Pai C. Yu

Cardiovascular prevention in HIV patients: Results from a successful intervention program

OBJECTIVESnTo analyze the effect of a prevention program on the estimated cardiovascular risk calculated by three risk scores.nnnMETHODSnWe prospectively evaluated 87 HIV+patients with elevated cardiovascular risk estimation. Framingham (FRS), PROCAM and National Cholesterol Education Program (ATP-III) were applied. Cardiovascular risk was defined as elevated if >10%. All patients received non-pharmacological (diet, exercise, smoking cessation) and, when appropriate, pharmacological therapy.nnnRESULTSnMean age was 52 years, 92% were male, 39.1% were smokers, 70.1% had hypertension, 18.4% had diabetes. All patients were under HAART, 56.3% were receiving protease inhibitors (PI). After 6 months, intervention was associated to significant changes on triglycerides (298+/-242 and 206+/-135 mg/dL, p<0.05), total-cholesterol (224+/-47 and 189+/-38 mg/dL, p<0.001), LDL-cholesterol (129+/-44 and 109+/-30 mg/dL, p<0.001). Frequencies of patients with elevated cardiac risk before and 6 months after intervention were 92% x 27.6% (p<0.0001), 80.5% x 50.6% (p<0.0002), and 25.3% x 14.9% (p=0.12), for FRS, ATP III and PROCAM, respectively.nnnCONCLUSIONSnAn intervention program focused on reduction of traditional risk factors was able to decrease the frequency of patients with HIV infection and elevated cardiovascular risk estimation. FRS showed greater sensitivity than the other scores.

Perioperative cardiovascular evaluation: heads or tails?

When dealing with surgical patients, a perioperative evaluation is essential to anticipate complications and institute measures to reduce the risks. Several algorithms and exams have been used to identify postoperative cardiovascular events, which account for more than 50% of perioperative mortality. However, they are far from ideal. Some of these algorithms and exams were proposed before important advances in cardiology, at a time when pharmacological risk reduction strategies for surgical patients were not available. New biomarkers and exams, such as C-reactive protein, brain natriuretic peptide, and multislice computed tomography have been used in cardiology and have provided important prognostic information. The ankle-brachial index is another significant marker of atherosclerosis. However, specific information regarding the perioperative context of all these methods is still needed. The objective of this article is to evaluate cardiovascular risk prediction models after noncardiac surgery.

Prediction of major cardiac events after vascular surgery

Objective: Predicting cardiac events is essential to provide patients with the best medical care and to assess the risk‐benefit ratio of surgical procedures. The aim of our study was to evaluate the performance of the Revised Cardiac Risk Index (Lee) and the Vascular Study Group of New England Cardiac Risk Index (VSG) scores for the prediction of major cardiac events in unselected patients undergoing arterial surgery and to determine whether the inclusion of additional risk factors improved their accuracy. Methods: The study prospectively enrolled 954 consecutive patients undergoing arterial vascular surgery, and the Lee and VSG scores were calculated. Receiver operating characteristic curves for each cardiac risk score were constructed and the areas under the curve (AUCs) compared. Two logistic regression models were done to determine new variables related to the occurrence of major cardiac events (myocardial infarction, heart failure, arrhythmias, and cardiac arrest). Results: Cardiac events occurred in 120 (12.6%) patients. Both scores underestimated the rate of cardiac events across all risk strata. The VSG score had AUC of 0.63 (95% confidence interval [CI], 0.58–0.68), which was higher than the AUC of the Lee score (0.58; 95% CI, 0.52–0.63; P = .03). Addition of preoperative anemia significantly improved the accuracy of the Lee score to an AUC of 0.61 (95% CI, 0.58–0.67; P = .002) but not that of the VSG score. Conclusions: The Lee and VSG scores have low accuracy and underestimate the risk of major perioperative cardiac events in unselected patients undergoing vascular surgery. The Lee scores accuracy can be increased by adding preoperative anemia. Underestimation of major cardiac complications may lead to incorrect risk‐benefit assessments regarding the planned operation.

Impact of cardiology referral: clinical outcomes and factors associated with physicians' adherence to recommendations

OBJECTIVES: Cardiology referral is common for patients admitted for non-cardiac diseases. Recommendations from cardiologists may involve complex and aggressive treatments that could be ignored or denied by other physicians. The purpose of this study was to compare the outcomes of patients who were given recommendations during cardiology referrals and to examine the clinical outcomes of patients who did not follow the recommendations. METHODS: We enrolled 589 consecutive patients who received in-hospital cardiology consultations. Data on recommendations, implementation of suggestions and outcomes were collected. RESULTS: Regarding adherence of the referring service to the recommendations, 77% of patients were classified in the adherence group and 23% were classified in the non-adherence group. Membership in the non-adherence group (p<0.001; odds ratio: 10.25; 95% CI: 4.45-23.62) and advanced age (pu200a=u200a0.017; OR: 1.04; 95% CI: 1.01-1.07) were associated with unfavorable outcomes. Multivariate analysis identified four independent predictors of adherence to recommendations: follow-up notes in the medical chart (p<0.001; OR: 2.43; 95% CI: 1.48-4.01); verbal reinforcement (pu200a=u200a0.001; OR: 1.86; 95% CI: 1.23-2.81); a small number of recommendation (pu200a=u200a0.001; OR: 0.87; 95% CI: 0.80-0.94); and a younger patient age (pu200a=u200a0.002; OR: 0.98; 95% CI: 0.96-0.99). CONCLUSIONS: Poor adherence to cardiology referral recommendations was associated with unfavorable clinical outcomes. Follow-up notes in the medical chart, verbal reinforcement, a limited number of recommendations and a patient age were associated with greater adherence to recommendations.

β-blocker therapy in non-cardiac surgery

The POISE trial (May 31, p 1839) of perioperative β blockade was admirable. However, I wonder whether the noble goal of the trial led to a design that was predictably fl awed and that should have been viewed as unethical. It was foreseeable that use of a controlled-release formulation of meto prolol that resulted in stable 24-h concentrations in plasma might have been problematic in an acute perio perative setting where a patient’s physiology can change strikingly in hours. Yet the justifi cation consisted of weak, disconnected pieces of evidence in irrelevant settings. The decision to use this potentially hazardous, longacting preparation was not evinced to be independent of the study’s association with AstraZeneca. Furthermore, although conceding “there is strong evidence that perioperative β blockers cause hypotension and bradycardia requiring treatment”, the arbitrary dose and dosing regimen lacked reference to any physiological or experimental rationale. The quasi justifi cation provided, post-hoc, in the Discussion was not sustainable. Similarly, no justifi cation was provided for why rigid, uniform, absolute haemodynamic cut-off values for withholding the drug were superior to a regimen which included consideration of an individual patient’s preoperative and contemporaneous clinical condition. Did any centres refuse to participate because of these concerns? Was the fact that intentionto-treat analysis underestimates adverse eff ects considered when the POISE Study Group examined the pretrial literature? In light of these issues, were patients reasonably informed? The premise that such a rigid, one-size-fi ts-all regimen could ever “provide a reliable assessment of the eff ects of β-blocker therapy in patients undergoing non-cardiac surgery” is highly unlikely. We are predictably left in a situation where the next question is: “What about 150 mg then?” The lack of a pretrial, sample-size correction for predictable non-compliance further confuses this issue. If there are too many factors to control to allow individualisation of the drug regimen, the answer is to conceive a more relevant study design.

Acute pericarditis with transient constriction: surgical impetus must be contained

Constrictive pericarditis is typically a chronic and progressive condition characterised by debilitating chronic right heart failure and surgical pericardiectomy remains the treatment of choice. Although most cases of acute pericarditis are self-limiting, an uncommon but known complication is a transient form of constrictive pericarditis that shares the same clinical features with the chronic form but resolves without surgical intervention. We report a case of a 29-year-old man with acute idiopathic pericarditis complicated with overt signs of constriction with complete recovery after medical treatment. The knowledge of this transient pattern of cardiac constriction complicating acute pericarditis may avoid unnecessary morbidity and mortality related to surgical procedure in a pericardium with acute inflammatory reaction.

A Prospective Randomized Controlled Trial of the Metabolic Effects of Sleeve Gastrectomy with Transit Bipartition

PurposeTo compare the effects of the sleeve gastrectomy with transit bipartition (SGu2009+u2009TB) procedure with standard medical therapy (SMT) in mildly obese patients with type II diabetes (T2D).MethodsThis is a prospective, randomized, controlled trial. Twenty male adults, ≤u200965xa0years old, with T2D, body mass index (BMI)u2009>u200928xa0kg/m2 and <u200935xa0kg/m2, and HbA1c levelu2009>u20098% were randomized to SGu2009+u2009TB or to SMT. Outcomes were the remission in the metabolic and cardiovascular risk variables up to 24xa0months.ResultsAt 24xa0months, SGu2009+u2009TB group showed a significant decrease in HbaA1c values (9.3u2009±u20092.1 versus 5.5u2009±u20091.1%, Pu2009=u2009<u20090.05) whereas SMT group maintained similar levels from baseline (8.0u2009±u20091.5 versus 8.3u2009±u20091.1%, Pu2009=u2009NS). BMI values were lower in the SGu2009+u2009TB group (25.3u2009±u20092.8xa0kg/m2 versus 30.9u2009±u20092.5xa0kg/m2; Pu2009=u2009<u20090.001). At 24xa0months, none patient in SGu2009+u2009TB group needed medications for hyperlipidemia/hypertension. HDL-cholesterol levels increased in the SGu2009+u2009TB group (33u2009±u20098 to 45u2009±u200915xa0mg/dL, Pu2009<u20090.001). After 24xa0months, the area under the curve (AUC) of GLP1 increased and in the SGu2009+u2009TB group and the AUC of the GIP concentrations was lower in the SGu2009+u2009TB group than in the SMT. At 3xa0months, SGu2009+u2009TB group showed a marked increase in FGF19 levels (74.1u2009±u200945.8 to 237.3u2009±u2009234xa0pg/mL; Pu2009=u20090.001).ConclusionsSGu2009+u2009TB is superior to SMT and was associated with a better metabolic and cardiovascular profile.

Comparison of high-sensitivity cardiac troponin I and T for the prediction of cardiac complications after non-cardiac surgery

Background: We aimed to directly compare preoperative high‐sensitivity cardiac troponin (hs‐cTn) I and T concentration for the prediction of major cardiac complications after non‐cardiac surgery. Methods: We measured hs‐cTnI and hs‐cTnT preoperatively in a blinded fashion in 1022 patients undergoing non‐cardiac surgery. The primary endpoint was a composite of major cardiac complications including cardiac death, cardiac arrest, myocardial infarction, clinically relevant arrhythmias, and acute heart failure within 30 days. We hypothesized that the type of surgery may impact on the predictive accuracy of hs‐cTnI/T and stratified all analyses according to the type of surgery. Results: Major cardiac complications occurred in 108 (11%) patients, 58/243 (24%) patients undergoing vascular surgery and 50/779 (6%, P < .001) patients undergoing non‐vascular surgery. Using regulatory‐approved 99th percentile cut‐off concentrations, preoperative hs‐cTnI elevations were less than one‐fifth as common as preoperative hs‐cTnT elevations (P < .001). Among patients undergoing vascular surgery, preoperative hs‐cTnI concentrations, but not hs‐cTnT, was an independent predictor of cardiac complications (adjusted odds ratio (aOR) 1.5, 95% confidence interval (95% CI) 1.0–2.1). The area under the receiver‐operating characteristics curve (AUC) was 0.67 (95% CI, 0.59–0.75) for hs‐cTnI versus 0.59 (95% CI 0.51–0.67, P = .012) for hs‐cTnT. In contrast, among patients undergoing non‐vascular surgery both preoperative hs‐cTnI and hs‐cTnT were independent predictors of the primary endpoint (aOR 1.6, 95% CI 1.3–2.0, and aOR 3.0, 95% CI 2.0–4.6, respectively) and showed higher predictive accuracy (AUC 0.77, 95% CI, 0.71–0.83, and 0.79, 95% CI 0.73–0.85, P = ns). Conclusions: Preoperative hs‐cTnI and hs‐cTnT concentrations predict major cardiac complications after non‐vascular surgery, while, in patients undergoing vascular surgery, hs‐cTnI may have better accuracy.