Robert DuBroff

Ultra-fast track hospital discharge using conventional cardiac surgical techniques.

BACKGROUND Recent introduction of minimally invasive adult cardiac surgical techniques has emphasized the advantage of early hospital discharge. However, we chose an alternative approach to determine the safety, efficacy, and feasibility of ultra-fast track protocols while retaining both standard surgical exposure (median sternotomy) and conventional cardiac surgical techniques (hypothermia, cardiopulmonary bypass with cardiac arrest, and optimal myocardial protection). METHODS From September 1995 to January 1998, a total of 258 consecutive patients underwent cardiac procedures by a single surgeon. Acceleration of clinical pathways was used to initiate earlier discharges. Stringent postdischarge follow-up was implemented. Prospectively entered data were then analyzed retrospectively. RESULTS A variety of isolated as well as combined coronary and valve procedures were performed. Of the 258 patients operated on during this entire study period, a total of 144 patients (56%) were discharged within postoperative days 1 to 4 (ultra-fast track discharge). Over the past 12 months, this incidence increased to 70% (76 of 108 patients). Approximately 50% of these patients were operated on urgently or emergently. To date, there have been no deaths in this ultra-fast track group. There were eight brief readmissions, of which one was for rewiring of a noninfected sternal dehiscence, and the remaining were for cardiac diagnostic studies or a noncardiac problem altogether. CONCLUSIONS Conventional cardiac operation can allow ultrafast hospital discharges while retaining the advantage of time-tested techniques and providing wider application without requiring new or additional training or equipment.

Cholesterol confusion and statin controversy

The role of blood cholesterol levels in coronary heart disease (CHD) and the true effect of cholesterol-lowering statin drugs are debatable. In particular, whether statins actually decrease cardiac mortality and increase life expectancy is controversial. Concurrently, the Mediterranean diet model has been shown to prolong life and reduce the risk of diabetes, cancer, and CHD. We herein review current data related to both statins and the Mediterranean diet. We conclude that the expectation that CHD could be prevented or eliminated by simply reducing cholesterol appears unfounded. On the contrary, we should acknowledge the inconsistencies of the cholesterol theory and recognize the proven benefits of a healthy lifestyle incorporating a Mediterranean diet to prevent CHD.

Cholesterol paradox: a correlate does not a surrogate make

The global campaign to lower cholesterol by diet and drugs has failed to thwart the developing pandemic of coronary heart disease around the world. Some experts believe this failure is due to the explosive rise in obesity and diabetes, but it is equally plausible that the cholesterol hypothesis, which posits that lowering cholesterol prevents cardiovascular disease, is incorrect. The recently presented ACCELERATE trial dumbfounded many experts by failing to demonstrate any cardiovascular benefit of evacetrapib despite dramatically lowering low-density lipoprotein cholesterol and raising high-density lipoprotein cholesterol in high-risk patients with coronary disease. This clinical trial adds to a growing volume of knowledge that challenges the validity of the cholesterol hypothesis and the utility of cholesterol as a surrogate end point. Inadvertently, the cholesterol hypothesis may have even contributed to this pandemic. This perspective critically reviews this evidence and our reluctance to acknowledge contradictory information.

The statin diabetes conundrum: short-term gain, long-term risk or inconvenient truth?

Statin drugs have become the mainstay of many cardiovascular disease prevention guidelines and are recommended for most adult patients with diabetes. A careful review of the evidence, however, suggests that the clinical benefits of statins in diabetes may have been overstated by relying on meta-analyses that incorporate randomised controlled trials (RCTs) neither designed nor powered to assess the effects of statins in diabetes. Multiple RCTs specifically designed and powered to study the effects of statins in diabetes have demonstrated inconsistent clinical benefits and no mortality benefit. The conclusions of these meta-analyses should not supersede the results of these large, well-conducted RCTs. Reports that conclude that the benefits of statins outweigh the risks have probably underestimated the long-term risks of statin exposure and the deleterious consequences of long-term diabetes.

Should Statin Therapy Be Guided by Cardiovascular Risk Models

Cholesterol-lowering statin drugs have become the mainstay of many cholesterol guidelines and are intended to reduce the risk of atherosclerotic cardiovascular disease and death. In general, the use of statins after a cardiovascular event is well established, whereas the recommendation for primary prevention statin therapy is often based upon a risk calculation. If a patient’s estimated 10-year atherosclerotic cardiovascular disease risk exceeds 7.5%, then statin therapy is recommended because higher-risk patients are believed to benefit most from statin therapy. Tremendous effort has been expended to find the best risk calculator, but rather than debate which risk calculator is best, it may be more productive to examine the fundamental assumption that statin therapy guided by an atherosclerotic cardiovascular disease risk calculation actually saves lives, reduces atherosclerotic cardiovascular disease, and avoids unnecessary treatment in low-risk individuals.

Intestinal Tamponade: Cardiac Compression by Intestinal Contents

Intrapericardial herniations represent a rare complication of abdominal or chest trauma. We describe clinical tamponade that developed in an elderly patient after manual reduction of an umbilical hernia. Echocardiography disclosed loops of bowel within the pericardium confirming the clinical diagnosis and leading to successful surgical repair.

Are diabetes guidelines truly evidence based

The global epidemic of obesity and diabetes underscores the urgency to develop strategies to prevent cardiovascular (CV) disease in this vulnerable population. Clinical guidelines are intended to help the clinician manage these patients, but guidelines are often discordant among professional organizations and not always evidence based. Clinicians must rely upon the best available evidence, and therefore we critically reviewed the evidence behind the American Diabetes Association (ADA) 2016 guidelines on the prevention of CV disease in diabetes. We believe the most robust evidence comes from randomized controlled trials specifically designed for diabetes with hard clinical endpoints such as mortality and CV events. Our analysis supports the ADA recommendations regarding a Mediterranean diet, glycemic control, and BP control, but we believe the evidence to support aspirin and statin therapy in diabetes is inconclusive. This discordance may be multi-factorial including the exclusion of some relevant studies and an over-reliance upon subgroup and meta-analysis. Given the lack of mortality benefit and inconsistent clinical benefits of aspirin and statins, it is essential that clinicians individualize treatment decisions while carefully weighing the risks and harms of any intervention.