RESUMEN
Little published information regarding current pharmacotherapeutic treatment patterns for congestive heart failure (CHF) in nonacademic, ambulatory care settings is available. We sought to assess, in a nonacademic primary care environment, pharmacotherapeutic treatment patterns for CHF with respect to consistency with clinical trial evidence and published treatment guideline recommendations. Over an 18-month period, we examined CHF pharmacotherapy using a computerized, integrated clinical diagnoses and prescription database from an outpatient community healthcare center without academic affiliations. We identified adult patients meeting contact criteria and with diagnosis of CHF by International Classification of Diseases (ICD-9-CM) coding and assessed prescribed therapy as well as select comorbid conditions. Drugs of interest included those with known or suspected benefit or detriment and those with unproven benefit. An eligible group of 14,983 patients was identified, from which a cohort of 148 patients with CHF was selected. Forty-one percent of these 148 patients were prescribed an angiotensin converting enzyme (ACE) inhibitor, 34% digoxin, 12% diuretic, 12% hydralazine + nitrate, 20% inhaled beta-agonists, and 66% warfarin. Only 5% of patients were prescribed the combination of an ACE inhibitor, digoxin, and diuretic. Thirty-one percent had a comorbid diagnosis of atrial fibrillation, of whom 44% were prescribed digoxin, 22% diltiazem, 15% beta-blockers, 15% digoxin and diltiazem, 7% digoxin and a beta-blocker, and 33% warfarin. In general, recommended therapies for CHF appeared underutilized in this cohort, whereas those of unclear benefit and potential detriment appeared overutilized. Although these results may not be readily generalized to the entire healthcare system, they do suggest a need for additional analysis and potential intervention.
Asunto(s)
Fármacos Cardiovasculares/uso terapéutico , Revisión de la Utilización de Medicamentos/estadística & datos numéricos , Insuficiencia Cardíaca/tratamiento farmacológico , Atención Primaria de Salud/normas , Adolescente , Adulto , Anciano , Estudios de Cohortes , Femenino , Adhesión a Directriz , Humanos , Masculino , Persona de Mediana Edad , New England , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricosRESUMEN
BACKGROUND: Despite extensive professional debate regarding the optimal thrombolytic therapy strategy in acute myocardial infarction (AMI), patient preferences have not been explored. METHODS: Preferences among patients with known or suspected coronary artery disease for treatment with tissue plasminogen activator (tPA) or streptokinase (SK) for AMI were determined using a questionnaire presenting GUSTO-1 trial and drug cost data. Preferences were based on consideration of 30-day mortality (M) alone, hemorrhagic stroke rate (SR) alone, overall preference (M + SR), drug acquisition costs, and the estimated annual costs of using a single agent to treat all AMIs. Cost-related responses were provided under payer designations of self, third-party insurance, and federal government. RESULTS: The response rate was 81% (101/125 patients). tPA was preferred by 84%, and SK by 66%, for M alone and SR alone, respectively (chi 2, p < 0.01). Overall preference (M + SR) favored tPA (78%, p < 0.01). tPA preference decreased to 43% considering drug acquisition costs under the self-pay option (p < 0.01 vs M + SR). Similar trends of lesser magnitude were also observed for the third-party and government-payer options. CONCLUSIONS: Under conditions of zero cost and consideration of mortality plus stroke-risk data, tPA were preferred overall due to its lower mortality. Introduction of drug-cost data significantly shifted the preference toward SK, particularly under the self-payer designation. Patient preferences for thrombolytic therapy in AMI indicate tradeoffs between clinical attributes and costs, and should assist in framing medical debate and decision making.
Asunto(s)
Actitud Frente a la Salud , Toma de Decisiones , Infarto del Miocardio/tratamiento farmacológico , Terapia Trombolítica , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Trastornos Cerebrovasculares/epidemiología , Costos de los Medicamentos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Activadores Plasminogénicos/uso terapéutico , Análisis de Regresión , Estreptoquinasa/uso terapéutico , Terapia Trombolítica/economía , Activador de Tejido Plasminógeno/uso terapéutico , Estados Unidos/epidemiologíaRESUMEN
A markedly prolonged quinidine elimination half-life due to hepatic failure and resultant quinidine toxicity occurred in a 57-year-old man with a history of atrial fibrillation. A prolonged QT interval, development of torsades de pointes, and a serum quinidine concentration of 3.1 micrograms/ml contributed to a decision favoring permanent pacemaker implantation. The apparent quinidine half-life ranged from 66-99 hours and was associated with QT prolongation and persistent U waves. On discontinuing quinidine, all signs associated with toxicity resolved as serum quinidine concentrations decreased, which resulted in reversal of the decision to implant a permanent pacemaker. This case reports an extremely long quinidine elimination half-life and reillustrates the importance of drug pharmacokinetics in patient care.
Asunto(s)
Antiarrítmicos/efectos adversos , Fallo Hepático/metabolismo , Quinidina/efectos adversos , Antiarrítmicos/sangre , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/tratamiento farmacológico , Electrocardiografía , Semivida , Humanos , Fallo Hepático/complicaciones , Síndrome de QT Prolongado/inducido químicamente , Masculino , Persona de Mediana Edad , Quinidina/sangre , Quinidina/uso terapéutico , Torsades de Pointes/inducido químicamenteRESUMEN
OBJECTIVE: To compare and contrast the activated partial thromboplastin time (aPTT) and the activated clotting time (ACT) for the therapeutic monitoring of heparin therapy. DATA SOURCES: Relevant articles were identified through an English-language MEDLINE search from 1966 to 1995. Additional sources were identified from the reference lists of these articles. STUDY SELECTION: Studies that investigated the use and limitations of the individual assays and those offering direct comparisons were chosen for review. DATA EXTRACTION: Features demonstrating clinical applications and limitations of the aPTT and the ACT were extracted. Where possible, data suggesting preferential application of either assay also were extracted. DATA SYNTHESIS: Both the aPTT and ACT are clinically useful for the monitoring of heparin therapy. The aPTT is used more frequently for routine monitoring; the ACT is used in specialized situations requiring large heparin doses. The ACT is typically performed at bedside and is capable of yielding results rapidly and perhaps at a lower cost than an aPTT performed by a central laboratory. Most practitioners are familiar with the central laboratory aPTT. A bedside aPTT device is available, but is not yet in widespread clinical use. Both assay techniques are subject to various limitations. CONCLUSIONS: The ACT is theoretically equally as useful as the aPTT for the routine monitoring of heparin therapy, but has not been well-studied. The ACT appears more useful in situations in which high serum concentrations of heparin are required. Further cost-effectiveness and clinical outcome studies directly comparing the ACT and the aPTT is specific clinical situations are needed.
Asunto(s)
Anticoagulantes/uso terapéutico , Heparina/uso terapéutico , Tiempo de Tromboplastina Parcial , Tiempo de Coagulación de la Sangre Total , Monitoreo de Drogas , HumanosRESUMEN
1. The effect of naltrexone pellets containing either 10 or 30 mg of naltrexone base on the development of tolerance and physical dependence on morphine was assessed in male Sprague-Dawley rats. Tolerance-dependence on morphine was induced by s.c. implantation of six morphine pellets, each containing 75 mg morphine base for 7 days. 2. Naltrexone pellet implantation blocked the development of tolerance to the analgesic and hyperthermic effects of morphine. Similarly, naltrexone pellet implantation reversed morphine withdrawal-induced body weight loss. The effect of pellets containing 10 and 30 mg naltrexone did not differ. 3. The effect of naltrexone (10 mg) pellet implantation on various signs of naltrexone-precipitated withdrawal such as body weight loss, hypothermia and increases in urinary and fecal output was investigated. Naltrexone pellet implantation did not alter the naltrexone-precipitated withdrawal-induced body weight loss. Concurrent naltrexone pellet implantation blocked the naltrexone-precipitated withdrawal-induced hypothermia, increased fecal and urinary output in morphine-dependent rats. 4. These results indicate that a single pellet of 10 mg of naltrexone can effectively block morphine tolerance and physical dependence in the rat. Such a procedure may be useful in studying biochemical, endocrinological and immunological mechanisms involved in opioid addiction processes.