Pearila Brickner Namerow

Microvolt T-Wave Alternans Distinguishes Between Patients Likely and Patients Not Likely to Benefit From Implanted Cardiac Defibrillator Therapy A Solution to the Multicenter Automatic Defibrillator Implantation Trial (MADIT) II Conundrum

Background—In 2003, the Centers for Medicaid and Medicare Services recommended QRS duration as a means to identify MADIT II–like patients suitable for implanted cardiac defibrillator (ICD) therapy. We compared the ability of microvolt T-wave alternans and QRS duration to identify groups at high and low risk of dying among heart failure patients who met MADIT II criteria for ICD prophylaxis. Methods and Results—Patients with MADIT II characteristics and sinus rhythm had a microvolt T-wave alternans exercise test and a 12-lead ECG. Our primary end point was 2-year all-cause mortality. Of 177 MADIT II–like patients, 32% had a QRS duration >120 ms, and 68% had an abnormal (positive or indeterminate) microvolt T-wave alternans test. During an average follow-up of 20±6 months, 20 patients died. We compared patients with an abnormal microvolt T-wave alternans test to those with a normal (negative) test, and patients with a QRS >120 ms with those with a QRS ≤120 ms; the hazard ratios for 2-year mortality were 4.8 (P=0.020) and 1.5 (P=0.367), respectively. The actuarial mortality rate was substantially lower among patients with a normal microvolt T-wave alternans test (3.8%; 95% confidence interval: 0, 9.0) than the mortality rate in patients with a narrow QRS (12.0%; 95% confidence interval: 5.6, 18.5). The corresponding false-negative rates are 3.5% and 10.2%, respectively. Conclusion—Among MADIT II–like patients, a microvolt T-wave alternans test is better than QRS duration at identifying a high-risk group and also better at identifying a low-risk group unlikely to benefit from ICD therapy.

Mechanisms of Death in the CABG Patch Trial A Randomized Trial of Implantable Cardiac Defibrillator Prophylaxis in Patients at High Risk of Death After Coronary Artery Bypass Graft Surgery

BACKGROUND The CABG Patch trial compared prophylactic implantable cardiac-defibrillator (ICD) implantation with no antiarrhythmic therapy in coronary bypass surgery patients who had a left ventricular ejection fraction <0.36 and an abnormal signal-averaged ECG. There were 102 deaths among the 446 ICD group patients and 96 deaths among the 454 control group patients, a hazard ratio of 1.07 (P=0.63). The mechanisms of death were classified, and hypotheses were tested about the effects of ICD therapy on arrhythmic and nonarrhythmic cardiac deaths in the CABG Patch Trial and the Multicenter Automatic Defibrillator Implantation Trial (MADIT). METHODS AND RESULTS The 198 deaths in the trial were reviewed by an independent Events Committee and classified by the method of Hinkle and Thaler. Only 54 deaths (27%) occurred out of hospital; 145 deaths (73%) were witnessed. Seventy-nine (82%) of the 96 deaths in the control group and 76 (75%) of the 102 deaths in the ICD group were due to cardiac causes. Cumulative arrhythmic mortality at 42 months was 6.9% in the control group and 4.0% in the ICD group (P=0. 057). Cumulative nonarrhythmic cardiac mortality at 42 months was 12. 4% in the control group and 13.0% in the ICD group (P=0.275). Death due to pump failure was significantly associated with death >1 hour from the onset of symptoms, dyspnea within 7 days of death, and overt heart failure within 7 days of death. CONCLUSIONS In the CABG Patch Trial, ICD therapy reduced arrhythmic death 45% without significant effect on nonarrhythmic deaths. Because 71% of the deaths were nonarrhythmic, total mortality was not significantly reduced.

Coronary Artery Bypass Grafting in Patients With Low Ejection Fraction

Background—Patients with low ejection fraction (EF) are at a higher risk for postoperative complications and mortality. Our objective was to assess the effect of low EF on clinical outcomes after coronary artery bypass grafting (CABG). Methods and Results—We analyzed 55,515 patients from New York State database who underwent CABG between 1997 and 1999. Patients were stratified into 1 of the 4 EF groups: Group I (EF≤20%), Group II (EF 21% to 30%), Group III (EF 31% to 40%), and Group IV (EF>40%). History of previous myocardial infarction, renal failure, and congestive heart failure were higher in patients with low EF (all P<0.001). Group I experienced a higher incidence of postoperative respiratory failure (10.1% versus 2.9%), renal failure (2.5% versus 0.6%), and sepsis (2.5% versus 0.6%) compared with Group IV. In-hospital mortality was significantly higher in Group I (6.5% versus 1.4%; P<0.001). Multivariate analysis showed hepatic failure [odds ratio (OR), 11.2], renal failure (OR, 4.1), previous myocardial infarction (OR, 3.4), reoperation (OR, 3.4), emergent procedures (OR, 3.2), female gender (OR, 1.7), congestive heart failure (OR, 1.6), and age (OR, 1.04) as independent predictors of in-hospital mortality in the low EF group. The discharges to home rate were significantly lower in Group I versus Group IV (73.1% and 87.7%, respectively; P<0.001). Conclusions—Patients with low EF are sicker at baseline and have >4 times higher mortality than patients with high EF. However, outcomes are improving over time and are superior to historical data. Therefore, CABG remains a viable option in selected patients with low EF.

Illness representations and psychological distress in patients undergoing coronary artery bypass graft surgery.

Abstract Preoperative psychological distress has been shown to predict both postoperative distress and subsequent cardiac morbidity in patients undergoing coronary artery bypass graft (CABG) surgery. This study assessed the associations between illness perceptions and psychological well-being among 56 patients awaiting CABG surgery using the Profile of Mood States (POMS) and the Illness Perception Questionnaire-Revised (IPQ-R). Patient perceptions of their illness as chronic were associated with reduced beliefs in both personal control over illness and efficacy of treatment, and increased perceived consequences of illness in terms of life functioning. In addition, psychological distress regarding illness was significantly correlated with psychological distress in general. Reduced illness coherence was also associated with increased psychological distress. Preoperative psycho-education aimed at helping patients better understand their illness, treatment, and its effects may reduce psychological distress, and perhaps improve future well-being as a result.

Pregnancy outcomes among adolescent and older women receiving comprehensive prenatal care.

This study compares three birth outcomes, gestational age, birthweight, and type of delivery, among adolescent and older mothers. Data were collected from 911 women who attended a comprehensive prenatal-care program in a large urban teaching hospital. Women aged 13-19 years were at increased risk for low-birth-weight babies (less than 2500 g) and for preterm infants of fewer than 38 weeks gestation, even with antenatal care, ethnicity, and other factors controlled. Results of bivariate analyses suggested that women aged 20-36 years are more likely than adolescent mothers to have a cesarean section; however, multivariate analyses suggested that maternal age was not an important factor in relation to type of delivery. Thus, even with similar comprehensive care, pregnant adolescents were at an increased risk of some adverse outcomes. However, the amount of antenatal care is a more important predictor of pregnancy outcome than is maternal age.

A pilot study to assess the effects of a guided imagery audiotape intervention on psychological outcomes in patients undergoing coronary artery bypass graft surgery.

Depression and anxiety are associated with increased risk of postoperative cardiac events and death in patients who have undergone coronary artery bypass graft surgery. These risks persist even several months after the procedure. Guided imagery has been used with cardiac surgery patients for some time and with numerous anecdotal reports of considerable benefit. In addition, this therapy is low-cost and easy to implement, and the literature holds ample evidence for its efficacy in symptom reduction in various patient populations. It was thus hypothesized that preoperative use of guided imagery would reduce postoperative distress in patients undergoing coronary artery bypass graft. Fifty-six patients scheduled to undergo coronary artery bypass graft at Columbia University Medical Center were randomized into 3 groups: guided imagery, music therapy, and standard care control. Patients in the imagery and music groups listened to audiotapes preoperatively and intraoperatively. All patients completed psychological, complementary medicine therapies use, and other assessments preoperatively and at 1 week and 6 months postoperatively. Only preoperative distress was predictive of postoperative distress at follow-up. Use of complementary medicine therapies was high in all groups and this fact, in addition to the small sample size, may have accounted for the lack of significant relationship between imagery and postoperative distress. Regardless, this complementary and alternative medicine therapy remains palatable to patients. Given its efficacy in other patient populations, it is worth exploring its potential utility for this population with a larger sample.

Adoption Versus Parenting Among Young Pregnant Women

Three groups of young pregnant women living in maternity residences--those who intended to place their babies for adoption, those who considered adoption but planned to parent and those who never considered adoption--were compared regarding their socioeconomic characteristics, attitudes toward adoption and the personal influences on their decisions. Of the 430 young women, those who intended to place their babies for adoption tended to be at one extreme on most profile variables, those who had considered placing were in an intermediate position, and those who never considered placing their babies were at the other extreme. Placers were both the most advantaged socioeconomically and held the most positive attitudes toward adoption, while young women who never considered adoption were the least advantaged and held the least favorable attitudes. Placers consistently reported that their choice to place their babies rather than parent would increase the likelihood of outcomes such as continuing with school, having enough money to live comfortably and benefiting the babys emotional development, while those young women who did not consider adoption tended to feel that these outcomes would be more likely if they parented, or that the likelihood of the outcomes would not be affected by their choice. Young women who intended to place their babies were encouraged in that direction by their mothers, fathers and boyfriends, while the two groups of women who chose parenting were encouraged to do so by those in their social networks.

Pregnancy Risk Taking among Adolescents

This research tests the utility of Kristin Lukers cost-benefit theory for adding to explanations of pregnancy risk taking among teenagers. The data come from interviews with 425 teen women in New York. The findings offer support for the Luker model since in an equation also including background variables and level of ego development, four of the six Luker variables (the subjective probabilities of pregnancy and abortion and the disadvantages of pregnancy and birth control) were significantly related to pregnancy risk taking. The most parsimonious model to explain risk taking includes five Luker variables, as well as welfare history, a measure of previous risk taking, and level of ego development.

The effectiveness of contingency-planning counseling.

A longitudinal study assessed the effectiveness of contingency-planning counselling on contraceptive use and pregnancy outcomes among patients at a family planning clinic. Of 914 women enrolled in the study, 502 received traditional family planning counseling that focused on the provision of information and the selection of a contraceptive method, and 412 received contingency-planning counseling, which provided additional attention to possible problems that might arise with contraceptive use and the particular method selected. Although contingency-planning counseling was favorably received by both patients and staff members, patients in the two groups did not differ significantly on most of the outcomes considered. The two counseling groups had remarkably similar rates of clinic continuation at both the six- and 12-month follow-ups and analogous patterns of contraceptive use. In an exception to this pattern, the six-month pregnancy rate was significantly reduced among contingency-counseled patients who had ever been pregnant. However, the effectiveness of the intervention in reducing the likelihood of unintended pregnancy was short-lived: At 12 months, the pregnancy rate among ever-pregnant women was the same for traditionally counseled patients as for those receiving contingency-planning counseling.

The effectiveness of contraceptive programs for teenagers

This paper critically reviews the effectiveness of adolescent family planning programs in the United States. Various models for evaluating family planning programs and the findings from empirical studies of adolescent programs are reviewed. During the past decade there have been major increases in the availability and utilization of contraceptive services by adolescents. Most of those who are sexually active are now aware that these services exist. Program continuation rates among adolescents are not high, in part, because of the sporadic nature of adolescent sexual activity. Data on contraceptive continuation and pregnancy rates in these programs are limited, since few studies follow up clinic noncontinuers. Among clinic continuers pregnancy rates are relatively low, suggesting that at least some programs are effective in reducing pregnancy and/or fertility rates (number of children born) in their target populations. Ecological analyses seem to indicate that programs have had an impact on adolescent marital fertility.