RESUMEN
The purpose of Medicare's Cooperative Cardiovascular Project (CCP) is to improve the care of Medicare patients presenting with acute myocardial infarction (AMI). MetaStar is Wisconsin's Medicare peer review organization that administers Phase II of the CCP. A major Phase II objective is to increase the use of reperfusion strategies (thrombolysis and angioplasty) and angiotensin converting enzyme (ACE) inhibitors (when the ejection fractions is < 40%) in patients presenting with AMI. After MetaStar presented Wausau Hospital's baseline Phase II data to us, we were asked to define a plan to improve the use of reperfusion therapy and ACE inhibitors. To verify the accuracy of the data presented to us, we reviewed the patient records used by MetaStar to calculate our baseline data for these 2 quality-of-care indicators. Our MetaStar reported reperfusion rate (48.4%) and ACE inhibitor rate (20.9%) were significantly different from that which we calculated (100% and 97%). Causes for the discrepancy included MetaStar abstractor's failure to exclude two patients who did not have an AMI, failure to correctly count patients who received the targeted treatment, and an inability of the abstractors to identify important CCP exclusion criteria. Thus, numerous patients who should have been excluded were inappropriately classified as "ideal" candidates for the targeted therapy. WE CONCLUDE: There are major flaws in the data collection techniques used by MetaStar in Phase II of the CCP. These flaws produced erroneous conclusions concerning our use of reperfusion strategies and ACE inhibitors. Since these quality-of-care indicators are major targeted goals of Phase II, the errors are of special concern. We believe better-designed abstract forms, due diligence, and more thorough training could have prevented the errors. In presenting our concerns, we hope to foster a response by MetaStar to improve the quality of the peer review process.
Asunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Recolección de Datos , Organizaciones de Normalización Profesional , Calidad de la Atención de Salud , Cateterismo Cardíaco , Humanos , Reperfusión Miocárdica , Selección de Paciente , WisconsinRESUMEN
Idiopathic or congenital coronary artery ectasias and aneurysms are uncommon forms of coronary artery disease. The prognosis and optimal management of such patients remains unknown. The authors describe the case of an otherwise healthy 30-year-old man with concomitant severe right coronary artery ectasia and left main coronary artery aneurysm who sustained a mild anterior myocardial infarction. There was no obstructive coronary artery disease, and no cause for the lesions could be identified. Chronic anticoagulation and antiplatelet therapy were initiated with resolution of symptoms.
Asunto(s)
Aneurisma Coronario/complicaciones , Anomalías de los Vasos Coronarios/complicaciones , Infarto del Miocardio/complicaciones , Adulto , Aneurisma Coronario/patología , Anomalías de los Vasos Coronarios/patología , Humanos , Masculino , Infarto del Miocardio/patologíaRESUMEN
Emergent percutaneous transluminal coronary angioplasty (PTCA) is an effective treatment for acute myocardial infarction. However, occasionally results of angioplasty are suboptimal due to coronary dissection or elastic recoil, leading to a high chance of recurrent ischemia. Coronary stents are occasionally employed in such settings, but a high incidence of stent thrombosis was noted by early investigators when stents were placed into areas of active thrombus formation. Since coronary thrombosis and stent thrombosis are both initiated by platelets, the potent antiplatelet agent abciximab might be useful in preventing stent thrombosis. Little information is available concerning early outcome or 6-month clinical event rate when coronary artery stents are placed for suboptimal angioplasty results for acute myocardial infarction in patients given abciximab. We deployed 75 stents as part of angioplasty for acute myocardial infarction in 40 patients given abciximab. All patients had suboptimal angioplasty results leading to stent deployment. Each obtained normal flow angiographically and no stent thrombosis or acute closure was observed. Early mortality occurred in 1 patient. All patients were followed at least 6 months, and no patient died after hospital discharge. Three patients experienced recurrent ischemic events within the first 6 months. Two of these events were due to infarct vessel restenosis. We conclude the combined use of coronary artery stents and abciximab for suboptimal PTCA results during acute myocardial infarction is associated with a low incidence of culprit vessel recurrent ischemic events within 6 months of intervention.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Anticuerpos Monoclonales/administración & dosificación , Fragmentos Fab de Inmunoglobulinas/administración & dosificación , Infarto del Miocardio/terapia , Inhibidores de Agregación Plaquetaria/administración & dosificación , Stents , Abciximab , Adulto , Anciano , Anciano de 80 o más Años , Terapia Combinada , Angiografía Coronaria , Trombosis Coronaria/diagnóstico por imagen , Trombosis Coronaria/mortalidad , Trombosis Coronaria/prevención & control , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/mortalidad , Recurrencia , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
Current prepping of the Johnson & Johnson stent deployment balloon can be suboptimal. This simple technique allows for an improved preparation of the stent delivery balloon prior to deployment, resulting in less air in the balloon during inflation.
Asunto(s)
Cateterismo/métodos , Vasos Coronarios , Stents , Cateterismo/instrumentación , Diseño de Equipo , HumanosRESUMEN
Percutaneous transluminal coronary angioplasty has been shown to be an effective treatment for acute myocardial infarction. Despite encouraging results, this form of treatment is limited by a high incidence of recurrent ischemia either due to early rethrombosis or to restenosis of the infarct vessel within the first six months. Coronary artery stents decrease restenosis but are considered contraindicated in situations were thrombus is present. c7E3 is a potent anti-platelet agent which inhibits thrombus formation. We developed 44 stents as part of angioplasty for acute myocardial infarction in 18 patients given c7E3. All patients obtained normal flow angiographically and no stent thrombosis was observed.
Asunto(s)
Angioplastia Coronaria con Balón , Anticuerpos Monoclonales/uso terapéutico , Trombosis Coronaria/prevención & control , Fragmentos Fab de Inmunoglobulinas/uso terapéutico , Infarto del Miocardio/terapia , Inhibidores de Agregación Plaquetaria/uso terapéutico , Abciximab , Adulto , Anciano , Anciano de 80 o más Años , Angioplastia Coronaria con Balón/instrumentación , Anticuerpos Monoclonales/administración & dosificación , Terapia Combinada , Angiografía Coronaria , Femenino , Humanos , Fragmentos Fab de Inmunoglobulinas/administración & dosificación , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/administración & dosificación , Stents , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
It has been suspected that the increased sympathetic activity seen in patients with chronic congestive heart failure from dilated cardiomyopathy may be harmful. We therefore tested the long-term effect of metoprolol on eight patients in a double-blind, randomized protocol and 12 patients in an unblinded, crossover protocol who were treated for 12 months (range 10 to 24), and compared them with 16 similar subjects who were treated with placebo for 10 months (range 6 to 12) in a double-blind, randomized protocol. Patients were followed by serial clinical assessment, treadmill testing, radionuclide ventriculography, and echocardiography. Metoprolol-treated patients had an improvement in mean exercise capacity by 3 mets (p less than .0001) while experiencing a significant improvement in functional classification (p less than .001) during both the double-blind and open-label crossover studies and had an improved ejection fraction during the double-blind study (p less than .02). These improvements were not seen in matched control subjects receiving placebo. Seven of 20 patients receiving long-term metoprolol therapy had resolution of nearly all symptoms of heart failure, doubled their exercise capacity, and had progressive improvement in resting radionuclide left ventricular ejection fraction (12.6 +/- 3% to 26.9 +/- 6%) and echocardiographic left ventricular end-diastolic dimension (7.7 +/- 0.5 to 6.5 +/- 0.5 cm). Only one of 21 patients treated was intolerant of metoprolol. We conclude that metoprolol can be given safely to a select group of patients with dilated cardiomyopathy in doses that substantially reduce both resting and exercise heart rates. Long-term beta-blockade improved functional class and exercise capacity in 14 of 20 patients while producing an exceptional clinical response in seven that was accompanied by improved resting parameters of left ventricular function.
Asunto(s)
Cardiomiopatía Dilatada/fisiopatología , Insuficiencia Cardíaca/fisiopatología , Metoprolol/farmacología , Adulto , Bradicardia/inducido químicamente , Cardiomiopatía Dilatada/tratamiento farmacológico , Ensayos Clínicos como Asunto , Prueba de Esfuerzo , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Metoprolol/efectos adversos , Metoprolol/uso terapéutico , Persona de Mediana Edad , Esfuerzo Físico , Placebos , Distribución AleatoriaRESUMEN
Dilated cardiomyopathy is a heterogeneous group of disorders with a prognosis that is dependent upon the severity of presenting clinical and hemodynamic abnormalities. Although this condition is characterized by a high mortality, spontaneous improvement is noted in 25% of cases. Standard therapeutic modalities are nonspecific and consist of the therapy of congestive heart failure and ventricular arrhythmia. Recent studies suggest that beta blockade and cardiac transplantation may soon become accepted modalities in this condition. Acute viral myocarditis is a common disease that has a good prognosis, however occasionally progression to chronic myocardial disease has been identified. The therapy of acute viral myocarditis should be limited to symptomatic treatment, anti-coagulation, and bed rest. When chronic myocarditis is identified on endomyocardial biopsy in patients with heart failure of unknown cause, the treatment differs little from that of dilated cardiomyopathy with the exception that recognizing that efficacy has not been proven; immunosuppressive therapy may be added in life-threatening situations. Future studies will be directed at further clarification of the prognosis of each of these conditions with intensive evaluation of the role of beta blockade and immunosuppression.
Asunto(s)
Cardiomiopatía Dilatada/tratamiento farmacológico , Miocarditis/tratamiento farmacológico , Enfermedad Aguda , Adulto , Antiinflamatorios/uso terapéutico , Cardiomiopatía Dilatada/mortalidad , Cardiomiopatía Dilatada/fisiopatología , Cardiotónicos/uso terapéutico , Enfermedad Crónica , Femenino , Corazón/fisiopatología , Humanos , Inmunosupresores/uso terapéutico , Masculino , Persona de Mediana Edad , Miocarditis/mortalidad , Miocarditis/fisiopatología , Pronóstico , Presión Esfenoidal Pulmonar , Volumen Sistólico , Vasodilatadores/uso terapéuticoRESUMEN
The natural history of dilated cardiomyopathy is variable, and the prognosis difficult to predict. Several clinical and hemodynamic parameters have been proposed as prognostic indicators. Reports on the relationship between ventricular arrhythmias, degree of hemodynamic impairment, and sudden death are controversial. To define accurately the prognosis in dilated cardiomyopathy, 55 patients with this clinical syndrome underwent clinical evaluation, radionuclide ventriculography, echocardiography, 12-lead electrocardiography, and 24 hr ambulatory monitoring, and the data thus obtained were evaluated based on predictive value. Over a follow-up period of 14.1 +/- 7.9 months, 11 patients (20%) died, all suddenly. Univariate analysis revealed that patients with more severe functional impairment (P = 0.0449), lower cardiac index (P = 0.0226), lower ejection fraction (P = 0.0426), and higher pulmonary artery wedge pressure (P = 0.0314) had greater mortality risk. Age, duration of symptoms, 12-lead electrocardiographic abnormalities, and atrial arrhythmias were not predictive of higher mortality. The number of PVCs per hr, the occurrence of couplets, the degree of PVCs prematurity, and the presence, frequency, rate, and duration of ventricular tachycardia did not have prognostic significance. A stepwise discriminant analysis identified functional class, cardiac index, and presence or absence of multiform PVCs as the group of variables that together could more accurately predict outcome in our dilated cardiomyopathy patients. Using a formula derived from the results of this analysis, the outcomes of 36 of 49 patients (74%) was correctly predicted, with a specificity of 100% and a sensitivity of 70%.
Asunto(s)
Arritmias Cardíacas/etiología , Cardiomiopatía Dilatada/fisiopatología , Hemodinámica , Adulto , Arritmias Cardíacas/fisiopatología , Cateterismo Cardíaco , Cardiomiopatía Dilatada/complicaciones , Electrocardiografía , Femenino , Humanos , Persona de Mediana Edad , Monitoreo Fisiológico , PronósticoRESUMEN
We report a patient with extensive infiltration of the left ventricle with amyloid who presented with severe mitral regurgitation which led to mitral valve replacement. The right ventricular biopsy showed minimal focal deposits of amyloid.