Jens Hagemeister

Hypertension guidelines and their limitations--the impact of physicians' compliance as evaluated by guideline awareness.

Objective The initial step of an optimal therapeutic strategy for patients with arterial hypertension is the recognition and acceptance of new recommendations by the physicians themselves. This guideline awareness of the physicians has never been evaluated in detail. Design The awareness of content of current recommendations in hypertension diagnosis, treatment and treatment control was therefore assessed in primary care physicians using a questionnaire. The guidelines of the German Hypertension Society were used as the reference standard. Participants A total of 24 899 German physicians, including all internists, all cardiologists and 22% of general practitioners were contacted in a nationwide survey. Main outcome measures The number of answers in agreement with the guideline was used as a measure of guideline awareness. Adequate awareness of content of guideline recommendations was defined as the correct answer to five out of eight questions; the correct answers had to include the appropriate definition of hypertension. Results The analysis was based on 11 547 returned questionnaires (47.1%). An adequate guideline awareness was found in 23.7% of the total study population, especially in 37.1% of cardiologists, in 25.6% of internists and in 18.8% of general practitioners. While the guideline awareness was significantly influenced by the duration of private practice, regional and municipal factors had only minor influence on the results. Conclusion The impact of hypertension guidelines on actual medical knowledge is modest. Thus, the information strategies about current treatment guidelines must be improved and tailored to the needs of physicians in clinical practice to ultimately improve patient care.

NT-pro-BNP predicts worsening renal function in patients with chronic systolic heart failure

Background: Worsening renal function (WRF) is frequently observed in patients with heart failure and is associated with worse outcome. The aim of this study was to examine the association of the cardiac serum marker N‐terminal pro‐B‐type natriuretic peptide (NT‐pro‐BNP) and WRF.

NT-pro-BNP for diagnostic and prognostic evaluation in patients hospitalized for syncope

BACKGROUND Single clinical parameters are inaccurate for diagnostic and prognostic estimation in patients with syncope. The cardiac marker NT-pro-BNP has not thoroughly been evaluated for this application. METHODS NT-pro-BNP was assessed in 161 consecutive patients (median age 69 years, 58% male) hospitalized for syncope in a cardiological university department and association (odds ratio: OR, 95% confidence interval: CI) with diagnosis of cardiac cause and 6-months outcome was analyzed. RESULTS NT-pro-BNP levels were significantly higher in patients with cardiac (n=78) compared to non-cardiac syncope (n=83). At a cutoff of 156 pg/ml, NT-pro-BNP showed a sensitivity of 89.7%, a specificity of 51.8% and a negative predictive value of 84.3% for the diagnosis of cardiac syncope. Increasing NT-pro-BNP was a significant predictor of cardiac syncope (OR 3.7, 95% CI 2.3-5.8 per standard deviation of Log NT-pro-BNP, p<0.001) and addition of NT-pro-BNP significantly improved a predictive model including heart rate, history of structural heart disease and abnormal ECG. Adding left-ventricular ejection fraction to the model did not change results. Sixty-three patients had an adverse event during hospitalization or 6-months follow-up. NT-pro-BNP>156 pg/ml significantly predicted an adverse outcome (OR 2.7, 95% CI 1.04-6.9, p=0.04) after multivariate adjustment. CONCLUSIONS In patients hospitalized for syncope, NT-pro-BNP was a strong and independent diagnostic and prognostic marker and addition to conventional criteria of history and examination improved the discriminatory performance. Randomized trials must clarify the benefit and position of NT-pro-BNP in the management algorithm of patients with syncope.

Compliance of a cobalt chromium coronary stent alloy – the COVIS trial

BackgroundCobalt chromium coronary stents are increasingly being used in percutaneous coronary interventions. There are, however, no reliable data about the characteristics of unfolding and visibility of this stent alloy in vivo. The aim of this study is to compare cobalt chromium coronary stents with conventional stainless steel stents using intracoronary ultrasound.MethodsTwenty de novo native coronary stenoses ≤ 20 mm in length (target vessel reference diameter ≥ 2.5 and ≤ 4.0 mm) received under sequential intracoronary ultrasound either a cobalt chromium stent (Multi-Link Vision®; n = 10) or a stainless steel stent (Multi-Link Zeta®; n = 10).ResultsFor optimal unfolding, the cobalt chromium stent requires a higher balloon deployment pressure (13.90 ± 2.03 atm) than the stainless steel stent (11.50 ± 2.12 atm). Furthermore, the achieved target vessel diameter of the cobalt chromium stent (Visibility-Index QCA/IVUS Multi-Link Vision®1.13 / Multi-Link Zeta® 1.04) is more easily overrated by Quantitative Coronary Analysis.ConclusionThese data indicate that stent material-specific recommendations for optimal implantation pressure and different stent material with an equal design should both be considered in interpreting QCA-analysis.

An increase in HbA1c after percutaneous coronary intervention raises the risk for restenosis in patients without Type 2 diabetes mellitus

Aims  The influence of dynamic changes in glycated haemoglobin (HbA1c) on restenosis after elective percutaneous coronary intervention (PCI) in patients without diabetes has not been analysed. Therefore, the rate of restenosis was investigated after elective PCI in 101 consecutive patients without diabetes mellitus in relation to dynamic changes of HbA1c levels.

Implementation of guidelines for the treatment of acute ST-elevation myocardial infarction: the Cologne Infarction Model Registry.

Background—The aim of the Köln (Cologne) Infarction Model is to examine the feasibility of obligatory treatment of ST-segment–elevation myocardial infarction (STEMI) by first-line percutaneous coronary intervention. Methods and Results—The study was performed in Cologne with >1 million citizens, 5 coronary intervention centers, and 11 primary care hospitals. Twelve-lead ECG was available for all emergency medical service (EMS) teams. Partners guaranteed direct transfer of STEMI patients to a catheterization laboratory. A total of 519 patients treated within KIM in 2006 were included in the study. Of these, 24% presented at a primary care hospital, 11% presented directly at a coronary intervention center, 5% were transferred by EMS to primary care hospitals, and 60% were directly transferred by EMS to a catheterization laboratory. In 91% of cases, the catheterization laboratory was notified of the patient’s arrival in advance. False-positive ECG diagnosis of STEMI by EMS accounted for 6%. Median treatment times were as follows: from the start of symptoms to first medical contact, 120 minutes; phone to balloon, 70 minutes; and door to balloon, 49 minutes. Of all patients, 93% underwent angiography; 409 patients were treated by coronary intervention, and 24 underwent emergency coronary artery bypass graft. Thrombolysis in Myocardial Infarction grade 3 flow was obtained in 89%. In the hospitals, deaths and new myocardial infarctions were observed in 12.1% and in 1.9% of all patients, respectively. Conclusion—The Cologne Infarction Model provides evidence for the feasibility of obligatory treatment of STEMI by primary coronary intervention in a metropolitan setting. Acceptance of treatment pathways allowed nearly all STEMI patients to undergo coronary angiography. ECG competence of EMS was excellent. Treatment times were within postulated limits. Results, including mortality, were within a high quality range.

Inefficacy of different strategies to improve guideline awareness – 5-year follow-up of the hypertension evaluation project (HEP)

BackgroundIn spite of numerous guidelines for evidence based diagnostic and therapy adequate knowledge of current recommendations is disappointingly low. In the Hypertension Evaluation Project (HEP I) we showed that awareness of national hypertension guidelines under German practitioners was less than 25% in the year 2000. This indicates the need for efficient strategies to relevantly improve guideline awareness.MethodsTo asses different tools for amending guideline knowledge we used three strategies (guideline in print, interactive guideline, expert seminars) to train 8325 randomised physicians, who had participated in the HEP I trial. Guideline knowledge of the trained physicians was again tested with the HEP questionnaire and compared to a control group of HEP I physicians.ResultsThe return rate of questionnaires was 57.9% without a significant distinction between the groups. Overall guideline awareness was still low but remarkably improved compared to the results of HEP I (37.1% vs. 23.7%, p < 0.0001). There was no difference between the trained physicians and the control group (35.8% and 35.9% vs. 39.7%, p = n.s.).ConclusionWe investigated the influence of different strategies to improve guideline awareness among German physicians. None of our interventions (guideline in print, interactive guideline, expert seminars) brought a notable benefit compared to control group. However, overall knowledge of guideline contents increased from 23.7% to 37.1% over five years. Therefore, other probably multimodal interventions are necessary to significantly improve guideline awareness beyond spontaneous advancement.Trial RegistrationISRCTN53383289

Delta-glycated hemoglobin: A novel independent risk factor for cardiovascular events in patients without diabetes mellitus

Background: A single measurement of glycated hemoglobin (HbA1c) is a weak predictor for cardiovascular events in patients without Type 2 diabetes mellitus. We hypothesized that dynamic changes in HbA1c (Delta-HbA1c) would better predict cardiovascular outcome than a single value. Methods: In 99 consecutive patients with stable coronary artery disease (CAD) and without diabetes mellitus who were seen twice in our outpatient clinic (4–6 months apart) in 1998, Delta-HbA1c (follow-up HbA1c–baseline HbA1c) was assessed. Between August and September 2007 (mean observation period 9.1 yr), patients and their physicians were contacted by telephone to evaluate the incidence of cardiovascular endpoints. The combined primary endpoint of our study was defined as the incidence of myocardial infarction, stroke or death from any cause. The endpoints were validated by chart review. Results: Multivariate analysis demonstrated that the change of HbA1c between first and second examination in 1998 was the most powerful parameter for prediction of the combined primary endpoint in the next 9 yr. The hazard ratio was 5.03 [95% confidence interval (CI) 1.4–17.9] for any increase in HbA1c and 1.99 (95%CI 1.3–3.0) for an HbA1c increase of 0.3%. In addition, Kaplan-Meier survival analysis showed a significant association between endpoint-free survival and dynamic changes in HbA1c. Conclusions: Hence, changes in the glucometabolic milieu within 4–6 months calculated by the difference of two values of HbA1c affect the long-term prognosis of patients with CAD but without diabetes mellitus.

Implementation of Guidelines for the Treatment of Acute ST-Elevation Myocardial InfarctionCLINICAL PERSPECTIVE: The Cologne Infarction Model Registry

Background—The aim of the Köln (Cologne) Infarction Model is to examine the feasibility of obligatory treatment of ST-segment–elevation myocardial infarction (STEMI) by first-line percutaneous coronary intervention. Methods and Results—The study was performed in Cologne with >1 million citizens, 5 coronary intervention centers, and 11 primary care hospitals. Twelve-lead ECG was available for all emergency medical service (EMS) teams. Partners guaranteed direct transfer of STEMI patients to a catheterization laboratory. A total of 519 patients treated within KIM in 2006 were included in the study. Of these, 24% presented at a primary care hospital, 11% presented directly at a coronary intervention center, 5% were transferred by EMS to primary care hospitals, and 60% were directly transferred by EMS to a catheterization laboratory. In 91% of cases, the catheterization laboratory was notified of the patient’s arrival in advance. False-positive ECG diagnosis of STEMI by EMS accounted for 6%. Median treatment times were as follows: from the start of symptoms to first medical contact, 120 minutes; phone to balloon, 70 minutes; and door to balloon, 49 minutes. Of all patients, 93% underwent angiography; 409 patients were treated by coronary intervention, and 24 underwent emergency coronary artery bypass graft. Thrombolysis in Myocardial Infarction grade 3 flow was obtained in 89%. In the hospitals, deaths and new myocardial infarctions were observed in 12.1% and in 1.9% of all patients, respectively. Conclusion—The Cologne Infarction Model provides evidence for the feasibility of obligatory treatment of STEMI by primary coronary intervention in a metropolitan setting. Acceptance of treatment pathways allowed nearly all STEMI patients to undergo coronary angiography. ECG competence of EMS was excellent. Treatment times were within postulated limits. Results, including mortality, were within a high quality range.

Implementation of Guidelines for the Treatment of Acute ST-Elevation Myocardial InfarctionCLINICAL PERSPECTIVE

Background—The aim of the Köln (Cologne) Infarction Model is to examine the feasibility of obligatory treatment of ST-segment–elevation myocardial infarction (STEMI) by first-line percutaneous coronary intervention. Methods and Results—The study was performed in Cologne with >1 million citizens, 5 coronary intervention centers, and 11 primary care hospitals. Twelve-lead ECG was available for all emergency medical service (EMS) teams. Partners guaranteed direct transfer of STEMI patients to a catheterization laboratory. A total of 519 patients treated within KIM in 2006 were included in the study. Of these, 24% presented at a primary care hospital, 11% presented directly at a coronary intervention center, 5% were transferred by EMS to primary care hospitals, and 60% were directly transferred by EMS to a catheterization laboratory. In 91% of cases, the catheterization laboratory was notified of the patient’s arrival in advance. False-positive ECG diagnosis of STEMI by EMS accounted for 6%. Median treatment times were as follows: from the start of symptoms to first medical contact, 120 minutes; phone to balloon, 70 minutes; and door to balloon, 49 minutes. Of all patients, 93% underwent angiography; 409 patients were treated by coronary intervention, and 24 underwent emergency coronary artery bypass graft. Thrombolysis in Myocardial Infarction grade 3 flow was obtained in 89%. In the hospitals, deaths and new myocardial infarctions were observed in 12.1% and in 1.9% of all patients, respectively. Conclusion—The Cologne Infarction Model provides evidence for the feasibility of obligatory treatment of STEMI by primary coronary intervention in a metropolitan setting. Acceptance of treatment pathways allowed nearly all STEMI patients to undergo coronary angiography. ECG competence of EMS was excellent. Treatment times were within postulated limits. Results, including mortality, were within a high quality range.