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Patients with chest pain are typically taken by ambulance to the nearest hospital approved to take emergency cases; but your patients are getting the message through the popular press that the hospital closest to their home (or closest to the site of their infarction) may not be the best place to go if they get a heart attack.
Media such as The New York Times had front-page stories in late May announcing findings of Johns Hopkins investigators who compared 30-day and one-year mortality rates of 100,000 infarction patients who were treated at 4,000 hospitals — high-volume and low-volume facilities closest to their homes.1
The investigators found that after they adjusted for differences in severity, the patients treated at the lowest-volume hospitals were 17% more likely to die within 30 days after admission than were those treated at the highest-volume hospitals. High-volume hospitals were those that averaged at least 4.4 heart attack patients a week, and low-volume sites treated 1.4 or fewer. Also, the investigators found that the use of aspirin, beta-blockers, and other treatments accounted for about one-third of the survival benefit at the high-volume hospitals. The rest is chalked up to experience of doctors, nursing staff, and technicians.
1. Thiemann DR, Coresh J, Oetgen WJ, et al. The association between hospital volume and survival after acute myocardial infarction in elderly patients. N Engl J Med 1999; 340:1,640-1,648.
Late in May, the Food and Drug Administration (FDA) approved dalteparin sodium injection (Pharmacia & Upjohn’s Fragmin) for the treatment of unstable angina and non-Q-wave myocardial infarction for patients on concurrent aspirin therapy. A low molecular weight heparin, Fragmin provides the cardiologist an opportunity to stabilize a patient awaiting additional testing and treatment of underlying causes during the acute phase, decreasing the risk of unexpected heart attack.
The FDA approval of Fragmin was based on the results of two large, international clinical studies that showed use of Fragmin significantly lowers the risk of heart attack and death when administered twice-daily concurrently with aspirin to patients during the acute phase of treatment — five to eight days — of unstable angina and non-Q-wave myocardial infarction. Fragmin has a predictable anti-thrombotic effect, eliminating the need for laboratory monitoring. First approved in the United States in 1995 for prevention of deep-vein thrombosis in patients undergoing abdominal surgery who are at risk for thromboembolic complications, it is also indicated for patients undergoing hip replacement surgery. Fragmin injection is available in packs of 10 single-dose prefilled syringes in two strengths, 2500 IU and 5000 IU, as well as a 95,000 IU multi-dose vial. Fragmin should not be given to patients undergoing regional anesthesia or patients with active major bleeding, and it should be used with caution in patients receiving neuroaxial anesthesia or spinal puncture, and in those with a history of heparin-induced thrombocytopenia.
The use of ß2-agonist metered-dose inhalers increases the risk of myocardial infarction (MI) by more than threefold in patients with a history of cardiovascular disease, according to a recent study presented at the American Lung Association/American Thoracic Society International Conference in San Diego in April. Investigators reviewed the records of nearly 1,500 patients hospitalized for a first MI and more than 4,000 matched controls. Patients who had received one ß2-agonist inhaler during the three months prior to hospitalization were 67% more likely than others to have a first MI.
The investigators said that ß2-agonists prescribed for airflow limitation may themselves increase the risk of MI via a biologic mechanism, or the therapy might be coincident in that it is prescribed for nonspecific chest discomfort, which could be the result of angina.
"Regardless," stated the lead researcher, "physicians should use caution when prescribing ß2-agonists for the first time in patients with cardiovascular disease." He recommended that physicians consider alternative diagnoses, such as angina, in patients with a history of cardiovascular disease or several cardiovascular risk factors and present with symptoms of airway inflammation, particularly if symptoms do not resolve with ß2-agonist therapy.
However, he stressed that ß2-agonists are relatively safe and remain the first-line therapy for airflow limitation caused by asthma and chronic obstructive pulmonary disease.
At the American Heart Association’s recent Scientific Conference on Compliance in Healthcare and Research in Boston, a cardiologist reported that many of his colleagues fail to implement guidelines for risk factor management of patients with coronary heart disease (CHD).
Joseph P. Frolkis, MD, of the Cleveland (OH) Clinic said he had done previous research that found that many cardiologists fail to screen for risk factors in post-CABG patients and fail to implement strategies to reduce risk at the time these patients are discharged. That spurred his present study for which he and his team screened and developed specific recommendations for post-surgery risk management for half of 150 patients and offered no intervention for the other half. Frolkis stated in a press release that they found two things: As in the initial study, cardiologists dealt with risk factors less than half the time, and even when the team did risk assessments for them and made treatment recommendations, it made "absolutely no difference."
People with Marfan syndrome should be carefully monitored for development of an aortic aneurysm and should be treated early, according to a large international study led by physicians at the Johns Hopkins Hospital in Baltimore.1
The risk of death for Marfan syndrome patients is eight times higher when they wait until they require emergency surgery for the aneurysms. Results of the study showed that death rates from surgical repair of the aneurysm were only 1.5% when done early, compared to 12% among patients who underwent emergency repair.
In Marfan, a connective tissue disorder, the aorta is weakened and prone to enlargement. Without proper monitoring and medications to reduce stress on the aorta, it could tear, resulting in sudden death. Surgery to repair an aortic aneurysm is no longer a high-risk procedure when done early, stated lead study author Vincent L. Gott, MD. Results are similar to those from bypass operations.
"The frightening thing for Marfan syndrome patients is that often the aneurysm has no symptoms until it becomes life-threatening, at which point they have terrible chest pain," Gott said. Aneurysms frequently are not seen on chest X-rays, so, he said, physicians need to pay close attention to their patients and check for aneurysms by echocardiogram.
For the study, researchers examined the records of 675 Marfan syndrome patients who underwent replacement of the aortic root at 10 surgical centers. The average size of their aneurysms was 6.5 cm. Among 455 patients who underwent elective surgery to repair the aneurysm, the death rate was 1.5%. By contrast, the mortality rate was 2.6% among the 117 patients who underwent urgent repair within seven days of surgical consultation and 12% among the 103 patients who underwent emergency repair within 24 hours. While all patients had a high risk of death for approximately 60 days following surgery, 93% of patients were still alive a year later, and 59% were still alive 20 years later.
1. Gott VL, Greene PS, Alejo DE, et al. Replacement of the aortic root in patients with Marfan’s syndrome. N Engl J Med 1999; 340:1,307-1,313.