Nicholas Brooks

Has the publication of cardiac surgery outcome data been associated with changes in practice in northwest England: an analysis of 25 730 patients undergoing CABG surgery under 30 surgeons over eight years

Objectives: To study changes in coronary artery surgery practice in the years spanning publication of cardiac surgery mortality data in the UK. Methods: A retrospective analysis of prospectively collected data from all National Health Service centres undertaking adult cardiac surgery in northwest England was carried out. Patients undergoing coronary artery surgery for the first time between April 1997 and March 2005 were included. Changes in observed, predicted and risk adjusted mortality (EuroSCORE) were studied. Evidence of risk-averse behaviour was looked for by examining the number of patients at low risk (EuroSCORE 0–5), high risk (6–10), and very high risk (11 or more), before and after public disclosure. Results: 25 730 patients underwent coronary artery surgery during the study period. The observed mortality decreased from 2.4% in 1997–8 to 1.8% in 2004–5 (p = 0.014). The expected mortality (EuroSCORE) increased from 3.0 to 3.5 (p<0.001). The observed to expected mortality ratio decreased from 0.8 to 0.51 (p<0.05). The total number and percentage of patients who were at low risk, high risk and very high risk was 2694 (84.6%), 449 (14.1%) and 41 (1.3%) before and 2654 (81.7%), 547 (16.8%) and 47 (1.4%) after public disclosure, respectively, demonstrating a significant increase in the number and proportion of high risk patients undergoing surgery (p<0.001). Conclusions: Publication of cardiac surgery mortality data in the UK has been associated with decreased risk adjusted mortality on retrospective analysis of a large patient database. There is no evidence that fewer high risk patients are undergoing surgery because mortality rates are published.

Beta-blockers are associated with lower C-reactive protein concentrations in patients with coronary artery disease

PURPOSE C-reactive protein is an important risk factor for coronary artery disease, and plasma concentrations are lowered by treatment with pravastatin and aspirin. We examined whether other cardiovascular drugs that are used in the treatment of ischemic heart disease affect C-reactive protein concentrations. SUBJECTS AND METHODS Plasma C-reactive protein concentration was measured by high sensitivity immunonephelometric assay in 333 consecutive patients with stable angina and confirmed coronary artery disease who underwent diagnostic angiography. RESULTS Patients prescribed beta-blockers had significantly lower mean C-reactive protein concentrations than did patients in whom these were not prescribed (by 1.2 mg/L, or 40% difference in geometric mean concentration; P <0.001). This association remained significant (P = 0.03) after excluding patients with contraindications to the use of beta-blockers, and adjusting for the probability of beta-blocker therapy (propensity score) and other clinical predictors of C-reactive protein concentration, including body mass index, high-density lipoprotein cholesterol level, family history of coronary artery disease, and angiographic severity. No differences among types or dosages of beta-blockers were evident. CONCLUSION Beta-blockers may affect C-reactive protein concentrations. Randomized studies are required to confirm these findings.

β blocker treatment is associated with improvement in renal function and anaemia in patients with heart failure

Over the past three decades, there has been rapid progress in the diagnosis and management of patients with chronic congestive heart failure (CHF). However, the mortality from CHF remains high, partly due to comorbidity, the very existence of which may have excluded some patients from previous large-scale clinical trials. Hence, the full effect of modern treatment on non-trial “real life” patients with CHF in clinical practice remains uncertain. Chronic renal impairment (CRI) and anaemia are common comorbidities associated with CHF, and are both independent predictors of poor prognosis.1 It has previously been shown that treatment with either angiotensin-converting enzyme inhibitors (ACEI) or β blockers improves prognosis in patients with CHF with or without CRI.2,3 Among the most recent treatments of CHF, ACEIs are potentially nephrotoxic and may cause worsening of anaemia.3 Thus, the relationship between treatment and outcome in patients with CHF with CRI and anaemia needs further investigation. We aimed to assess the effect of β blocker treatment on renal function and anaemia in consecutive ambulatory patients with CHF in routine clinical practice. A retrospective case study of 134 consecutive patients (alive at the time of analysis) with stable CHF, attending our heart failure clinic between 2002 and 2004, was conducted. Serum creatinine and haemoglobin levels checked …

The effects of adding torasemide to standard therapy on peak oxygen consumption, natriuretic peptides, and quality of life in patients with compensated left ventricular systolic dysfunction.

Diuretics, when used to treat congestion in patients with chronic heart failure, improve symptoms and, perhaps, prognosis but little information is available to guide their use in patients with left ventricular systolic dysfunction (LVSD) who are not congested. Chronic diuretic therapy causes persistent and potentially harmful neuroendocrine activation. Alternatively, in patients in whom neuroendocrine activation is blocked with angiotensin‐converting enzyme (ACE)‐inhibitors and β‐blockers, diuretics may be beneficial by decreasing preload and afterload and preventing congestion. We aimed to assess the effect of the loop diuretic, torasemide on quality of life, and surrogate markers of prognosis when given to patients with LVSD who were not clinically congested and who were optimally treated with ACE‐inhibitors (or angiotensin receptor antagonists) and β‐blockers.

Quantitative 2-D colour tissue Doppler derived ratio of early diastolic mitral inflow velocity to early diastolic annular velocity is influenced by age and gender in clinically normal population

Purpose: The ratio of early diastolic mitral inflow velocity ( E ) to early diastolic tissue Doppler (TDI) annular velocity ( E ′), or E / E ′, is an index of diastolic dysfunction. Pulsed wave (PW) TDI measures peak E ′ while colour TDI measures mean E ′. Previously reported normal PW TDI derived E / E ′ values are therefore not interchangeable with those derived …