardiac catheterisation facilities than men. Mortality rates were similar for both sexes. Diagnostic coronary angiography was performed less frequently on women compared with men, both within 1 day (31% vs 42%; p<0.001) and within 60 days (67% vs 80%; p<0.001), yielding adjusted female-male HRs of 0.83 (0.79-0.87) and 0.86 (0.84-0.89), respectively.Among the 39,677 patients undergoing coronary angiography, non-obstructive coronary artery disease was more frequent among women than men (22% vs 9%; p<0.001). Women were less likely to undergo percutaneous coronary intervention (58% vs 72%; p<0.001) and coronary artery bypass (6% vs 11%, p<0.001) within 60 days than men, yielding adjusted HRs of 0.96 (0.92-0.99) and 0.81 (0.74-0.89), respectively. The sex-related differences were not attenuated over time for any of the invasive cardiac procedures (p values for trend >0.05).

CONCLUSIONS

In this nationwide study, men were more likely to undergo an invasive approach than women when hospitalised with a first ACS--a difference persisting from 2005 to 2011. Future studies should focus on the potential mechanisms behind this differential treatment.

[No evidence for renal protective effect of loop diuretics for patients having oliguria]

In many intensive care units, loop diuretics are used more or less routinely to achieve a urinary output above 1 ml/kg/h in critically ill patients. We do not in the literature find any basis of this strategy. In contrast, this practice may cause a risk of circulatory instability in the critically ill patient due to large diuresis and volume depletion. There is no evidence so far that the use of loop diuretics has a renal protective effect or any other beneficial impact on the renal function. The use of loop diuretics in oliguric critically ill patients may be harmful. Consequently an individual assessment is required.

Improvement of systolic and diastolic heart function after physical training in sedentary women

The present study examined the cardiac effects of football training and running for inactive pre-menopausal women by standard echocardiography and tissue Doppler imaging. Thirty-seven subjects were randomized to two training groups (football: FG; n=19; running; RG; n=18) training 1 h with equal average heart rates twice a week for 16 weeks and compared with a matched inactive control group (CG; n=10). During the training period, left ventricular end-diastolic volume increased by 13% in FG and 11% in RG (P<0.05). Left ventricular posterior wall thickness increased in FG from 8.5+/-1.4 to 9.0+/-1.3 mm (P<0.05). Right ventricle diameter increased by 12% in FG and 10% in RG (P<0.05). Tissue Doppler imaging demonstrated increased left ventricular systolic and diastolic performances in both training groups. Peak systolic velocity increased by 26% in FG and 17% in RG (P<0.05) and left ventricular longitudinal displacement increased in both groups by 13% (P<0.05). Isovolumetric relaxation time decreased significantly more in FG than in RG (26% vs 14%, respectively P<0.05). In conclusion, 16 weeks of football and running exercise training induced significant changes of cardiac dimensions and had favorable effects on both left ventricular systolic and diastolic function. These training-induced cardiac adaptations appeared to be more consistent after football training compared with running.

Health-related quality of life one month after thrombolysis or primary PCI in patients with ST-elevation infarction. A DANAMI-2 sub-study

OBJECTIVES

To evaluate the health-related quality of life (HRQoL) following Primary percutaneous coronary intervention (PCI) or thrombolytic treatment for ST-elevation myocardial infarction (STEMI).

DESIGN

A questionnaire based study on patients randomised in the DANAMI-2 study to Primary PCI or thrombolysis for STEMI. A total of 1 351 patients (93.2% response rate) randomised in the DANAMI-2 study completed the HRQoL questionnaire one month after the infarction.

RESULTS

With respect to the primary end-points (SF-36 physical component score, angina pectoris, and dyspnoea), patients randomised to primary PCI scored better on the SF-36 physical component score (PCS) (p=0.007), and reported significantly less angina pectoris (p=0.010) and dyspnoea (p=0.010). Higher scores among PCI patients were also found on the SF-36 scales physical functioning (p=0.015), role-physical (p=0.017), and general health (p=0.009).

CONCLUSION

The results in this study support the hypothesis that primary PCI is superior to thrombolysis in treating STEMI, not only in clinical outcome, but also in quality of life outcome.

Prevalence of hyperglycaemia and undiagnosed diabetes mellitus in patients with acute myocardial infarction

The prevalence of hyperglycaemia and undiagnosed diabetes mellitus was assessed in 214 consecutive patients admitted to the coronary care units with acute myocardial infarction (AMI). On admission, 16 patients (7.5%) had known diabetes, and 19 patients, not previously known to be diabetic, had blood glucose concentrations of greater than or equal to 9 mmol/l. Fifteen patients survived for 2 months at which time a 75 g oral glucose tolerance test showed diabetes in 9 (60%) and impaired glucose tolerance in 4 (27%). Ten of these 13 patients (77%) with abnormal glucose tolerance had elevated glycosylated haemoglobin (HbA1c) on admission, indicating pre-existing glucose intolerance or diabetes. The prevalence of undiagnosed diabetes was 4.5% (9/198). However, we may have overlooked undiagnosed diabetes in a small number of patients on admission, since only a random blood glucose less than 8 mmol/l rules out diabetes, WHO criteria. Elevated blood glucose in patients with AMI is more likely to reflect a stationary pre-existing abnormal glucose tolerance than a temporary stress-induced phenomenon.

Initiation and persistence with clopidogrel treatment after acute myocardial infarction: a nationwide study

AIMS

To identify possible underuse by analysing initiation and persistence with clopidogrel treatment in an unselected population of patients admitted with myocardial infarction (MI) with or without subsequent percutaneous coronary intervention (PCI).

METHODS

Patients admitted with first-time MI from 2000 to 2005 and subsequent prescription claims of clopidogrel were identified by individual-level linkage of nationwide administrative registries in Denmark. Independent factors affecting initiation and persistence with treatment were analysed by multivariable logistic regression models and Cox proportional hazard models.

RESULTS

A total of 46,190 MI patients were included in the study, of whom 14,939 were treated with PCI. From 2000 to 2005 initiation of clopidogrel increased from 80.4 to 93.7% among MI patients with PCI and from 2.8 to 39.3% among MI patients without PCI. MI patients with concomitant heart failure received less treatment [odds ratio (OR) 0.49, confidence interval (CI) 0.43, 0.56 among patients with PCI and OR 0.90, CI 0.81, 0.99 among patients without PCI in 2002-2003, and OR 0.89, CI 0.80, 1.00 in 2004-2005, respectively]. Of MI patients with PCI, 77.5% completed 9 months' clopidogrel treatment in 2004-2005, the corresponding figures for MI patients without PCI being 53.9%.

CONCLUSIONS

Initiation and persistence with clopidogrel treatment is high in MI patients with PCI. However, we found substantial underuse among MI patients without PCI and in MI patients with heart failure.

Treatment of Young Subjects at High Familial Risk of Future Hypertension With an Angiotensin-Receptor Blocker

Offspring of hypertensive parents are at high risk of future hypertension and subsequent cardiovascular diseases. We investigated whether early treatment with an angiotensin-receptor blocker in young normotensive offspring of hypertensive parents persistently lowered blood pressure after treatment withdrawal, a possibility supported by animal studies. The study is an investigator-initiated, double-blind study of 110 healthy normotensive subjects aged 18 to 36 years where both parents have essential hypertension randomly assigned to 1 of 2 treatment groups: candesartan (Atacand, Astra Zeneca), 16 mg o.d. or placebo. The intervention period was 12 months, with 24 months of follow-up. Primary outcome was mean 24-hour ambulatory blood pressure recordings (mean AMBP) after 12 and 24 months follow-up and was based on intention to treat (n=110). Secondary outcomes were changes during treatment in mean AMBP, left ventricular mass, renal hemodynamics, and adverse events during intervention and were based on those completing the intervention period (n=105). Primary outcome: At 12 and 24 months follow-up, mean AMBP was not different to placebo. Secondary outcomes: After 12 months of intervention, mean AMBP was reduced: −3.9/−3.4 mm Hg for candesartan versus 0.3/0.6 mm Hg for placebo, P <0.0001. Renal vascular resistance and left ventricular mass were also reduced ( P =0.0007, P =0.019, respectively). There were no significant differences in adverse advents between the 2 groups. In conclusion, temporary treatment of subjects at high familial risk of future hypertension with an angiotensin receptor blocker is feasible, but the treatment had no persistent effect on blood pressure when treatment was withdrawn.

Pharmacological modulation of the ATP sensitive potassium channels during repeated coronary occlusions: no effect on myocardial ischaemia or function

BACKGROUND

Repeated episodes of myocardial ischaemia may lead to ischaemic preconditioning. This is believed to be mediated by the ATP sensitive potassium channels.

OBJECTIVE

To examine the effect of pharmacological modulation of the ATP sensitive potassium channels during repeated coronary occlusions.

DESIGN

Double blind, double dummy study.

METHODS

38 patients with a proximal stenosis of the left anterior descending coronary artery and no visible coronary collateral vessels underwent three identical 90 second balloon occlusions, each followed by five minutes of reperfusion. The patients were randomised to pinacidil 25 mg, glibenclamide 10.5 mg, or matching placebo 90 minutes before the start of the procedure. Myocardial ischaemia was measured by continuous monitoring of ECG ST segment changes. Changes in left ventricular function were recorded with a miniature radionuclide detector, and angina was scored on the Borg scale.

RESULTS

In all patients the first balloon occlusion led to significant ST segment elevation, a clear decrease in left ventricular ejection fraction, and angina pectoris. This response was not attenuated at the second or third balloon occlusion, either in the placebo group or in the patients pretreated with pinacidil or glibenclamide.

CONCLUSIONS

Under the given experimental conditions, this randomised and double blind study did not support the view that the human myocardium has an intrinsic protective mechanism that is activated by short lasting episodes of ischaemia.

[The value of exercise test in acute coronary syndrome]

In general, exercise testing in acute coronary syndrome (ACS) has been used in the assessment of physical capacity and to obtain prognostic information. Within recent years, however, a number of randomized studies have addressed the role of exercise testing in identifying patients, who may benefit from an invasive versus a conservative treatment strategy. According to the literature, a normal exercise test result after ACS is associated with an excellent clinical outcome. Patients who for clinical reasons are unable to perform an exercise test comprise a high risk group for future cardiac events. An invasive strategy is warranted in patients who continue to have angina and exhibit significant ST-segment depression in the exercise-ecg or reversible defects on perfusion scintigraphy. Based on the results of a recent, large scale randomized study, patients with unstable angina or acute non-Q-wave infarction appear to benefit from an early invasive treatment strategy--regardless of the results of a preceding exercise test.

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.

[DANAMI. A Danish study of invasive versus conservative treatment of patients with post-infarction ischemia who had received thrombolytic therapy]

INTRODUCTION

To compare an invasive strategy employing percutaneous transluminal coronary angioplasty (PTCA) or coronary artery by-pass grafting (CABG) with a medical strategy in patients who had received thrombolytic treatment for first acute myocardial infarction (AMI), and with signs of inducible ischaemia.

METHODS

In a prospective study 1008 patients were randomized, 503 to invasive treatment, of whom 266 (52.9%) had PTCA, and 147 (29.2%) CABG, 505 to conservative treatment, of whom eight (1.6%) were revascularized within two months.

RESULTS

After a median follow-up of 2.4 years the mortality in the invasive group was 3.6% vs. 4.4% (p = 0.45) in the conservative group, re-infarction incidence was 5.6% vs. 10.5% (p = 0.0038) and percentage of admissions with unstable angina was 17.9% vs. 29.5% (p < 0.00001).

DISCUSSION

We conclude that post-infarct patients with inducible ischaemia should be referred to coronary angiography and revascularised accordingly.

Percutaneous transradial coronary angiography and angioplasty in patients with occlusive atherosclerotic iliofemoral disease

Not all coronary angiograms can be acquired through the femoral route. The transradial catheterisation procedure in patients with occlusive atherosclerotic iliofemoral disease is described. Transfemoral left-sided cardiac catheterisation was performed in approximately 99.5% of patients referred for coronary angiography, while out of 48 patients in whom transfemoral access was impossible, transradial coronary angiography was successful in 37. With the exception of one, all patients with coronary artery disease had lesions of the right coronary artery, more than 70% had multivessel disease and 14% had stenosis of the left main coronary artery. Ten patients had angioplasty performed during the same procedure. Complications occurred in 5 out of 39 cases, 2 (5%) of these were severe. Although the femoral route was used in more than 99% of an unselected population referred for coronary angiography, it was found that transradial angiography and angioplasty can be performed in patients with occlusive atherosclerotic iliofemoral disease with considerable success and an acceptable complication rate.

Amlodipine reduces myocardial ischaemia during exercise without compromising left ventricular function in patients with silent ischaemia: a randomised, double-blind, placebo-controlled study

BACKGROUND

Left ventricular systolic function is reduced during episodes of silent ischaemia in patients with coronary artery disease (CAD). In most normal subjects left ventricular ejection fraction (LVEF) increases at least 5% during exercise whereas LVEF often remains unchanged or decreases in patients with CAD. The anti-ischaemic effect of calcium antagonists is well documented including a capability to reduce exercise-induced electrocardiographic ST-depressions, whereas the effect of these drugs on LV volume changes during exercise in patients with silent ischaemia is unknown.

AIM

The aim of this study was to evaluate the effect of amlodipine on rest and exercise LVEF in patients with silent ischaemia.

METHODS

Twenty-one patients completed a double-blind placebo-controlled cross-over study. Conventional exercise test and radionuclide cardiographies during exercise were used for determining haemodynamic parameters.

RESULTS

Exercise-induced electrocardiographic ST-depressions were reduced in 83% of the patients having ST-deviations during placebo even though 10 patients were already treated with a beta-blocker. Amlodipine did not affect left ventricular systolic function compared to placebo, neither at rest nor during exercise.

CONCLUSION

The results indicated that amlodipine is a safe anti-ischaemic drug in patients with silent ischaemia concerning cardiac function.

Effects of revascularization after first acute myocardial infarction on the evolution of QRS complex changes (the DANAMI trial). DANish Trial in Acute Myocardial Infarction

The changes in QRS complex morphology associated with acute myocardial infarction (AMI) can resolve spontaneously over time. Whether complete revascularization of the infarct-related myocardial territory after AMI affects this QRS resolution has not been studied adequately. The present study compares the evolution of the changes in the QRS complex associated with AMI during 1-year follow-up in patients treated with or without revascularization after their first thrombolyzed AMI. The study is a substudy of the DANish Trial in Acute Myocardial Infarction (DANAMI) (n = 1,008) that randomized patients with inducible ischemia after their first AMI, treated with intravenous thrombolytic therapy, to conservative treatment or coronary angiography followed by the appropriate revascularization strategy. A total of 817 patients had complete sets of evaluable electrocardiograms. Electrocardiograms were obtained at randomization, and at 3, 6, and 12 months of follow-up and subjected to blinded core-laboratory evaluation according to the Selvester QRS scoring method. This score considers Q-, R-, and S-wave duration and ratios to provide a semiquantitative estimate of AMI size. The median electrocardiographic estimated infarct size in the entire population was 15% of the left ventricle at randomization. At the end of the follow-up period this estimate had decreased to 12% (p < 0.00001). There was no difference in the rate of QRS resolution whether the patients were subgrouped according to randomization or subgrouped according to actual treatment with or without revascularization. The present study confirms the findings from previous studies conducted in the prethrombolytic era, that considerable normalization of the QRS complex also occurs after AMI treated with thrombolytic therapy. This QRS normalization seems unaffected by an aggressive treatment strategy with revascularization via balloon angioplasty or bypass surgery.

Improvement in long-term prognosis of elderly patients with acute myocardial infarction after the introduction of intravenous thrombolytic therapy

Survival rate from a "thrombolytic" period of 351 patients above 66 years of age with acute myocardial infarction (AMI) was compared with that of 289 patients from a "prethrombolytic" period. The two groups were comparable regarding sex, age, previous AMI, cerebrovascular events, morbidity and mortality during admission. Survival rates after four years were 45.0% in the "thrombolytic" group and 38.4% in the "prethrombolytic" group (p = 0.047, log rank test). Using the Cox proportional hazard analysis, thrombolytic therapy was shown to be an independent prognostic predictor in "the thrombolytic population" with a relative risk of death from day 30 to end of follow-up of 0.4 (95% confidence interval 0.2-0.8). No interaction was found between age and thrombolysis. Although only one-fifth of the patients with AMI were eligible for thrombolysis, this treatment may have contributed to the improved long-term survival.

The effect of felodipine on renal function and blood pressure in cyclosporin-treated renal transplant recipients during the first three months after transplantation

BACKGROUND

Due to their vasodilatory effect, calcium antagonist may have a renoprotective against cyclosporin (CsA)-induced nephrotoxicity and rise in blood pressure (BP) seen in renal transplantation.

METHODS

In order to evaluate the effect of the calcium antagonist felodipine on renal function and BP during cyclosporin treatment, 79 CsA-treated renal transplant recipients were investigated during the first 3 months after transplantation in a randomized, double-blind, placebo-controlled study with two parallel groups. Felodipine (ER tablets, 10 mg) or placebo was given prior to transplantation and each day during the study period. The patients were assessed twice, i.e. at 4-6 weeks and at 10-12 weeks after transplantation. Renal plasma flow (RPF) and glomerular filtration rate (GFR) were measured by constant infusion technique. Tubular function was estimated from clearance of lithium.

RESULTS

At 6 weeks after transplantation, felodipine caused a significantly higher RPF [felodipine: 219 +/- 70 ml/min; placebo: 182+/-56 ml/min (mean+/-1 SD); P=0.03]. No differences were found in GFR, filtration fraction (FF), tubular sodium handling, or sodium excretion. Felodipine lowered BP significantly. At 12 weeks after transplantation, felodipine caused a significantly higher GFR (felodipine: 49+/-18 ml/min; placebo: 40+/-16 ml/min; P=0.05) and RPF (felodipine: 225+/-77 ml/min; placebo: 175+/-48 ml/min; P<0.01). No difference was found in FF. Felodipine lowered BP significantly. No differences were found with regard to duration of primary anuria, hospitalization time, number of rejection episodes, plasma creatinine day 7 post-transplant, or treatment doses of CsA.

CONCLUSIONS

It is concluded that in renal transplant recipients treated with CsA, felodipine significantly increased both GFR and RPF 3 months after transplantation when compared with placebo, despite a concomitant lowering of BP. A possible antagonizing affect of felodipine against CsA-induced nephrotoxicity in these patients is suggested.

Effect of nitrendipine on renal function and on hormonal parameters after intravascular iopromide

PURPOSE

To evaluate the effect of the low-molecular nonionic radiographic contrast agent iopromide (Ultravist) on renal function, vasoactive peptides (angiotensin II, aldosterone, arginine vasopressin, and atrial natriuretic factor (ANF)), and blood pressure, and to evaluate the influence of the calcium antagonist nitrendipine on these parameters. The findings were evaluated in a prospective double-blind and placebo-controlled randomized study.

MATERIAL AND METHODS

Twenty-six patients undergoing routine aortofemoral arteriography for peripheral atherosclerotic disease were treated with nitrendipine tablets (10 mg) or placebo twice daily for a week. Angiography was performed on the fifth day of medication. Efficacy variables were determined on the day before and 2 days after arteriography. The glomerular filtration rate and renal plasma flow were measured by the constant infusion technique. Renal tubular function was estimated from the clearance of lithium. Hormones were measured by radioimmunoassays.

RESULTS

Arteriography with iopromide did not change renal function. No differences between the nitrendipine and placebo groups were found in renal hemodynamics, tubular sodium handling, or blood pressure. Nitrendipine changed ANF (26.1%) compared to placebo (1.5%), whereas the other hormones were not affected.

CONCLUSION

The use of iopromide for angiography did not affect renal function in normotensive patients with peripheral atherosclerotic disease. Short-term treatment with nitrendipine may lower the plasma levels of ANF but it had no effect on renal function or blood pressure. Treatment with calcium antagonists prior to arteriography with iopromide is not indicated in these patients.

Continuous monitoring of global left ventricular ejection fraction during percutaneous transluminal coronary angioplasty

Continuous monitoring of left ventricular (LV) function during percutaneous transluminal coronary angioplasty (PTCA) was performed in 40 patients (53 +/- 2 years) with a miniature, nuclear detector system after labeling the patients' red blood cells with technetium-99m. Balloon dilation (113 seconds, range 60 to 240) induced on average a 0.12 ejection fraction (EF) unit (19%) decrease in the LVEF, which was explained by a 34% increase in end-systolic counts. Balloon dilation of the left anterior descending artery (n = 23) produced a decrease in the LVEF of 0.17 +/- 0.13 EF units compared with the decrease of 0.06 +/- 0.07 EF units in patients undergoing dilation of the left circumflex artery (n = 9) and 0.05 +/- 0.04 EF units in patients treated for a stenosis of the right coronary artery (n = 8), (p = 0.02). Balloon deflation was associated with an immediate return to pre-PTCA levels. In 10 patients with 2 identical balloon occlusions, the second occlusion led to a significantly less decrease in the LVEF (0.41 +/- 0.14 vs 0.44 +/- 0.15) and electrocardiographic ST-segment deviation (88 +/- 54 microV vs 65 +/- 42 microV) than the first. We conclude that PTCA is associated with an abrupt transient decrease in the LVEF. The effect of balloon occlusion of the left anterior descending artery is more pronounced than balloon occlusion of the left circumflex and the right coronary arteries. Neither single nor multiple balloon occlusions were associated with post-PTCA global LV dysfunction, whereas the lesser degree of LV dysfunction and electrocardiographic signs of myocardial ischemia during the second of 2 identical balloon occlusions suggests that preconditioning can be induced during PTCA.

Significance and management of early graft failure after coronary artery bypass grafting: feasibility and results of acute angiography and re-re-vascularization

Perioperative ischaemia and infarction after CABG are associated with increased morbidity and mortality.

OBJECTIVE

To study causes of perioperative ischaemia and infarction by acute re-angiography and to treat incomplete re-vascularization caused by graft failure or any other cause.

METHODS

Between 1990 and 1995, 2003 patients underwent an isolated CABG operation. Myocardial ischaemia was suspected if one or more of the following criteria were present: New changes in the ST-segment in the ECG; a CKMB value greater than 80 U/L; new Q-waves in the ECG; recurrent episodes of, or sustained ventricular tachyarrhythmia; ventricular fibrillation; haemodynamic deterioration and left ventricular failure. Acute coronary angiography was performed in stable patients, while haemodynamically severely compromised patients were rushed to the operating room.

RESULTS

A total of 71 (3.5%) patients of all CABGs with suspected graft failure were identified and included in the study. Patients were grouped according to whether they had an acute re-angiography (n = 59; group 1) or an immediate re-operation (n = 12; group 2) performed. In group 1, the acute re-angiography demonstrated graft failure/incomplete re-vascularization in 43 patients (73%). The angiographic findings were: Occluded vein graft(s) in 19 (32%); poor distal run-off to the grafted coronary artery in ten (17%); internal mammary artery stenosis in four (7%); internal mammary artery occlusion in three (5%); vein graft stenoses in three (5%); left mammary artery subclavian artery steal in two (3%); and the wrong coronary artery grafted in one (2%). Based on the angiography findings, 27 patients were re-operated and re-grafted. At the time of re-operation, 18 patients (67%) had evolving infarction documented by ECG or CKMB. Two patients (3%) experienced stroke in immediate relation to the re-angiography. The 30-day mortality was three (7%). In group 2, graft occlusions were found in 11 patients (92%). The 30-day mortality was six (50%).

CONCLUSION

An acute re-angiography demonstrated graft failure or incomplete re-vascularization in the majority of patients with myocardial ischaemia early after CABG. Re-operation for re-re-vascularization was performed with low risk. Few patients with circulatory collapse could be saved by an immediate re-operation without preceding angiography.

Danish multicenter randomized study of invasive versus conservative treatment in patients with inducible ischemia after thrombolysis in acute myocardial infarction (DANAMI). DANish trial in Acute Myocardial Infarction

BACKGROUND

The aim of the DANish trial in Acute Myocardial Infarction (DANAMI) study was to compare an invasive strategy of percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) with a conservative strategy in patients with inducible myocardial ischemia who received thrombolytic treatment for a first acute myocardial infarction (AMI).

METHODS AND RESULTS

Of the 503 patients randomized to an invasive strategy, PTCA was performed in 266 (52.9%) and CABG in 147 (29.2%) from 2 to 10 weeks after the AMI. Of the 505 patients in the conservative treatment group, only 8 (1.6%) had been revascularized 2 months after the AMI. The patients were followed up from 1 to 4.5 years. The primary end points were mortality, reinfarction, and admission with unstable angina. At 2.4 years' follow-up (median), mortality was 3.6% in the invasive treatment group and 4.4% in the conservative treatment group (not significant). Invasive treatment was associated with a lower incidence of AMI (5.6% versus 10.5%; P=.0038) and a lower incidence of admission for unstable angina (17.9% versus 29.5%; P<.00001). The percentages of patients with a primary end point were 15.4% and 29.5% at 1 year, 23.5% and 36.6% at 2 years, and 31.7% versus 44.0% at 4 years (P=<.00001) in the invasive and conservative treatment groups, respectively. At 12 months, stable angina pectoris was present in 21% of patients in the invasive treatment group and 43% in the conservative treatment group.

CONCLUSIONS

Invasive treatment in post-AMI patients with inducible ischemia results in a reduction in the incidence of reinfarction, fewer admissions due to unstable angina, and lower prevalence of stable angina. We conclude that patients with inducible ischemia before discharge who have received treatment with thrombolytic drugs for their first AMI should be referred to coronary arteriography and revascularized accordingly.

Effects of the calcium antagonist felodipine on renal haemodynamics, tubular sodium handling, and blood pressure in cyclosporin-treated dermatological patients

BACKGROUND

Deterioration of renal function and rise in blood pressure are clinically important side-effects of cyclosporin (CsA) treatment. Calcium antagonists may have a renoprotective effect against CsA nephrotoxicity.

PURPOSE

To investigate the effect of the dihydropyridine calcium-channel blocker felodipine on renal haemodynamics, tubular sodium handling, and blood pressure in CsA-treated patients with no primary renal disease, 18 patients with various CsA-treated dermatological diseases were allocated to receive either felodipine 5 mg (extended release tablets) once daily for 4 weeks followed by placebo for 4 weeks, or vice versa, in a prospective, randomized, double-blind study. The patients were investigated before treatment and at the end of each treatment period.

RESULTS

After felodipine, both glomerular filtration rate (GFR) and renal plasma flow (RPF) were significantly higher compared to placebo (89.4 +/- 17.5 (mean +/- SD) vs 79.0 +/- 15.9 ml/min and 412.0 +/- 107.6 vs 326.1 +/- 78.0 ml/min respectively, P < 0.001 for both), and filtration fraction (FF) was lower (0.22 +/- 0.03 vs 0.25 +/- 0.03, P < 0.001). Both systolic and diastolic blood pressure were lower after felodipine compared to placebo (116 +/- 11/71 +/- 7 vs 133 +/- 18/83 +/- 10 mmHg, P < 0.001 for both). Furthermore, proximal output of sodium, i.e. fractional excretion of lithium, was higher after felodipine (26.9 +/- 7.3% vs 20.4 +/- 5.5%, P < 0.001) as well as total sodium excretion (0.33 +/- 0.19 vs 0.19 +/- 0.08 mmol/min, P < 0.001).

CONCLUSIONS

It is concluded, that felodipine 5 mg once daily for 4 weeks increased GFR, RPF, and sodium excretion in cyclosporin-treated dermatological patients with no primary renal disease. Furthermore, felodipine lowers blood pressure in these patients. The effects of felodipine may be due to an antagonizing effect against CsA-induced nephrotoxicity.

Metoprolol abolishes exercise-induced left ventricular dysfunction in patients with silent ischemia

Left ventricular systolic function is reduced during episodes of silent ischemia in patients with coronary artery disease (CAD). Left ventricular ejection fraction (LVEF) is increased at least 5 absolute percent during exercise in most normal subjects; however, in patients with CAD, LVEF often remains unchanged or decreases. The anti-ischemic effect of beta-adrenergic receptor blockade is well documented, including a reduction of exercise-induced electrocardiographic ST depressions; however, the effect of these drugs on left ventricular volume changes during exercise in patients with silent ischemia is unknown. The aim of this study was to evaluate the effect of a cardio-selective beta-blocking agent, metoprolol, on rest and exercise LVEF in patients with silent ischemia, using radionuclide cardiography. Fifteen patients with silent ischemia completed a double-blind, placebo-controlled crossover study at rest and during submaximal exercise. LVEF remained unchanged during exercise in the placebo phase (56% to 58%; p = NS), but even though LVEF tended to decrease 56% during rest after metoprolol versus 52% after placebo (p = NS), the LVEF increase from rest to exercise resembled a normal LVEF response, 52% to 58% (p = 0.005). Exercise-induced electrocardiographic ST depressions were also reduced during metoprolol treatment. In patients with silent ischemia, the exercise-induced change in LVEF rises significantly during metoprolol treatment. The mechanism may be a reduction in myocardial ischemia as indicated by a reduction in ischemic electrocardiographic findings.

Verapamil and angiotensin-converting enzyme inhibitors in patients with coronary artery disease and reduced left ventricular ejection fraction

Verapamil is effective as antianginal medication but contraindicated in patients with congestive heart failure. Angiotensin-converting enzyme (ACE) inhibitors improve survival in patients with congestive heart failure but have limited effect on patients with angina pectoris. No studies have been published on the combined treatment with verapamil and ACE inhibitors in patients with stable angina pectoris and left ventricular dysfunction. We performed an open study in 14 patients with angina pectoris and ejection fraction < 40%. The patients received verapamil 180 mg and trandolapril 2 mg twice daily for 3 months. We found a significant increase in ejection fraction from 28 +/- 6 to 35 +/- 11 (p < 0.03), wall motion index from 1.0 +/- 0.3 to 1.2 +/- 0.3 (p < 0.03), exercise duration from 6.9 +/- 2.5 to 7.7 +/- 2.9 minutes (p < 0.01), and ratio of exercise to rest rate-pressure product from 2.2 +/- 0.4 to 2.5 +/- 0.6 (p < 0.02). Use of nitroglycerin and number of angina pectoris attacks were both significantly reduced after 3 months of treatment. These findings support the hypothesis that the combination of verapamil and trandolapril is useful in patients with attenuated left ventricular function and angina pectoris.

Improvement in renal function by felodipine during cyclosporine treatment in acute and short-term studies

The purpose was to study whether the calcium entry blocker, felodipine, could reduce the nephrotoxic and hypertensive effect of cyclosporine. The effect of felodipine on glomerular filtration rate (GFR), renal plasma flow (RPF), fractional excretion of sodium, lithium clearance and blood pressure was measured in three randomized, placebo-controlled studies of cyclosporine treated patients. In study one, 10 renal transplant recipients were examined within the first six months after transplantation in a cross-over design. Renal hemodynamics were determined after the acute ingestion of felodipine or placebo, with an interval of less than one week between the two examinations. In study two, 79 renal transplant recipients were randomized to a treatment with felodipine or placebo just before transplantation, and renal hemodynamics were determined after twelve weeks. In study three, 18 patients, who were treated with cyclosporine due to dermatological diseases, were examined in a cross-over design to determine their renal hemodynamics after four weeks of treatment with felodipine or placebo. Felodipine increased renal hemodynamics in study one (GFR 16%, RPF 33%, P < 0.01 for both), in study two (GFR 23%, RPF 28%, P < 0.05 for both), and in study three (GFR 13%, RPF 26%, P < 0.01 for both). FE(Na) was significantly increased by felodipine in studies one and three, but not in study two. Lithium clearance was significantly increased and blood pressure significantly reduced by felodipine in all three studies. It can be concluded that felodipine counteracts both the cyclosporine induced impairment in renal hemodynamics and the increase in blood pressure in acute and short-term studies.

High prevalence of smoking in young patients with acute myocardial infarction

Of 35 patients with acute myocardial infarction (AMI) at the age of 40 years or less, 32 (91%) smoked and only three patients were non-smokers. The age at AMI related significantly to the extent of smoking (p < 0.001, Kruskall-Wallis test). Five patients with AMI at the age < 30 years smoked more heavily than the 30 with AMI at the age of 30-40 years (p = 0.04, Mann Whitney U test). Heavy smoking men > 30 years at the AMI had a Q-wave infarction as often (11 of 13 (85%)) as those with multivessel disease or a coronary artery occlusion (8 of 9 (89%) and 14 of 16 (88%) respectively) on coronary arteriography after the infarction. Smoking may be the most important modifiable risk factor in young patients with AMI.

Comparison of dose requirement, serum erythropoietin and blood pressure following intravenous and subcutaneous erythropoietin treatment of dialysis patients. IV and SC erythropoietin

OBJECTIVE

The purpose of the study was to investigate the effect of route of administration of erythropoietin (EPO) on the dose requirement in dialysis patients after intravenous (IV) and subcutaneous (SC) therapy.

METHODS

The study was performed as a single centre, prospective, open, combined parallel and cross-over study of 50 dialysis patients, consecutively randomised to IV or SC treatment with EPO. The initial dose was 49 U.kg-1 3-times weekly, adjusted to increase haemoglobin (Hgb) from a median 5.3 mmol.1(-1) to a target of haemoglobin 6.5-7.5 mmol.1(-1). After reaching the target level, the haemoglobin was maintained for 4 months (Period 1). Then IV and SC treatment was switched for a further 4 months (Period 2). The study included high risk patients. The adjustment period was completed by 38 patients, Period one by 32 patients (IV/SC = 15/17; male/female = 19/13; age = 54 (24- 71) y), and Period two by 22 patients.

RESULTS

No significant difference was found between the two groups in the reticulocyte response, the rate of Hgb increase (IV 0.7 versus SC 0.5, mmol.1(-1). month-1), time to reach target level (IV 43 versus SC 60 days), or total EPO dose per increase in haemoglobin to target level (IV 663 versus SC 946 (U.kg-1) per (mmol Hgb.1(-1)). The overall median maintenance dose during the last month of the two four month periods was 105 (range IV 51-336) U.kg-1.w-1 and SC 104 (range 21-321) U.kg-1.w-1. Through serum EPO levels were significantly higher during SC treatment. The blood pressure did not change significantly from the base level after either route of administration; start 133/80 versus 143/80 mmHg, target 127/78 versus 154/85 mmHg, and maintenance period 140/84 versus 142/85 mmHg. Thus, three-times weekly IV or SC EPO did not differ significantly in efficacy or in the effect on blood pressure in dialysis patients.

Pharmacokinetic interaction between cyclosporine and the dihydropyridine calcium antagonist felodipine

OBJECTIVE

In a double blind, randomised, placebo-controlled, cross-over study 12 healthy male volunteers were allocated to receive felodipine + placebo, cyclosporine + placebo, and felodipine + cyclosporine in order to investigate the interaction between the calcium channel blocker felodipine and cyclosporine as it affects the pharmacokinetics of felodipine, dehydrofelodipine, and cyclosporine, and 24-hour blood pressure measurements.

METHODS

Single doses of cyclosporine (capsules, 5 mg/kg body weight) and of felodipine (extended release (ER) tablets 10 mg) were given at a 1-2 week interval. Plasma drug concentrations were followed for 2 days after drug intake.

RESULTS

For cyclosporine, Cmax was increased after combined treatment (16%) compared to cyclosporine alone, but felodipine did not influence other kinetic parameters of cyclosporine. For felodipine, combined treatment with cyclosporine and felodipine increased AUC and Cmax (58% and 151%, respectively) and lowered mean residence time (24%) significantly compared to felodipine alone. For the metabolite dehydrofelodipine, too, AUC and Cmax were increased after the combined treatment (43% and 94%, respectively). Mean 24-hour systolic and diastolic blood pressures were significantly lower after felodipine, both when felodipine was given alone (121/68 mmHg) and in combination with cyclosporine (122/68 mmHg) compared to cyclosporine alone (127/73 mmHg).

CONCLUSION

A combined single dose of cyclosporine and felodipine in healthy subjects increased the AUC and Cmax of felodipine suggesting a cyclosporine-induced decrease in the first-pass metabolism of felodipine, whereas the AUC of cyclosporine was only slightly increased by felodipine.

Effect of felodipine on renal haemodynamics and tubular sodium handling after single-dose cyclosporin infusion in renal transplant recipients treated with azathioprine and prednisolone

A total of 25 renal transplant recipients, treated solely with prednisolone and azathioprine, were investigated in a randomized, double-blind, placebo-controlled, cross-over study. The effect of a single oral dose of felodipine 5 mg or placebo on: glomerular filtration rate (GFR); renal plasma flow (RPF); renal vascular resistance (RVR); renal tubular sodium and water handling, measured by the lithium clearance technique; plasma levels of angiotensin II (AngII), aldosterone (Aldo), atrial natriuretic factor (ANF) and arginine vasopressin (AVP); blood pressure (BP), and heart rate (HR) was studied before, during, and after an intravenous infusion of cyclosporin (CyA). Three consecutive clearance periods were performed, each lasting 1 h. During the second period, CyA (0.75 mg kg-1 body weight) was infused. Before infusion of CyA, felodipine caused a significant rise (6.7%) in RPF and lowered RVR, but did not change GFR significantly. The rise in RPF was abolished by infusion of CyA. After infusion, both GFR (7.8%) and RPF (9.4%) were significantly higher and RVR lower after felodipine than after placebo. Proximal tubular output and total sodium excretion were higher on the felodipine day before and after, but not during CyA infusion. In all three periods felodipine reduced both systolic and diastolic BP. In conclusion, a single dose of felodipine increases RPF and decreases blood pressure in renal transplant recipients not treated with CyA. Although some of these changes are abolished by an acute intravenous infusion of CyA, the effects of felodipine are present again also during the 1st hour after the infusion and thereby indicate at least in part some renal protective effect of felodipine. It is suggested that a higher dose of felodipine might also have been preventive against CyA renal side-effects during the acute infusion.

[10-year mortality of patients admitted to coronary units with or without confirmed diagnosis of myocardial infarction. A relation to anamnesis and diagnosis at discharge]

The ten-year mortality in patients with suspected myocardial infarction with (AMI) and without (non-AMI) confirmed diagnosis was evaluated in 1897 non-AMI patients and 1401 AMI patients who were consecutively admitted to hospital during The Danish Verapamil Infarction Study. The following risk factors contained independent prognostic information about mortality for non-AMI patients: age, previous AMI, sex and diabetes. In patients with AMI the risk factors were: age, previous AMI, clinical heart failure, diabetes and angina pectoris. When the diagnosis at discharge for non-AMI patients was included in the Cox-analysis, only the diagnoses of bronchopneumonia, musculoskeletal disorders and observation only of added prognostic information. We conclude that non-AMI patients are at high risk for mortal events in the long-term. High risk patients can be identified from the medical history and should be carefully evaluated regarding coronary artery disease at the time of discharge in order to improve the risk stratification, treatment and prognosis.

[Should silent ischemia be diagnosed and treated?]

Silent ischaemia (objective signs of myocardial ischaemia without symptoms) can be diagnosed using a conventional exercise-test or ambulatory Holter monitoring. Silent ischaemia is a frequent phenomenon in patients with ischaemic heart disease, i.e. patients with angina pectoris or previous myocardial infarction. The reason why ischaemia is symptomatic in some cases, and asymptomatic in others is unknown. Different possible mechanisms are discussed. Myocardial ischaemia, symptomatic or not is accompanied by a compromised function of the left ventricle, including reduced ejection fraction during exercise. In selected groups of patients, silent ischaemia is related to an impaired prognosis, while it does not seem to carry any prognostic information in other groups of patients. Silent ischaemia can be treated/reduced using antianginal medication or revascularization, but for the time being it is not known if treatment can improve prognosis. Studies concerning the latter are under way.

The metabolism of erythropoietin in liver cirrhosis patients compared with healthy volunteers

The purpose of the investigation was to study the metabolism of erythropoietin (EPO) in patients with liver disease. Twelve patients with liver cirrhosis and 10 healthy volunteers were studied. The patients were moderately anemic with a hematocrit of 33 vs 42% (medians) in the volunteers. The pharmacokinetic parameters were calculated after an intravenous (i.v.) injection of 100 U/kg of recombinant human EPO. The serum EPO was measured by radioimmunoassay at regular intervals until 48 h. The median terminal elimination half life in the cirrhosis patients was 5.15 h vs 5.37 h in the control subjects. The clearance was 7.78 vs 7.52 ml/min/1.73 m2 (ns). The steady-state volume of distribution was 3.69 vs 3.09 1/1.73 m2 (ns). The estimated endogenous EPO production was significantly higher in liver cirrhosis (486 vs 290 U/d/1.73m2, p < 0.01). The basal serum EPO was significantly higher in the cirrhosis patients (43.5 vs 26.3 U/l, p < 0.01). The hematocrit correlated inversely with the basal serum EPO level in the cirrhosis patients (r = -0.63, p < 0.04). The EPO-clearance was not related to the presence of ascites, esophageal varices, or to abnormal blood chemistry. It was concluded that normal metabolism of EPO was maintained in liver cirrhosis and that the cirrhotic patients had a moderate compensatory increase of EPO production in response to anemia.

Long-term risk factors from non-invasive evaluation of patients with acute chest pain, but without myocardial infarction

The aims were to identify long-term risk factors for cardiac events, i.e. cardiac death and non-fatal acute myocardial infarction (AMI), and for development of angina pectoris among patients admitted with acute chest pain, but without confirmed AMI (non-AMI). A total of 257 consecutive non-AMI patients without other severe disease and below 76 years of age were included. Medical history and variables from the ECG while exercising, thallium scintigrams, Holter-monitoring, echocardiography and chest X-ray were recorded. The patients were followed for 7 years regarding cardiac death, non-fatal AMI and development of angina pectoris. The variables recorded at admission were compared to follow-up results by means of Uni- and multivariate analyses. During follow-up, 69 cardiac events, 44 cardiac deaths and 25 non-fatal AMIs occurred. The following variables provided independent prognostic information (relative risk factors with 95% confidence limits in brackets): age (1.05, 1.01-1.09), abnormal ECG at rest (2.81, 1.33-5.90), low increase in rate pressure product (4.57, 2.21-9.44), multiform premature ventricular beats (VPB) (2.61, 1.34-5.09) and transient thallium defects (2.64, 1.33-5.24). Sub-analysis of patients with and without a history of coronary artery disease (CAD) prior to admission identified the following risk factors: (1) Patients with previous CAD: abnormal ECG on admission, low increase in rate pressure product, ST depression during exercise. (2) Patients without previous CAD: abnormal ECG at rest, multiform VPBs and low increase in rate pressure product. Development of angina pectoris during follow-up of patients without previous CAD could not be predicted by any of the variables.(ABSTRACT TRUNCATED AT 250 WORDS)

Short-term effects of captopril on exercise tolerance in patients with chronic stable angina pectoris and normal left ventricular function

A double-blind, placebo-controlled, crossover study was carried out to evaluate the short-term effects of captopril on exercise tolerance in 18 normotensive patients with chronic stable angina pectoris and normal left ventricular function. Captopril 25 mg (or placebo) was given twice, i.e. in the evening (10 p.m.) and the following morning (8 a.m.), prior to a maximal symptom-limited bicycle exercise test (11 a.m.). Captopril reduced the systolic and diastolic blood pressures at rest (p < 0.01) without causing any reflex tachycardia. The time to onset of S-T depression was prolonged (p < 0.05), and the maximal S-T depression was reduced (p < 0.02). No differences were found between captopril and placebo in total exercise duration or time to onset of angina. The effects of captopril on exercise-induced ischemia were demonstrated most clearly in patients who responded with a greater than 10 mm Hg fall in the resting systolic blood pressure. In conclusion, this study suggests that captopril has anti-ischemic properties, which may be of importance in the treatment of patients with chronic stable angina and normal left ventricular function. These beneficial effects probably relate to a reduction in afterload and myocardial wall stress and therefore a reduction in myocardial oxygen demand.

Reduced production, absorption, and elimination of erythropoietin in uremia compared with healthy volunteers

The purpose of this study was to investigate the metabolism of erythropoietin (EPO) in uremia compared with healthy subjects. Twenty-one patients (nine men and 12 women) with end-stage renal failure and anemia and 12 healthy volunteers (3 women and nine men) were studied. The pharmacokinetic parameters were calculated after an i.v. and a femoral sc injection of 100 U/kg of recombinant human EPO. The serum EPO (s-EPO) was measured by radio-immunoassay at regular intervals until 48 h (i.v.) and 120 h (sc). In uremia, the median terminal elimination half-life was significantly longer (8.31 versus 4.92 h; P < 0.001) and the clearance was reduced (5.00 versus 7.88 mL/min per 1.73 m2; P < 0.01). The volume of distribution was (3.70 versus 3.31 L/1.73 m2) not significant. The estimated endogenous EPO production was significantly lower in uremia (146 versus 290 U/day per 1.73 m2; P < 0.001). After sc administration, the bioavailability was significantly lower in the patients (23.7 versus 38.5%; P < 0.01), and the maximal s-EPO was lower (113 versus 153 U/L; P < 0.05) and delayed (15.4 versus 11.0 h; P < 0.02), but the mean input time (sc) was not significantly different (23.3 versus 27.8 h). The basal s-EPO was lower in the uremic patients (20.0 versus 26.3 U/L; P < 0.05). There was no difference between patients treated with hemodialysis and peritoneal dialysis or between uremic men and women. There was no correlation between the pharmacokinetic parameters and age.(ABSTRACT TRUNCATED AT 250 WORDS)

[The effect of thrombolytic therapy on the outcome of early exercise test in patients with acute myocardial infarction]

Exercise test variables, such as an impaired heart rate response, are known to be related to left ventricular function and patient prognosis following acute myocardial infarction. The present study was performed to compare exercise test variables in acute myocardial infarct patients following either intravenous thrombolysis or placebo. Symptom-limited bicycle ergometer tests, carried out one to two weeks from the infarction, were performed in 85 patients randomized to intravenous streptokinase (n = 41) or placebo (n = 44) given within 12 hours from onset of symptoms. Resting heart rate, systolic blood pressure and rate-pressure product were similar in the two groups. At maximum workload the streptokinase treated patients had a significantly higher median maximal heart rate than controls (136 vs. 126 min-1; p < 0.01) but only a trend towards higher systolic blood pressure was seen (175 vs. 163 mmHg; p = 0.09). Rate-pressure product at maximal exercise was 23.620 vs. 20.100 mmHg x min-1; p < 0.01). A significantly smaller number of patients in the streptokinase group had exercise capacity below 50 W (0% vs. 15.9%; p < 0.01).

IN CONCLUSION

patients treated with intravenous streptokinase for acute myocardial infarction reach both higher heart rates and rate-pressure products at maximum workload than their controls thus indicating that the beneficial effects of thrombolysis after acute myocardial infarction are reflected in an improved heart rate response during exercise.