Postoperative atrial fibrillation and mortality after coronary artery bypass surgery.
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OBJECTIVES: We sought to determine if the occurrence of postoperative atrial fibrillation (AF) affects early or late mortality following coronary artery bypass surgery (CABG). BACKGROUND: Atrial fibrillation is the most common arrhythmia seen following CABG. METHODS: The Texas Heart Institute Cardiovascular Research Database was used to identify all patients that developed AF after isolated initial CABG from January 1993 to December 1999 (n = 994). This population was compared with patients who underwent CABG during the same period but did not develop AF (n = 5,481). In-hospital end points were adjusted using logistic regression models to account for baseline differences. Long-term survival was evaluated using a retrospective cohort design, where Cox proportional hazards methods were used to adjust for baseline differences, and with case-matched populations (n = 390, 195 per arm). RESULTS: Atrial fibrillation was diagnosed in 16% of the population. Postoperative AF was associated with greater in-hospital mortality (odds ratio [OR] 1.7, p = 0.0001), more strokes (OR 2.02, p = 0.001), prolonged hospital stays (14 vs. 10 days, p < 0.0001), and a reduced incidence of myocardial infarction (OR 0.62, p = 0.01). At four to five years, survival was worse in patients who developed postoperative AF (74% vs. 87%, p < 0.0001 in the retrospective cohort; 80% vs. 93%, p = 0.003 in the case-matched population). On multivariate analysis, postoperative AF was an independent predictor of long-term mortality (adjusted OR 1.5, p < 0.001 in the retrospective cohort; OR 3.4, p = 0.0018 in the case-matched population). CONCLUSIONS: The occurrence of AF following CABG identifies a subset of patients who have a reduced survival probability following CABG. The impact of various strategies, such as antiarrhythmics and warfarin, aimed at reducing AF and its complications deserves further study. (+info)
Use of biological based therapy in patients with cardiovascular diseases in a university-hospital in New York City.
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BACKGROUND: The use of complementary and alternative products including Biological Based Therapy (BBT) has increased among patients with various medical illnesses and conditions. The studies assessing the prevalence of BBT use among patients with cardiovascular diseases are limited. Therefore, an evaluation of BBT in this patient population would be beneficial. This was a survey designed to determine the effects of demographics on the use of Biological Based Therapy (BBT) in patients with cardiovascular diseases. The objective of this study was to determine the effect of the education level on the use of BBT in cardiovascular patients. This survey also assessed the perceptions of users regarding the safety/efficacy of BBT, types of BBT used and potential BBT-drug interactions. METHOD: The survey instrument was designed to assess the findings. Patients were interviewed from February 2001 to December 2002. 198 inpatients with cardiovascular diseases (94 BBT users and 104 non-users) in a university hospital were included in the study. RESULTS: Users had a significantly higher level of education than non-users (college graduate: 28 [30%] versus 12 [12%], p = 0.003). Top 10 BBT products used were vitamin E [41(43.6%)], vitamin C [30(31.9%)], multivitamins [24(25.5%)], calcium [19(20.2%)], vitamin B complex [17(18.1%)], fish oil [12(12.8%)], coenzyme Q10 [11(11.7%)], glucosamine [10(10.6%)], magnesium [8(8.5%)] and vitamin D [6(6.4%)]. Sixty percent of users' physicians knew of the BBT use. Compared to non-users, users believed BBT to be safer (p < 0.001) and more effective (p < 0.001) than prescription drugs. Forty-two potential drug-BBT interactions were identified. CONCLUSION: Incidence of use of BBT in cardiovascular patients is high (47.5%), as is the risk of potential drug interaction. Health care providers need to monitor BBT use in patients with cardiovascular diseases. (+info)
Is a chest pain observation unit likely to be cost effective at my hospital? Extrapolation of data from a randomised controlled trial.
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OBJECTIVES: The ESCAPE trial showed that chest pain observation unit (CPOU) care appeared to be cost effective compared with routine care. This finding may not be generalizable to hospitals that currently admit fewer patients than the trial hospital or that require higher direct costs to provide CPOU care. This study aimed to explore these issues in sensitivity analyses and develop a nomogram to allow prediction of whether a CPOU will be cost effective in a specific hospital. METHODS: Data from the ESCAPE trial was used to populate a decision analysis model comparing CPOU with routine care. Sensitivity analyses examined the effect of varying the admission rate with routine care and the direct running costs of CPOU care following which the nomogram was created. RESULTS: CPOU care provided improved outcome (0.3936 v 0.3799 QALYs) at lower cost (pound sterling 478 v pound sterling 556 per patient), with fewer patients admitted (37% v 54%). Mean cost of CPOU and routine care was pound sterling 116 and pound sterling 73, respectively, and of inpatient hospital stay was pound sterling 312. The mean post-discharge cost for CPOU and routine care was pound sterling 253 and pound sterling 309, respectively. Sensitivity analyses showed that CPOU care will not reduce costs at a hospital that currently admits fewer than 35% of patients, or a hospital that expects to incur direct CPOU running costs of pound sterling 60 per patient more than the trial hospital. CONCLUSIONS: Findings of the ESCAPE trial are likely to be generalizable to most settings. The nomogram presented here can be used to predict cost effectiveness in a specific hospital. (+info)
Spatial variation in the management and outcomes of acute coronary syndrome.
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BACKGROUND: Regional disparities in medical care and outcomes with patients suffering from an acute coronary syndrome (ACS) have been reported and raise the need to a better understanding of links between treatment, care and outcomes. Little is known about the relationship and its spatial variability between invasive cardiac procedure (ICP), hospital death (HD), length of stay (LoS) and early hospital readmission (EHR). The objectives were to describe and compare the regional rates of ICP, HD, EHR, and the average LoS after an ACS in 2000 in the province of Quebec. We also assessed whether there was a relationship between ICP and HD, LoS, and EHR, and if the relationships varied spatially. METHODS: Using secondary data from a provincial hospital register, a population-based retrospective cohort of 24,544 patients hospitalized in Quebec (Canada) for an ACS in 2000 was built. ACS was defined as myocardial infarction (ICD-9: 410) or unstable angina (ICD-9: 411). ICP was defined as the presence of angiography, angioplasty or aortocoronary bypass (CCA: 480-483, 489), HD as all death cause at index hospitalization, LoS as the number of days between admission and discharge from the index hospitalization, and EHR as hospital readmission for a coronary heart disease +info)
Complications of diagnostic cardiac catheterisation: results from a confidential inquiry into cardiac catheter complications.
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OBJECTIVES: To estimate the frequency and nature of complications in patients undergoing diagnostic cardiac catheterisation and to assess time trends in complications since the introduction of a voluntary cooperative audit. METHODS: Cardiac centres undertaking diagnostic cardiac catheterisation in England and Wales during the 10 years 1990-9 were invited to join the study. Each participating centre reported numbers of patients catheterised each month and details of complications and deaths as they occurred. Complication rates were calculated for the main diagnostic procedures and for each participating hospital and time trends in complications were examined. RESULTS: 41 cardiac centres contributed. 211 645 diagnostic procedures in adults and 7582 paediatric procedures were registered. The majority (87%) of diagnostic catheter studies in adults were left heart studies with coronary arteriography. The overall complication rate for adult procedures was 7.4/1000, with mortality at 0.7/1000; for paediatric procedures the complication rate was similar but mortality rather higher. Complication rates varied between centres but there was little association with caseload. Time trends across the decade showed both complication and mortality decreasing; from 9.5 to 5.8/1000 and from 1.4 to 0.4/1000, respectively. CONCLUSION: Complication rates of diagnostic catheterisation are low but neither negligible nor irreducible. While voluntary audit of cardiac catheter complications is useful and inexpensive, there is a clear need to establish a formal reporting system in all cardiac catheter laboratories, with clear definitions of reportable complications. (+info)
A prospective comparison of 3 new-generation pulse oximetry devices during ambulation after open heart surgery.
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OBJECTIVE: To assess the clinical performance of 3 new-generation pulse-oximetry signal-processing software systems (Philips FAST, Masimo SET, and Nellcor N-3000) during ambulation after open-heart surgery. DESIGN: Prospective, convenience sample. SETTING: Cardiac surgical progressive care unit in a 629-bed, not-for-profit, tertiary-care teaching hospital. PATIENTS: Status post-cardiac-surgery patients (n = 36) during their first postoperative ambulation. INTERVENTIONS: None. PROTOCOL: Randomization was used for digit and hand selection, and all 3 devices were used continuously during ambulation. Data on dropouts, false alarms, and correlation with heart rate were recorded. We continuously measured arterial oxygen saturation via pulse oximetry during ambulation with all 3 devices. RESULTS: Pairwise comparisons indicated significant differences among the 3 devices for data dropout and false alarm. In repeated-measures analysis, the Nellcor N-3000 had the greatest likelihood of data dropout (odds ratio of 31.9 to Masimo and 5.6 to Philips, at the 95% confidence interval). However, the converse was true for false alarms; the Masimo had the most false alarms, with an odds ratio of 17.9 to Nellcor and 2.3 to Philips, at the 95% confidence interval. There were also significantly more dropouts with all 3 devices when readings were taken on a hand on an arm from which a radial graft had been taken (p = 0.004). For heart-rate correlation, the mean absolute difference among the 3 devices was similar: Philips = 4.3 beats/min, Masimo = 5.1 beats/min, and Nellcor = 3.0 beats/min. CONCLUSIONS: There are significant differences among the 3 devices with regard to dropout and false alarms. High numbers of dropouts are problematic because no pulse-oximetry patient information is available during dropout. However, false alarms are even more problematic, because they desensitize clinicians to alarms and call into question the accuracy of displayed data. While our data highlight the statistical differences between the studied oximeters, the clinical implications of these differences warrant further study. (+info)
Do physician-owned cardiac hospitals increase utilization?
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This paper looks at whether physicians' investment in heart hospitals during 1997-2001 was followed by an increase in the number of relatively profitable cardiac surgeries paid for by Medicare or in a shift toward operating on healthier (more profitable) Medicare patients. Although markets with physician-owned hospitals had slightly above-average growth rates in profitable cardiac surgeries during this period, the magnitude of the increase was small and statistically significant only for bypass surgery. There was no increase in the proportion of surgeries performed on healthier patients. These findings contrast with earlier studies of less-invasive services such as diagnostic imaging. (+info)
Access to myocardial revascularization procedures: closing the gap with time?
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BACKGROUND: Early access to revascularization procedures is known to be related to a more favorable outcome in myocardial infarction (MI) patients, but access to specialized care varies widely amongst the population. We aim to test if the early gap found in the revascularization rates, according to distance between patients' location and the closest specialized cardiology center (SCC), remains on a long term basis. METHODS: We conducted a population-based cohort study using data from the Quebec's hospital discharge register (MED-ECHO). The study population includes all patients 25 years and older living in the province of Quebec, who were hospitalized for a MI in 1999 with a follow up time of one year after the index hospitalization. The main variable is revascularization (percutaneous transluminal coronary angioplasty or a coronary artery bypass graft). The population is divided in four groups depending how close they are from a SCC (< 32 km, 32-64 km, 64-105 km and > or = 105 km). Revascularization rates are adjusted for age and sex. RESULTS: The study population includes 11,802 individuals, 66% are men. The one-year incidence rate of MI is 244 individuals per 100,000 inhabitants. At index hospitalization, a significant gap is found between patients living close (< 32 km) to a SCC and patients living farther (> or = 32 km). During the first year, a gap reduction can be observed but only for patients living at an intermediate distance from the specialized center (64-105 km). CONCLUSION: The gap observed in revascularization rates at the index hospitalization for MI is in favour of patients living closer (< 32 km) to a SCC. This gap remains unchanged over the first year after an MI except for patients living between 64 and 105 km, where a closing of the gap can be noticed. (+info)