NEWS BRIEFS
NEWS BRIEFS
ACI-TIPI accurately distinguishes conditions
A computerized prediction device could be in your future, but can it improve the accuracy of triage decisions on the probability of acute ischemia? Yes, say researchers who recently looked at nearly 11,000 chest pain patients presenting at 10 emergency departments (ED) around the country. They determined that use of their "acute cardiac ischemia time-insensitive predictive instrument" (ACI-TIPI) could discriminate among patients with and without ischemia.1
The researchers estimate that wide use of their system could safely prevent more than 200,000 unnecessary hospitalizations and more than 100,000 unnecessary admissions to coronary care units. More than half of ED diagnoses of acute myocardial infarction (AMI) or unstable angina prove to be incorrect, they say, and those incorrect diagnoses result in 2 million unnecessary hospitalizations and $8 billion each year.
Underdiagnoses also occur, sending home about 2% of AMI patients. To help correct that situation, the study authors developed a predictive instrument for triage decisions that is incorporated into a conventional computerized EKG. It computes a patient’s probability of having acute ischemia on the basis of seven yes/no questions, including the presence of chest pain, history of heart attack, and EKG ST-segment of T-wave abnormalities.
Reference
1. Selker HP, Beshansky JR, Griffith JL, et al. Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. Ann Intern Med 1998; 129:845-855.
CIBIS-II evaluates bisoprolol; gives nod
Among studies reported last fall at the Second Annual Scientific Meeting of the Heart Failure Society of America in Boca Raton, FL, is the CIBIS-II trial which evaluated the effects of bisoprolol, a selective beta 1 beta-blocker, in patients with left ventricular dysfunction and heart failure. The trial was stopped prematurely because of positive results in the beta-blocker arm. Approximately 2,600 patients throughout Europe with Class III or IV congestive heart failure were slowly up-titrated with bisoprolol or placebo over a period of several months. All were on an angiotensin converting enzyme (ACE) inhibitor and diuretics. Entry criteria included an ejection fraction (EF) of less than 35%. Eighty percent were male, and more than half had coronary artery disease. At the time the trial was stopped, all-cause mortality had decreased in the beta-blocker group by 32%. Total and heart failure hospitalizations were decreased in the beta-blocker group. In summary, CIBIS-2 resulted in a 32% reduction in all-cause mortality, 45% reduction in sudden death, 30% reduction in hospitalization for CHF, and 15% reduction in all-cause hospitalization. No significant adverse reactions occurred.
The results, says Jonathan Abrams, MD, of the University of New Mexico in Albuquerque, underscore the concept that all patients who have congestive heart failure with substantial EF depression should be given a beta-blocker unless contraindications exist. Beta-blockers clearly increase survival in heart failure with impaired left ventricular systolic function.
FDA approves expansion for prescribed aspirin uses
Substantially more indications for aspirin use in cardiovascular and cerebrovascular patients have been approved by the Food and Drug Administration (FDA).
Under a new ruling, a year from now, physicians will receive prescribing information about the use of aspirin in patients with transient ischemic attack, ischemic stroke, angina, and acute myocardial infarction; after certain revascularization procedures; and in the treatment of rheumatologic diseases.
The new labeling will not be included on over-the counter aspirin labels. The updated labeling will state, "To minimize adverse events, low dosages (50-325 mg) are recommended for cardiac and cerebral vascular uses. (75-325 mg are recommended for angina and previous heart attack.)"
It will also state that the FDA does not recommend or suggest the use of aspirin by healthy individuals to lower the risk of heart attack and concludes that there are not enough data to recommend the use of aspirin in patients with peripheral vascular disease.
ACCP: Aspirin for adults at any level of risk
The American College of Chest Physicians (ACCP) in Northbrook, IL, has issued a new consensus statement on antithrombotic therapy. Among the new recommendations is that 160-325 mg aspirin be taken daily by any adult over age 50 who has only a single risk factor for cardiovascular disease.
A substantial increase over past recommendations, the new guideline will affect a large number of apparently healthy adults. The American Heart Association’s recommendation for daily aspirin therapy is for individuals diagnosed with atherosclerosis and those with a history of infarction or recurrent angina. The association does not recommend daily aspirin therapy for persons without an established diagnosis of heart disease.
Warfarin still underused in high-risk stroke patients
It costs about $15,000 to prevent a stroke, and the average total cost for a 65-year-old stroke patient in this country is $100,000. Despite its cost-effectiveness, warfarin is used in only half of eligible patients, according to a new report.1
Among study participants not prescribed warfarin at discharge, 62% also were not prescribed aspirin. Elderly patients with an ischemic stroke associated with atrial fibrillation are at especially high risk for recurrent stroke, and the annual rate of recurrent stroke is higher than 10%. Warfarin has been shown to be highly effective in reducing this risk by two-thirds. The researchers believe there may be several reasons why warfarin is underused, including the misperception of hemorrhagic risk. To address the issue of underutilization of anticoagulation, the researchers suggest:
• The integration of data from many different sources including the results of new clinical trials and management guidelines.
• The use of simple, individualized reminders to change physician behavior — telephone or written follow-up.
• Computer-based alerts to improve compliance with treatment guidelines.
Reference
1. Brass LM,Krumholz HM, Scinto JD, et al. Warfarin use following ischemic stroke among medicare patients with atrial fibrillation. Arch Intern Med 1998; 158:2,093-2,100.
FDA approves verapamil for essential HT
The Food and Drug Administration has approved a chronotherapeutic form of verapamil hydrochloride (SchwarzPharma’s Verelan PM) for the management of essential hypertension. The once-a-day, 360 mg capsule containing the calcium channel blocker is designed for bedtime dosing and incorporates a four- to five-hour delay in drug delivery. The controlled onset delivery system results in a maximum plasma concentration of verapamil in the morning hours. The most frequently reported side effects of verapamil are constipation, headache, and dizziness.
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