Satish C. Sharma

Operative blood loss, blood transfusion, and 30-day mortality in older patients after major noncardiac surgery.

Objective:Anemia and operative blood loss are common in the elderly, but evidence is lacking on whether intraoperative blood transfusions can reduce the risk of postoperative death. Methods:We analyzed retrospective data from 239,286 patients 65 years of older who underwent major noncardiac surgery in 1997 to 2004 at veteran hospitals nationwide. Propensity-score matching was used to adjust for differences between patients who received intraoperative blood transfusions (9.4%) and those who did not, and data were used to determine the association between intraoperative blood transfusion and 30-day postoperative mortality. Results:After propensity-score matching, intraoperative blood transfusion was associated with mortality risk reductions in patients with preoperative hematocrit levels of <24% (odds ratio: 0.60, 95% CI: 0.41–0.87), and in patients with hematocrit of 30% or greater when there is substantial (500–999 mL) blood loss (odds ratio: 0.35, 95% CI: 0.22–0.56 for hematocrit levels between 30%–35.9% and 0.78, 95% CI: 0.62–0.97 for hematocrit levels of 36% or greater). When operative blood loss was <500 mL, transfusion was not associated with mortality reductions for patients with hematocrit levels of 24% or greater, and conferred increased mortality risks in patients with preoperative hematocrit levels between 30% to 35.9% (odds ratio 1.29, 95% CI: 1.04–1.60). Conclusions:Intraoperative blood transfusion is associated with a lower 30-day postoperative mortality among elderly patients undergoing major noncardiac surgery if there is substantial operative blood loss or low preoperative hematocrit levels (<24%). Transfusion is associated with increased mortality risks for those with preoperative hematocrit levels between 30% and 35.9% and <500 mL of blood loss.

Usefulness and tolerability of Hirulog, a direct thrombin-inhibitor, in unstable angina pectoris

In an open-label pilot study of 20 patients with unstable angina (Braunwald class I-IIIB), hirulog was administered as a continuous intravenous infusion for 5 days in a dose of 0.2 mg/kg/hour to produce an activated partial thromboplastin time of approximately 200% of control. The primary end points of the study were: death, development of a transmural myocardial infarction, and intractable angina needing interventions such as an intraaortic balloon pump insertion, angioplasty and surgery. The secondary end points were the presence of an intracoronary thrombus detected on angiography and hemorrhagic complications during therapy. There was no death or transmural infarction in this study cohort; however, 1 patient developed intractable angina. Intracoronary thrombus was documented in 2 patients. Infusion of hirulog resulted in a steady prolongation of the activated partial thromboplastin time without any hemorrhagic or other adverse effect. Hirulog appears to be an effective antithrombotic agent that is tolerated well and may have advantages over heparin in the management of patients with unstable angina.

Cause and impact of pulmonary hypertension in isolated aortic stenosis on operative mortality for aortic valve replacement in men

Significant pulmonary hypertension is considered to be an infrequent finding in patients with aortic stenosis (AS).1,2 When present, it is usually thought to be related to either markedly depressed left ventricular systolic function, or associated mitral valve or pulmonary disease.3,4 However, there are very few reports that examined the pathogenesis and clinical significance of pulmonary hypertension in isolated AS. Therefore, the objective of this study was to determine the incidence and pathophysiology of pulmonary hypertension in isolated AS, and its effect on operative mortality for aortic valve replacement.

Value of fluoroscopy in the detection of coronary stenosis: influence of age, sex, and number of vessels calcified on diagnostic efficacy

Although fluoroscopically detected coronary artery calcification is known to correlate with the presence of coronary artery stenosis, age, sex, and extent of calcification influence the strength of this association. To clarify its diagnostic potential, we performed fluoroscopy before coronary angiography in 600 patients and analyzed the results according to all three factors simultaneously. The sensitivity of fluoroscopy for significant stenosis exceeded 65% in all groups except women less than 45 years of age. Specificity exceeded 90% in patients less than 45 years and 85% in patients less than 55 years of age, and declined significantly with age. The number of vessels calcified was an important determinant of predictive value, except in those less than 45 years of age in whom even a single mild calcification markedly increased the chance of stenosis. In patients aged 45 to 64 years, calcification of two or three vessels substantially increased the chances of stenosis, but single-vessel calcification increased the risk only slightly. In patients more than 65 years of age, fluoroscopy was not helpful in detecting stenosis, regardless of the number of vessels calcified. Our findings were similar in men and women. We conclude that if both age and the number of vessels calcified are considered, fluoroscopy can provide useful information regarding the presence of stenosis in young and middle-aged patients.

Comparison of sotalol versus amiodarone in maintaining stability of sinus rhythm in patients with atrial fibrillation (Sotalol-Amiodarone Fibrillation Efficacy Trial [Safe-T])

The Sotalol-Amiodarone Fibrillation Efficacy Trial (SAFE-T) is a randomized, double-blind, multicenter, placebo-controlled trial in which the effects of sotalol and amiodarone in maintaining stability of sinus rhythm are being examined in patients with persistent atrial fibrillation at 20 Veterans Affairs medical centers. The time to the occurrence of atrial fibrillation or flutter in patients with atrial fibrillation converted to sinus rhythm is the primary outcome measure, with a number of parameters as secondary end points. SAFE-T had randomized 665 patients when enrollment terminated on October 31, 2001. Follow-up of patients continued until October 31, 2002, for a maximum period of 54 months and a minimum period of 12 months for all patients.

Emergency Department Use of Aspirin in Patients with Possible Acute Myocardial Infarction

Prompt administration of thrombolytic agents is strongly emphasized in the management of patients who have acute myocardial infarction [1, 2]. In contrast, timely use of aspirin in patients who have acute coronary syndromes has received less attention despite the proven efficacy of aspirin [3] and guidelines that advocate immediate administration of aspirin [4]. Several studies have reported suboptimal use of aspirin. Ellerbeck and colleagues [5] reported that 77% of patients who were hospitalized for myocardial infarction received aspirin when discharged. Krumholz and colleagues [6] reported that 61% of patients older than 65 years of age received aspirin during the first 2 days of hospitalization. To date, no in-depth study has analyzed the administration and timing of aspirin therapy in emergency department patients who have suspected or potential acute myocardial infarction. Our study, the Brown Acute Aspirin Intervention Review (BAAIR) Study, evaluated the use of aspirin in hospital emergency settings. Methods We conducted a retrospective analysis of admissions to the emergency departments of four hospitals affiliated with Brown University. Each hospital represented a different patient population and a different level of cardiovascular service. One was a Veterans Administration hospital without a cardiac catheterization laboratory, two were community hospitals with diagnostic cardiac catheterization laboratories, and one was a community hospital with an active referral center where percutaneous cardiovascular revascularization procedures and cardiac surgery are performed. After we received approval from the institutional review board of each hospital, we evaluated the records of all patients who were admitted between 1 January 1994 and 31 December 1994. We identified patients who had any of the following discharge diagnoses: acute myocardial infarction, other acute and subacute ischemic heart diseases, angina pectoris, other ischemic heart diseases, heart failure, other heart diseases, and chest pain (diagnosis-related group codes 410, 411, 413, 414, 428, 429, and 786.4). Records were excluded if documentation was incomplete, if the patient was directly admitted or transferred [that is, if an emergency department record did not exist], if the hospital record could not be located or was incomplete, or if an acute coronary syndrome had not been suspected by the emergency department physician. We tabulated 1) demographic variables; 2) history of cardiovascular disease and its risk factors [whether patients were older than 55 years of age; had a history of diabetes, hypertension, or hypercholesterolemia; had a family medical history positive for cardiovascular disease; and had a previous coronary event]; 3) current medical therapy; 4) initial clinical impression of the emergency department physician [acute myocardial infarction, unstable angina, chest pain with high or low suspicion of myocardial ischemia, and congestive heart failure]; 5) interpretation of the initial electrocardiogram; 6) allergy or contraindication to aspirin [history of a hemorrhagic stroke, gastrointestinal bleeding, or a bleeding disorder]; 7) amount of time between arrival in the emergency department and initiation of aspirin therapy; and 8) documentation of acute myocardial infarction during the subsequent hospital stay (the diagnosis was made if creatine kinase-MB levels increased to above normal as documented by serial measurement or if two of the following three criteria were met: chest pain, twofold elevation of the creatine kinase level, or new Q waves on the electrocardiogram). The mean age SD was determined, and the Student t-test was used to evaluate significant differences (P < 0.05) in aspirin administration (yes or no) as the grouping variable. Frequency tables were generated for remaining variables. The Pearson chi-square test was used for these data. Results Demographic and Clinical Characteristics We found 2383 medical records that met our study criteria (Table 1). Hypertension was the most prevalent cardiac risk factor (58% of patients); 43% of patients had previously documented coronary artery disease, and 35% reported receiving long-term aspirin therapy. Allergy or contraindication to aspirin was confirmed in 101 patients (4%). The initial electrocardiogram taken by emergency department staff showed an acute injury pattern in 190 patients (8%). Aspirin use was higher in younger persons, particularly those with ST-segment elevation on electrocardiography (P < 0.001). Aspirin was also used more frequently in male patients, current smokers, and patients with a family history of heart disease. Table 1. Characteristics of Study Patients Many factors were associated with less frequent use of aspirin. Among the patients already receiving long-term aspirin therapy, 23% received aspirin in the emergency department compared with 33% of patients who were not previously receiving an aspirin regimen (P < 0.001). Similarly, 17% of patients receiving long-term warfarin therapy were given aspirin compared with 31% of patients who were not receiving warfarin therapy (P < 0.001). Diagnosis on Admission to the Emergency Department The initial diagnosis made by the emergency department physician (Table 2) was acute myocardial infarction in 220 patients (9%), unstable angina in 911 patients (38%), chest pain with high suspicion of ischemia in 561 patients (24%), chest pain with low suspicion of ischemia in 262 patients (11%), and congestive heart failure in 382 patients (16%). In 47 patients (2%), the diagnosis on admission to the emergency department was not documented. Table 2. Initial Clinical Impression and Treatment Decision in the Emergency Department Compared with Discharge Diagnosis Timing and Relation of Aspirin Therapy to Diagnosis The overall frequency of the use of aspirin by emergency department physicians was 30% (712 of 2383 patients). The difference in the use of aspirin on the basis of initial clinical impression was significant: More patients received aspirin if the physician initially believed that they had acute myocardial infarction (P < 0.001) (Table 2). Of the patients who received aspirin, 22% received it within 30 minutes of arrival, 24% received it between 30 and 60 minutes of arrival, and 54% received it 1 hour after arrival. According to hospital records, acute myocardial infarction was subsequently diagnosed in 463 patients (19%); 253 of these patients (55%) did not receive aspirin in the emergency department. The discharge diagnosis of acute myocardial infarction was established in 17% of patients whose initial diagnosis had been unstable angina or congestive heart failure. Less than 5% of patients who had chest pain associated with a low likelihood of ischemia had a discharge diagnosis of acute myocardial infarction. Discussion Our study demonstrates that aspirin is underutilized in patients who are admitted with suspected myocardial infarction and related syndromes that prove to be acute myocardial infarctions at discharge. Furthermore, of the patients who did receive aspirin in the emergency department, the delay in administration of aspirin after arrival was substantial. Overall, 45% of patients who had been documented at discharge as having had acute myocardial infarction had received aspirin in the emergency department. Aspirin was most likely to be used when acute myocardial infarction was initially suspected. That this diagnosis also proved to be accurate in 17% of patients who were admitted with unstable angina or congestive heart failure is noteworthy. A rigid approach that restricts aspirin use to patients who are admitted with the strongest evidence of acute myocardial infarction deprives many others of the benefits of early aspirin therapy. Guidelines published in 1994 recommended the immediate administration of 160 mg of aspirin to patients in whom myocardial infarction is suspected [4]; this recommendation was recently reaffirmed [7]. Strong clinical evidence supports the efficacy of aspirin. The ISIS-2 (Second International Study of Infarct Survival) trial [3] that involved more than 17 000 patients with suspected myocardial infarction revealed a 23% reduction in the mortality rate of patients who received aspirin alone and an additional 19% reduction when aspirin was given with streptokinase. The incidence of nonfatal myocardial infarction was also reduced by 49% [3]. In patients who had unstable angina, several studies have shown strong evidence that supports the role of aspirin [8-10]. The use of aspirin has apparently been influenced by clinical trials. Between 1987 and 1990, aspirin use before myocardial infarction increased from 16% to 24% and aspirin use after myocardial infarction increased from 39% to 72% [11]. Krumholz and colleagues [6] reported that aspirin therapy was initiated in 56% of elderly Medicare patients within the first 24 hours of hospitalization. However, they did not evaluate the use of aspirin in emergency departments. Other evaluations of aspirin therapy have also shown that practitioners who refer patients for hospital admission underutilize aspirin therapy [12, 13]. Our data show that 17% of patients who were admitted with a diagnosis of unstable angina proved to have acute myocardial infarction at discharge. An identical rate was noted in patients who presented with congestive heart failure. Many elderly patients who have acute myocardial infarction may initially show signs of pulmonary congestion in the absence of chest pain. On the basis of our data, we propose that emergency department physicians give aspirin to all patients who are to be admitted to the hospital for possible myocardial infarction, with the possible exception of patients in whom suspicion of an acute coronary event is low. Aspirin may be particularly useful in elderly patients who present with unexplained heart failure. Our study, which addresses the underutilization of aspirin in patients wi

Multidisciplinary Group Behavioral and Pharmacologic Intervention for Cardiac Risk Reduction in Diabetes A Pilot Study

PURPOSE The purpose of this study was to evaluate the effectiveness of a multidisciplinary team providing both education and medication management in a group setting for cardiac risk reduction in patients with diabetes mellitus. METHODS The electronic medical records of patients with diabetes who participated in group behavioral and pharmacologic interventions for cardiac risk reduction during May to October 2002 at the Providence VA Medical Center were reviewed. Forty-one veterans with diabetes mellitus attended the weekly sessions of a diabetes education and intervention program directed by pharmacists for 1 month. Two groups of 15 to 20 patients received four 1.5-hour diabetes self-management education classes provided by a multidisciplinary team consisting of a pharmacist (leader), nurse educator, dietician, physical therapist, and social worker and four 1-hour group medication adjustment sessions provided by the pharmacist. Pharmacists followed medication adjustment algorithms for blood pressure, diabetes, and cholesterol management previously developed in collaboration with physician specialists in the field. Baseline and 3-month after-intervention data were collected for glycosylated hemoglobin A1C (A1C), systolic and diastolic blood pressure (SBP and DBP, respectively), low-density lipoprotein cholesterol, and body mass index. RESULTS Thirty-six patients attended 4 sessions, and 5 patients attended 3 sessions. All parameters improved after the intervention, with significant reductions in A1C (-1.5% +/- 1.0%) and DBP (-5 mm Hg). Reductions were further accentuated when baseline values were abnormal, with significant improvement in A1C (-2.0% +/- 0.5%), SBP (-14 +/- 3 mm Hg), and DBP (-13 +/- 3 mm Hg). CONCLUSIONS Short-term multidisciplinary group behavioral and pharmacologic intervention programs may be effective in improving cardiac risk factors in patients with diabetes.

Vulnerability to ventricular fibrillation in patients with clinically manifest ventricular tachycardia

Ventricular vulnerability may be assessed by measuring the threshold current for the induction of ventricular fibrillation (VF). This technique has been widely utilized in animal experimentation and has been safely applied in a small number of clinical studies. We measured the VF threshold (VFT), using the single stimulus technique in 10 patients with coronary artery disease just prior to the institution of cardiopulmonary bypass. There were no adverse effects of VFT measurement. Three patients had nonsustained ventricular tachycardia (VT) on 24-hour ambulatory monitoring and had VFTs of 10, 14, and 16 mA. In this group VF was induced without any preceding repetitive ventricular responses. Seven patients had no repetitive forms on ambulatory monitoring. Their VFTs ranged from 30 to greater than 40 mA (mean greater than 37). Repetitive extrasystoles were regularly observed in this group at current intensities which ranged from 53% to 80% of the VFT. Thus patients with manifest VT appear to have an enhanced vulnerability to VF. Single or multiple responses were not observed in these patients but appeared to be present in patients with coronary disease and no demonstrable rhythm disorder.

Echocardiographic predictors of mortality in patients with pulmonary hypertension and cardiopulmonary comorbidities.

Objective We aimed to identify the echocardiographic measures associated with survival in a patient population with a high prevalence of co-morbid cardiovascular and pulmonary disease that have significantly elevated estimated pulmonary artery systolic pressures (ePASP). Background Pulmonary hypertension (PH) is a clinical feature of several cardiopulmonary diseases that are prevalent among elderly. While certain echocardiographic parameters have been shown to be important in the prognosis in specific PH groups, the prognostic relevance of echocardiographic characteristics in a cohort with multiple cardiopulmonary comorbidities is unclear. Methods We retrospectively identified 152 patients with ePASP > 60 mmHg by echocardiography over a five year period (6/2006–11/2011) and followed until 4/2013. Candidate clinical and echocardiographic characteristics suggestive of PH severity were compared between deceased and surviving subpopulations. Cox proportional hazard modeling was used to identify echocardiographic predictors of death adjusted for age and clinical characteristics. Results This was a predominantly elderly (age 78.8 ± 10.2 years), male (98.7%) cohort with several cardiopulmonary comorbidities. Overall mortality was high (69.7%, median survival 129 days). After adjusting for age and clinical characteristics, decreased right ventricular (RV) systolic function assessed by tricuspid annular plane systolic excursion (HR 0.56, 95% CI 0.33–0.96, p = 0.034) and increased RV thickness (HR: 4.34, 95% CI: 1.49–12.59, p = 0.007) were independently associated with mortality. In contrast, left ventricular systolic function, left ventricular diastolic parameters, ePASP, or echo-derived pulmonary vascular resistance (PVR) were not associated with increased mortality. Conclusion In a cohort of patients with PH and high prevalence of cardio-pulmonary comorbidities, RV systolic function and hypertrophy are associated with mortality and may be the most relevant echocardiographic markers for prognosis.

Use of High-Sensitivity Troponin Assays Predicts Mortality in Patients With Normal Conventional Troponin Assays on Admission—Insights From a Meta-Analysis

Use of high‐sensitivity troponin (hs‐Tn) assays can detect small levels of myocardial damage previously undetectable with conventional troponin (c‐Tn) assays. However, prognostic utility of these hs‐Tn assays in prediction of mortality remains unclear in the presence of nonelevated c‐Tn levels on admission. A systematic review and meta‐analysis was performed to assess mortality risk of patients with hs‐Tn elevations in the setting of normal c‐Tn levels.