Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared With Usual Care

BACKGROUND

Increased involvement of pharmacists in patient care may increase access to health care and improve patient outcomes.

PURPOSE

To determine the effectiveness and harms of pharmacist-led chronic disease management for community-dwelling adults.

DATA SOURCES

MEDLINE, Cochrane Library, CINAHL, and International Pharmaceutical Abstracts from 1995 through February 2016, and reference lists of systematic reviews and included studies.

STUDY SELECTION

65 patient populations in 63 studies conducted in the United States of any design reported outcomes of pharmacist-led chronic disease management versus a comparator for community-dwelling adults in the United States. Studies set in retail pharmacies were excluded.

DATA EXTRACTION

Data extraction done by a single investigator was confirmed by a second investigator; risk of bias was assessed by 2 investigators; and strength of evidence was determined by consensus.

DATA SYNTHESIS

Pharmacist-led care was associated with similar numbers of office visits, urgent care or emergency department visits, and hospitalizations (moderate-strength evidence) and medication adherence (low-strength evidence) compared with usual care (typically continuing a prestudy visit schedule). Pharmacist-led care increased the number or dose of medications received and improved study-selected glycemic, blood pressure, and lipid goal attainment (moderate-strength evidence). Mortality and clinical events were similar (low-strength evidence). Evidence on patient satisfaction was mixed and insufficient. The reporting of harms was limited.

LIMITATIONS

Interventions were heterogeneous. Studies were typically short-term and designed to assess physiologic intermediate outcomes rather than clinical events. Reporting of many clinical outcomes of interest was limited, and often they were not the study-defined primary end points.

CONCLUSION

Pharmacist-led chronic disease management was associated with effects similar to those of usual care for resource utilization and may improve physiologic goal attainment. Further research is needed to determine whether increased medication utilization and goal attainment improve clinical outcomes.

PRIMARY FUNDING SOURCE

Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative.

Use of Bristol Stool Form Scale to predict the adequacy of bowel preparation - a prospective study

AIM

Inadequate bowel preparation continues to be a substantial problem for colonoscopy. The seven-point Bristol Stool Form Scale (BSFS) has been associated with delayed colonic transit in adults. We evaluated the utility of the BSFS to identify patients more likely to present with an inadequate preparation.

METHOD

Two large community-based academic medical centres in New Jersey, USA, studied a prospective cohort of 411 consecutive patients undergoing outpatient colonoscopy who were prescribed similar bowel preparations. The BSFS and several other study variables were collected by gastroenterology fellows during an outpatient visit prior to scheduling colonoscopy. All colonoscopy examinations were performed in the morning by a gastroenterologist who graded the adequacy of bowel preparation. Inadequate preparation was defined as one resulting in a repeat colonoscopy at a shorter time interval than would generally be recommended based solely on risk factors or pathological findings. The ability of study variables to discriminate those who did or did not have an adequate preparation was summarized by the c-statistic. The relationship between variables that provided some discrimination and the probability of an adequate preparation was modelled using logistic regression.

RESULTS

The mean age of the study sample was 56 ± 8 (SD) years and 63% were women. Bowel preparation was adequate in 337 (82%) of the patients. The BSFS ratings ranged from 1 to 7. The score was <3 in 144 (35%) indicating lower gastrointestinal motility. There was a statistically significant association between the score and the probability of an adequate bowel preparation (odds ratio 1.4; 95% confidence interval 1.2-1.7; P < 0.001) and the c-statistic was 0.64 (0.58-0.70).

CONCLUSION

Use of the BSFS may help identify patients for whom standard bowel preparation most probably will not be adequate.

All-cause hospitalizations for inflammatory bowel diseases: Can the reason for admission provide information on inpatient resource use? A study from a large veteran affairs hospital

BACKGROUND

Inflammatory bowel diseases (IBDs) are group of chronic inflammatory illnesses with a remitting and relapsing course that may result in appreciable morbidity and high medical costs secondary to repeated hospitalizations. The study's objectives were to identify the reasons for hospitalization among patients with inflammatory bowel diseases, and compare inpatient courses and readmission rates for IBD-related admissions versus non-IBD-related admissions.

METHODS

A retrospective chart review was performed on all patients with IBD admitted to the Minneapolis VA Medical Center between September 2010 and September 2012.

RESULTS

A total of 111 patients with IBD were admitted during the 2-year study period. IBD flares/complications accounted for 36.9 % of the index admissions. Atherothrombotic events comprised the second most common cause of admissions (14.4 %) in IBD patients. Patients with an index admission directly related to IBD were significantly younger and had developed IBD more recently. Unsurprisingly, the IBD admission group had significantly more gastrointestinal endoscopies and abdominal surgeries, and was more likely to be started on medication for IBD during the index stay. The median length of stay (LOS) for the index hospitalization for an IBD flare or complication was 4 (2-8) days compared with 2 (1-4) days for the other patients (P = 0.001). A smaller percentage of the group admitted for an IBD flare/complication had a shorter ICU stay compared with the other patients (9.8 % vs. 15.7 %, respectively); however, their ICU LOSs tended to be longer (4.5 vs. 2.0 days, respectively, P = 0.17). Compared to the other admission types, an insignificantly greater percentage of the group whose index admission was related to an IBD flare or complication had at least one readmission within 6 months of discharge (29 % versus 21 %; P = 0.35). The rate of admission was approximately 80 % greater in the group whose index admission was related to an IBD flare or complication compared to the other types of admission (rate ratio 1.8, 95 % confidence interval 0.96 to 3.4), although this difference did not reach statistical significance (P = 0.07).

CONCLUSION

Identifying the reasons for the patients' index admission, IBD flares versus all other causes, may provide valuable information concerning admission care and the subsequent admission history.

Are there racial/ethnic disparities in VA PTSD treatment retention?

BACKGROUND

Chronic posttraumatic stress disorder (PTSD) can result in significant social and physical impairments. Despite the Department of Veterans Affairs' (VA) expansion of mental health services into primary care clinics to reach larger numbers of Veterans with PTSD, many do not receive sufficient treatment to clinically benefit. This study explored whether the odds of premature mental health treatment termination varies by patient race/ethnicity and, if so, whether such variation is associated with differential access to services or beliefs about mental health treatments.

METHODS

Prospective national cohort study of VA patients who were recently diagnosed with PTSD (n = 6,788). Self-administered surveys and electronic VA databases were utilized to examine mental health treatment retention across racial/ethnic groups in the 6 months following the PTSD diagnosis controlling for treatment need, access factors, age, gender, treatment beliefs, and facility factors.

RESULTS

African American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and African American Veterans were less likely to receive a minimal trial of any treatment in the 6 months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino but not African American Veterans. Access factors did not contribute to treatment retention disparities.

CONCLUSIONS

Even in safety-net healthcare systems like VA, racial and ethnic disparities in mental health treatment occur. To improve treatment equity, clinicians may need to more directly address patients' treatment beliefs. More understanding is needed to address the treatment disparity for African American Veterans.

Impact of treatment beliefs and social network encouragement on initiation of care by VA service users with PTSD

OBJECTIVES

Despite the U.S. Department of Veterans Affairs' (VA) expansion of mental health services to treat VA service users with posttraumatic stress disorder (PTSD), many with PTSD do not engage in treatment. Numerous studies suggest that beliefs about treatment and social network factors, such as encouragement to seek treatment by others, affect engagement; however, prospective studies examining these factors are largely absent in this population. This study sought to understand social and attitudinal factors influencing treatment initiation, which may help to inform outreach interventions for VA service users with PTSD.

METHODS

A prospective, national cohort study of mental health care use among veterans recently diagnosed as having PTSD (N=7,645) was undertaken. Data from self-administered surveys and administrative databases were analyzed to assess contributions of treatment-related beliefs and social network encouragement to subsequent mental health care use, after facility, demographic, need, and access factors were controlled.

RESULTS

After the analysis controlled for treatment need and accessibility, the odds of initiating mental health care were greater for veterans who believed that they needed help for PTSD or other emotional problems and those who were encouraged to seek help by friends and family. Beliefs about the effectiveness of PTSD treatments were associated with the type of treatment received. Negative illness identity was not a barrier to treatment initiation.

CONCLUSIONS

VA service users' social networks, veterans' perceptions of their need for mental health care, and their beliefs about PTSD treatment effectiveness may be fruitful targets for future treatment engagement interventions.

Synchronous and metachronous malignancies: analysis of the Minneapolis Veterans Affairs (VA) tumor registry

PURPOSE

Multiple primary malignancies (MPMs) are increasing as cancer survivorship improves. A large analysis of the SEER database estimates that approximately 16 % of new cancers reported to their registry represent a second or higher order malignancy. The purpose of this study is to estimate the number of MPM diagnoses and to define differences in synchronous and metachronous cancers in the Veterans Affairs (VA) population.

METHODS

The primary objective of this study was to determine the proportion of second or higher order cancers diagnosed at the Minneapolis VA Medical Center from 1 January 2005 to 31 December 2009. The secondary objectives were to analyze and compare correlative demographic, exposure, clinical, and tumor data among those with synchronous and metachronous malignancies. We included any patient with a diagnosis of a malignant cancer during the study period.

RESULT

A total of 4,449 patients were diagnosed with malignancies during the study period. Of these, 506 patients (11.4 % of cancer diagnoses) had a diagnosis of a second or higher order malignancy. Of the 506 patients, 124 (24.3 %) had synchronous malignancies and 383 (75.5 %) had metachronous malignancies. The most common malignancy pairing was prostate cancer with bladder/ureter cancer (12 %) of MPM diagnoses. Differences between patients with synchronous and metachronous second occurrences were identified.

CONCLUSION

Multiple primary malignancies are a growing area of interest in cancer survivorship. At our institution, approximately 1 in 9 new cancer diagnoses during the 5-year study period represented second-order malignancies. Our data suggest that the VA population is at risk of developing second primary cancers. Further analysis of this population to identify unique risk factors is warranted.

Management of hyperglycemia, dyslipidemia, and albuminuria in patients with diabetes and CKD: a systematic review for a KDOQI clinical practice guideline

BACKGROUND

In 2007, the National Kidney Foundation (NKF) published clinical practice guidelines and recommendations for treating patients with diabetes and kidney diseases. Given recent studies that may enhance our understanding of the benefits and harms of glycemic, lipid, and albuminuria management in patients with diabetes and chronic kidney disease (CKD), the NKF commissioned a systematic review to evaluate data on the management of these patients.

STUDY DESIGN

Systematic review and evidence synthesis.

SETTING & POPULATION

Patients with type 1 or 2 diabetes with or without CKD.

SELECTION CRITERIA FOR STUDIES

English-language publications indexed in the MEDLINE database from January 2003 to October 2010, as well as cited references in these publications and publications identified after consultation with the NKF Diabetes Work Group were screened. Randomized controlled trials providing evidence for the management of hyperglycemia, dyslipidemia, and albuminuria in individuals with diabetes were included.

INTERVENTIONS

(1) Intensive glycemic control; (2) lipid management; (3) interventions aimed at prevention of incident albuminuria and/or progression of albuminuria in normotensive patients.

OUTCOMES

For all interventions, all-cause mortality was the primary outcome and secondary clinical outcomes included death from cardiovascular causes, incident kidney failure, and nonfatal cardiovascular events. Intermediate outcomes included changes in albuminuria and measures of kidney function. For intensive glycemic control only, severe and mild hypoglycemia were secondary and intermediate outcomes, respectively.

RESULTS

5 studies (n=27,159) assessed the impact of intensive versus conventional glycemic control strategies on clinical outcomes in type 2 diabetes. Intensive glycemic control reduced the development of micro- and macroalbuminuria, but did not reduce the incidence of primary or secondary clinical outcomes and was associated with a 2.5-fold increase in severe hypoglycemia. 11 studies (n=7,539) assessed lipid management. Statins did not reduce all-cause mortality or stroke compared to placebo in adults with diabetes and CKD. Fenofibrate increased regression of microalbuminuria to normoalbuminuria compared to placebo. 3 studies reported inconsistent effects of different angiotensin II receptor blockers on the incidence of microalbuminuria, and one study reported that telmisartan reduced macroalbuminuria in normotensive participants. No study demonstrated a benefit on primary or secondary clinical outcomes.

LIMITATIONS

Patients with CKD constituted a subgroup in most studies. Substantial heterogeneity with respect to population, interventions, outcome measures, and duration of follow-up.

CONCLUSIONS

Intensive glycemic control and lipid interventions did not improve clinical outcomes in patients with type 2 diabetes. Although interventions typically improved albuminuria, evidence was insufficient to determine whether treatment of albuminuria in normotensive patients provides beneficial effects on clinical outcomes. More intensive clinical management of patients with diabetes and CKD has inherent risks, including severe hypoglycemia, which should be considered when formulating treatment strategies.

Digoxin use and heart failure outcomes: results from the Valsartan Heart Failure Trial (Val-HeFT)

Several retrospective studies have raised concerns regarding digoxin therapy in select subgroups of heart failure patients. To assess the impact of digoxin therapy on outcomes in the current era of heart failure therapy, the authors analyzed data representing 5010 patients enrolled in the Valsartan Heart Failure Trial (Val-HeFT) to examine the relationship of baseline digoxin use and all-cause mortality, first morbid event, and heart failure hospitalizations. At baseline, 3374 patients (67%) were receiving digoxin therapy and 1636 (33%) were not. Patients receiving digoxin had features of worse heart failure with higher New York Heart Association class and lower blood pressure, ejection fraction, and β-blocker use (32.1% vs 40.8%). Digoxin use was associated with worse mortality (21.1 vs 15.0%, P<.001), first morbid event (34.6 vs 21.7, P<.001), and HF hospitalization rate (19.1 vs 10.1%, P<.001). After adjustment for baseline group differences including medical therapy and baseline rhythm, patients receiving digoxin remained at a higher risk for all-cause mortality (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.05-1.57), first morbid event (HR, 1.35; 95% CI, 1.15-1.59), and heart failure hospitalization (HR, 1.41; 95% CI, 1.12-1.78). These results remained materially unchanged with propensity matched analysis. No benefit with digoxin use was observed in this study, underscoring the need to reassess the role of digoxin in the contemporary management of heart failure.

Meeting KDOQI guideline goals at hemodialysis initiation and survival during the first year

BACKGROUND AND OBJECTIVES

To determine, in a national cohort of incident hemodialysis patients, whether meeting a greater number of National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guideline goals at dialysis initiation was independently associated, in a graded manner, with lower first-year mortality rates.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients who initiated hemodialysis between June 1, 2005, and May 31, 2007, in the US were included in this retrospective cohort analysis. Guidelines examined were (1) use of arteriovenous fistula or graft at initiation; (2) hemoglobin > or = 11 g/dl; and (3) albumin at goal. The primary predictor variable was number of guideline goals (zero, one, two, or three) met at dialysis initiation. Cox regression analysis was used to compare time to death, adjusting for baseline characteristics.

RESULTS

At dialysis initiation, 59%, 31%, 9%, and 1.6% of patients met zero, one, two, or three guideline goals, respectively (total n = 192,307). After multivariate adjustment, mortality hazard ratios (95% confidence intervals) were 0.81 (0.80 to 0.83) for patients who met one, 0.53 (0.51 to 0.56) for patients who met two, and 0.34 (0.30 to 0.39) for patients who met three guideline goals, compared with patients who met none. Meeting each individual goal was also associated with lower mortality.

CONCLUSIONS

These findings suggest a graded association between meeting a greater number of evidence-based guideline goals at dialysis initiation and lower risk of death during the first year on dialysis.

Prognostic significance of elevated cardiac troponin I after heart surgery

BACKGROUND

Cardiac troponin I (cTnI) measured after heart surgery has been associated with operative mortality. We sought to determine whether measuring cTnI after heart surgery provides additional prognostic information beyond that provided by validated preoperative risk scores, the Veterans Affairs (VA) risk score and the European System for Cardiac Operative Risk Evaluation (EuroSCORE).

METHODS

We retrospectively collected cTnI levels measured 24 hours after surgery in 1,186 patients who underwent coronary artery bypass graft surgery (n = 696) or valve surgery (n = 490). The outcomes were operative death and perioperative myocardial infarction. The ability of the cTnI and the risk scores to discriminate patients who did or did not have the study outcomes was assessed by the area under the receiver operating curve (c-index).

RESULTS

Mean age was 66 +/- 10 years. Median cTnI was 38 ng/mL after valve surgery versus 18 ng/mL after coronary artery bypass graft surgery (p < 0.0001). There were 51 operative deaths (4.3%) and 142 perioperative myocardial infarctions (12%). For every 50 ng/mL increase in cTnI, the odds of operative death increased by 40% (odds ratio, 1.4; 95% confidence interval: 1.2 to 1.6) after coronary artery bypass graft surgery and by 30% (odds ratio, 1.3; 95% confidence interval: 1.1 to 1.5) after valve surgery. Cardiac troponin I was a significant independent correlate of perioperative myocardial infarction and death (p < 0.0001) with a c-index of 0.70 for death. Addition of cTnI improved the c-indexes of the risk scores for predicting death (from 0.75 to 0.79 for the VA risk score; p = 0.1; and from 0.69 to 0.77 for the EuroSCORE; p = 0.005).

CONCLUSIONS

Postoperative cTnI measured 24 hours after heart surgery is independently associated with operative death and perioperative myocardial infarction and improves the ability to predict operative mortality in comparison with preoperative risk scores alone.

Does Quality of Care for Cardiovascular Disease and Diabetes Differ by Gender for Enrollees in Managed Care Plans?

PURPOSE

To assess gender differences in the quality of care for cardiovascular disease and diabetes for enrollees in managed care plans.

METHODS

We obtained data from 10 commercial and 9 Medicare plans and calculated performance on 6 Health Employer Data and Information Set (HEDIS) measures of quality of care (beta-blocker use after myocardial infarction [MI], low-density lipoprotein cholesterol [LDL-C] check after a cardiac event, and in diabetics, whether glycosylated hemoglobin [HgbA1c], LDL cholesterol, nephropathy, and eyes were checked) and a 7th HEDIS-like measure (angiotensin-converting enzyme [ACE] inhibitor use for congestive heart failure). A smaller number of plans provided HEDIS scores on 4 additional measures that require medical chart abstraction (control of LDL-C after cardiac event, blood pressure control in hypertensive patients, and HgbA1c and LDL-C control in diabetics). We used logistic regression models to adjust for age, race/ethnicity, socioeconomic status, and plan.

MAIN FINDINGS

Adjusting for covariates, we found significant gender differences on 5 of 11 measures among Medicare enrollees, with 4 favoring men. Similarly, among commercial enrollees, we found significant gender differences for 8 of 11 measures, with 6 favoring men. The largest disparity was for control of LDL-C among diabetics, where women were 19% less likely to achieve control among Medicare enrollees (relative risk [RR] = 0.81; 95% confidence interval [CI] = 0.64-0.99) and 16% less likely among commercial enrollees (RR = 0.84; 95%CI = 0.73-0.95).

CONCLUSION

Gender differences in the quality of cardiovascular and diabetic care were common and sometimes substantial among enrollees in Medicare and commercial health plans. Routine monitoring of such differences is both warranted and feasible.

C-Reactive Protein in Heart Failure

Background— The role of C-reactive protein (CRP) in heart failure is not well studied. We assessed the prognostic value of CRP in patients randomized in Val-HeFT (Valsartan Heart Failure Trial) and studied changes in CRP that were associated with valsartan.

Methods and Results— Characteristics of patients with baseline CRP levels above and below the median value were compared. Univariable and multivariable Cox proportional hazards regression models were used to examine the relationship of CRP to mortality and morbidity. Interactions were tested to determine whether differences in CRP changes from baseline to 4 and 12 months between groups randomly assigned to valsartan or placebo depended on baseline ACE inhibitor use. Median plasma CRP was 3.23 mg/L (interquartile range 1.42 to 7.56 mg/L), which is higher than in the general population. Patients with CRP above the median had features of more severe heart failure than those with CRP levels below the median. The cumulative likelihood of death and first morbid event increased with increasing quartile of CRP. Relative to the lowest CRP quartile, the risk of mortality (hazard ratio 1.51, 95% CI 1.2 to 1.9) and first morbid event (hazard ratio 1.53, 95% CI 1.28 to 1.84) was increased in the highest CRP quartile in multivariable models. CRP added incremental prognostic information to that provided by brain natriuretic peptide alone. CRP did not change significantly over time in the placebo group; however, after 12 months, valsartan was associated with a decrease in CRP in patients not receiving ACE inhibitors but not in those receiving ACE inhibitors at 12 months.

Conclusions— CRP is increased in heart failure. Higher levels are associated with features of more severe heart failure and are independently associated with mortality and morbidity. The ability of treatments to reduce CRP levels and the prognostic importance of reducing CRP require further study.

Use of geocoding in managed care settings to identify quality disparities

Tracking quality-of-care measures is essential for improving care, particularly for vulnerable populations. Although managed care plans routinely track quality measures, few examine whether their performance differs by enrollee race/ethnicity or socioeconomic status (SES), in part because plans do not collect that information. We show that plans can begin examining and targeting potential disparities using indirect measures of enrollee race/ethnicity and SES based on geocoding. Using such measures, we demonstrate disparities within both Medicare+Choice and commercial plans on Health Plan Employer Data and Information Set (HEDIS) measures of diabetes and cardiovascular care, including instances in which race/ethnicity and SES have distinct effects.

Consensus statement: Palliative and supportive care in advanced heart failure

BACKGROUND

A consensus conference was convened to define the current state and important gaps in knowledge and needed research on "Palliative and Supportive Care in Advanced Heart Failure."

EVIDENCE

Evidence was drawn from expert opinion and from extensive review of the medical literature, evidence-based guidelines, and reviews.

CONCLUSIONS

The conference identified gaps in current knowledge, practice, and research relating to prognostication, symptom management, and supportive care for advanced heart failure (HF). Specific conclusions include: (1) although supportive care should be integrated throughout treatment of patients with advanced HF, data are needed to understand how to best decrease physical and psychosocial burdens of advanced HF and to meet patient and family needs; (2) prognostication in advanced HF is difficult and data are needed to understand which patients will benefit from which interventions and how best to counsel patients with advanced HF; (3) research is needed to identify which interventions improve quality of life and best achieve the outcomes desired by patients and family members; (4) care should be coordinated between sites of care, and barriers to evidence-based practice must be addressed programmatically; and (5) more research is needed to identify the content and technique of communicating prognosis and treatment options with patients with advanced HF; physicians caring for patients with advanced HF must develop skills to better integrate the patient's preferences into the goals of care.

Incidence of Secondary Stroke and Myocardial Infarction Based on Managed Care Administrative Data

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Background: Little data exist on the incidence of subsequent acute ischemic events in persons with established atherosclerotic vascular disease in managed care plans. Objective: To estimate the incidence of secondary stroke and myocardial infarction (MI) over 3 years. Methods: Patients were identified as having atherosclerotic vascular disease (either stroke, MI, or peripheral arterial disease {PAD}) using administrative data from 11 UnitedHealthcare plans (3 with Medicare) from 1995–98. The stroke cohort includes patients ≥ 40 years old hospitalized with a primary or secondary ICD-9-CM code of either 434 or 436, and length of stay ≥ 1 day. Patients with a carotid endarterectomy or claims consistent with cardioembolic strokes were excluded. Persons age ≥ 40 with a primary ICD-9-CM code of 410 and a length of stay ≥ 2 days were included in the MI cohort. The PAD cohort included patients ≥ 40 with a hospital admission or an office visit with an ICD-9-CM code of 440.2x or 440.3. Cumulative incidences of subsequent stroke or MI were estimated for each cohort using Kaplan-Meier survival analysis. Results: For stroke, MI, and PAD cohorts, 3527 (49% Medicare), 9039 (26% Medicare), and 10,925 (46% Medicare) members were identified, respectively. Nearly 96% of MI and 89% of stroke patients were discharged alive. During an average follow-up period of 12 months in the stroke cohort, the cumulative incidences of stroke or MI were 4%, 7%, 12% and 14% at 0.5, 1, 2, and 3 years, respectively. Incidences in the MI cohort were 4%, 6%, 8% and 11% at 0.5, 1, 2, and 3 years (mean follow-up=15 months). In the PAD cohort with a mean follow-up of 15 months, the cumulative percentages with subsequent AMI or stroke were 2%, 3%, 5% and 8% after 0.5, 1, 2, and 3 years. Stroke accounted for 79%, 16%, and 39% of the secondary events in the stroke, MI, and PAD cohorts, respectively. Conclusions: Among persons with atherosclerotic vascular disease enrolled in managed care plans around the US, the incidence of subsequent ischemic events is consistent with a significant burden of symptomatic disease. Among stroke patients who have a subsequent ischemic event, stroke is the secondary event in the vast majority of cases.

Neurohormonal activation in patients with right ventricular failure from pulmonary hypertension: relation to hemodynamic variables and endothelin levels

OBJECTIVES

This study sought to determine whether neurohormonal activation occurs in isolated right heart failure.

BACKGROUND

Neurohormonal activation appears to parallel the severity of left heart failure, but little is known about its role in right heart failure.

METHODS

We evaluated neurohormonal activation and endothelin levels in 21 patients with primary pulmonary hypertension at the time of right heart catheterization.

RESULTS

Plasma norepinephrine levels correlated significantly with pulmonary artery pressure (r = 0.66, p < 0.01), cardiac index (r = -0.56, p < 0.01) and pulmonary vascular resistance (r = 0.69, p < 0.001). Atrial natriuretic peptide levels were higher in the pulmonary artery than the right atrium and femoral artery and correlated closely with pulmonary artery oxygen saturation (r = -0.73, p < 0.0001). Plasma renin levels were not elevated. Endothelin levels were increased and correlated with right atrial pressure (r = 0.74, p < 0.0001) and pulmonary artery oxygen saturation (r = -0.070, p < 0.0004).

CONCLUSIONS

Neurohormonal activation occurs in patients with isolated right ventricular failure and inherently normal left ventricles and appears to be related to the overall severity of cardiopulmonary derangements. The elevation in endothelin levels is consistent with its release in response to pulmonary hypertension.

Angiotensin-converting enzyme inhibition and beta-adrenoceptor blockade regress established ventricular remodeling in a canine model of discrete myocardial damage

OBJECTIVES

This study was designed to assess the effect of angiotensin-converting enzyme inhibition and beta-adrenoreceptor blockade on established ventricular remodeling.

BACKGROUND

Angiotensin-converting enzyme inhibitor therapy attenuates the development of ventricular remodeling when given shortly after myocardial infarction. However, regression of established ventricular remodeling after infarction has received little attention.

METHODS

The relative effects of angiotensin-converting enzyme inhibitor therapy and beta-adrenoceptor blockade on established ventricular remodeling were assessed in a canine model characterized by increased left ventricular mass and chamber dilation as a result of localized myocardial necrosis produced by transmyocardial direct current shock. Dogs were randomly assigned to 3 months of therapy with captopril (25 mg twice daily, n = 7) or metoprolol (100 mg twice daily, n = 7) or to a control group with no intervention (n = 6), 11 +/- 4 (mean +/- SD) months after acute myocardial damage.

RESULTS

Compared with the control group, dogs in both the captopril and metoprolol groups had reduced left ventricular mass as measured by magnetic resonance imaging (-8.1 +/- 3.8 vs. 1.7 +/- 2.8 g, p = 0.003 and -9.6 +/- 5.6 vs. 1.7 +/- 2.8 g, p = 0.001), respectively. Captopril and metoprolol also produced a reduction in left ventricular end-diastolic volume (-7.6 +/- 6.0 and -6.0 +/- 5.8 ml, respectively) compared with the control value (-1.6 +/- 3.8 ml) (p = 0.14 [NS]). Both agents reduced mean arterial pressure but had disparate effects on pulmonary wedge pressure and right atrial pressure. There was no significant correlation between change in ventricular mass or volume and change in any measured hemodynamic or neurohormonal variable.

CONCLUSIONS

These data suggest that pharmacologic intervention with angiotensin-converting enzyme inhibition or beta-adrenoceptor blockade can result in regression of established ventricular remodeling. The mechanism of this response will require further study, but these data did not support a close association between regression of remodeling and hemodynamic unloading of the ventricle or systemic neuroendocrine factors.

Evaluation of active compression-decompression CPR in victims of out-of-hospital cardiac arrest

OBJECTIVE--Active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) appears to improve ventilation and coronary perfusion when compared with standard CPR. The objective was to evaluate potential benefits of this new CPR technique in patients with out-of-hospital cardiac arrest in St Paul, Minn. DESIGN--Ten-month, prospective, randomized parallel-group design. SETTING--St Paul, Minn, population 270,000. PATIENTS--All normothermic victims of nontraumatic cardiac arrest older than 8 years who received CPR. MAIN OUTCOME MEASURES--Return of spontaneous circulation, admission to the intensive care unit (ICU), return of baseline neurological function (alert and oriented to person, place, and time), survival to hospital discharge, survival to hospital discharge with return of baseline neurological function, and complications. RESULTS--Seventy-seven patients received standard CPR and 53 patients received ACD CPR. The mean emergency medical services call response interval was less than 3.5 minutes. When all patients were considered, a higher percentage of ACD CPR patients had a return of spontaneous circulation and were admitted to the ICU vs standard CPR (45% vs 31%, and 40% vs 26%, respectively), but these trends were not statistically significant (P < .10 and P < .10). No statistically significant differences were found between hospital discharge rates (12 [23%] of 53 for ACD CPR vs 13 [17%] of 77 for standard CPR), return to baseline neurological function (10 [19%] of 53 for ACD CPR vs 13 [17%] of 77 for standard CPR), or return to baseline neurological function at hospital discharge (nine [17%] of 53 for ACD CPR vs 12 [16%] of 77 for standard CPR). Return of spontaneous circulation, ICU admission, and neurological recovery in both CPR groups were highly correlated with downtime (time from collapse to emergency medical system personnel arrival to the scene in witnessed arrests). With less than 10 minutes' downtime, survival to the ICU was 59% (19/32) with ACD CPR and 33% (16/49) with standard CPR (P < .02), return to baseline neurological function was 31% (10/32) with ACD CPR and 20% (10/49) with standard CPR (P = .27), and hospital discharge rate was 38% (12/32) with ACD CPR and 20% (10/49) with standard CPR (P = .17). Complication rates in patients admitted to the hospital were similar in both groups. CONCLUSIONS--This study demonstrates that ACD CPR appears to be more effective than standard CPR in a well-defined subset of victims of out-of-hospital cardiac arrest during the critical early phases of resuscitation. Based on this study, a larger study should be performed to evaluate the potential long-term benefits of ACD CPR.

Ejection fraction, peak exercise oxygen consumption, cardiothoracic ratio, ventricular arrhythmias, and plasma norepinephrine as determinants of prognosis in heart failure. The V-HeFT VA Cooperative Studies Group

BACKGROUND

Recognition of the complex pathophysiology of heart failure and its high mortality has emphasized the need for prognostic markers that can be used in clinical assessment as well as in the design of mortality trials. Data from the Department of Veterans Affairs Cooperative Vasodilator-Heart Failure Trials (V-HeFT I, 642 patients; V-HeFT II, 804 patients) were therefore examined to determine the influence of prerandomization measurements on subsequent mortality.

METHODS AND RESULTS

Patients entered into these trials were men with cardiac dysfunction and reduced peak exercise capacity. Measurements included in this analysis were left ventricular ejection fraction (EF) measured by radionuclide angiography, peak bicycle exercise oxygen consumption (VO2), cardiothoracic ratio (CTR) measured on a chest x-ray, ventricular arrhythmias assessed in a core laboratory by short-term Holter monitoring, plasma norepinephrine and plasma renin activity measured in a core laboratory only in V-HeFT II, and a variety of diagnostic and demographic data. The variables related only weakly to each other. EF, VO2, and CTR were powerful independent predictors of all-cause mortality in both studies. Ventricular arrhythmia was a significant independent predictor in V-HeFT II but not in V-HeFT I. Plasma norepinephrine but not plasma renin activity measured in V-HeFT II also had independent prognostic value. Other variables did not exert an independent effect on mortality.

CONCLUSIONS

Optimal assessment of the mortality risk in an individual or a group of individuals with heart failure uses measurement of EF, peak VO2, CTR, plasma norepinephrine, and the presence of ventricular arrhythmias.

Coronary revascularisation in insulin-dependent diabetic patients with chronic renal failure

Insulin-dependent diabetic patients found to have substantial coronary artery disease at the time of assessment for renal transplantation have 2-year survival of less than 50%. Because most of these patients have no angina symptoms their management is controversial. We tried to find out whether coronary artery revascularisation in such patients might decrease the combined incidence of unstable angina, myocardial infarction, and cardiac death. 151 consecutive insulin-dependent diabetic candidates for renal transplantation underwent coronary angiography. 31 had stenoses greater than 75% in one or more coronary arteries, atypical chest pain or no chest pain, and a left ventricular ejection fraction greater than 0.35. Of these, 26 agreed to be randomly assigned medical treatment (a calcium-channel-blocking drug plus aspirin) or revascularisation (angioplasty or coronary bypass surgery). 10 of 13 medically managed and 2 of 13 revascularised patients had a cardiovascular endpoint within a median of 8.4 months of coronary angiography (p < 0.01). 4 medically managed patients died of myocardial infarction during follow-up. Thus, revascularisation decreased the frequency of cardiac events in insulin-dependent diabetic patients with chronic renal failure and symptomless coronary artery stenoses. These findings suggest that diabetic renal transplant candidates should be screened for silent coronary artery disease, because revascularisation may decrease cardiac morbidity and mortality in this population.

Plasma norepinephrine as a guide to prognosis in patients with chronic congestive heart failure

Hemodynamics, plasma norepinephrine, and plasma renin activity were measured at supine rest in 106 patients (83 men and 23 women) with moderate to severe congestive heart failure. During follow-up lasting 1 to 62 months, 60 patients died (57 per cent); 47 per cent of the deaths were sudden, and 45 per cent were related to progressive heart failure. Statistically unrelated to the risk of mortality were cause of disease (60 patients had coronary disease, and 46 had cardiomyopathy), age (mean, 54.8 years), cardiac index (mean, 2.11 liters per minute per square meter of body-surface area), pulmonary wedge pressure (mean, 24.5 mm Hg), and mean arterial pressure (mean, 83.2 mm Hg). A multivariate analysis of the five significant univariate prognosticators--heart rate (mean, 84.4 beats per minute), plasma renin activity (mean, 15.4 ng per milliliter per hour), plasma norepinephrine (mean, 700 pg per milliliter), serum sodium (mean, 135.7 mmol per liter), and stroke-work index (mean, 21.0 g-meters per square meter)--found only plasma norepinephrine to be independently (P = 0.002) related to the subsequent risk of mortality. Norepinephrine was also higher in patients who died from progressive heart failure than in those who died suddenly. These data suggest that a single resting venous blood sample showing the plasma norepinephrine concentration provides a better guide to prognosis than other commonly measured indexes of cardiac performance.