Time trends in survival and readmission following coronary artery bypass grafting in Scotland, 1981-96: retrospective observational study

Improvements in coronary revascularisation techniques and an increase in the use of percutaneous interventions1 have led to a rise in the number of coronary artery bypass grafting operations in older patients with more severe cardiac disease and worse comorbidity and who have previously undergone revascularisation procedures. 2 3 Advances in surgical and anaesthetic techniques have prevented a worsening risk profile from being translated into an increase in perioperative deaths. 2 3 The aim of our study was to examine time trends in major outcomes up to two years after coronary artery bypass grafting

Efficacy of pulmonary artery pressure monitoring in patients with chronic heart failure: a meta-analysis of three randomized controlled trials

Background and Aims: Adjustment of treatment based on remote monitoring of pulmonary artery (PA) pressure may reduce the risk of hospital admission for heart failure (HF). We have conducted a meta-analysis of large randomized trials investigating this question. Methods: A systematic literature search was performed for randomized clinical trials (RCTs) with PA pressure monitoring devices in patients with HF. The primary outcome of interest was the total number of HF hospitalizations. Other outcomes assessed were urgent visits leading to treatment with intravenous diuretics, all-cause mortality, and composites. Treatment effects are expressed as hazard ratios, and pooled effect estimates were obtained applying random effects meta-analyses. Results: Three eligible RCTs were identified that included 1898 outpatients in New York Heart Association functional class II-IV, either hospitalized for HF in the prior 12 months or with elevated plasma NT-proBNP concentrations. Mean follow-up was 14.7 months, 67.8% of the patients were men, and 65.8% had an ejection fraction ≤40%. Compared to patients in the control group, the hazard ratio (95% confidence interval) for total HF hospitalizations in those randomized to PA pressure monitoring was 0.70 (0.58-0.86) (p=0.0005). The corresponding hazard ratio for the composite of total HF hospitalizations, urgent visits and all-cause mortality was 0.75 (0.61-0.91; p=0.0037) and for all-cause mortality 0.92 (0.73-1.16). Subgroup analyses, including ejection fraction phenotype, revealed no evidence of heterogeneity in the treatment effect. Conclusions: The use of remote PA pressure monitoring to guide treatment of patients with HF reduces episodes of worsening HF and subsequent hospitalizations

Nucleon Polarizabilities from Deuteron Compton Scattering within a Green's-Function Hybrid Approach

We examine elastic Compton scattering from the deuteron for photon energies ranging from zero to 100 MeV, using state-of-the-art deuteron wave functions and NN-potentials. Nucleon-nucleon rescattering between emission and absorption of the two photons is treated by Green's functions in order to ensure gauge invariance and the correct Thomson limit. With this Green's-function hybrid approach, we fulfill the low-energy theorem of deuteron Compton scattering and there is no significant dependence on the deuteron wave function used. Concerning the nucleon structure, we use Chiral Effective Field Theory with explicit \Delta(1232) degrees of freedom within the Small Scale Expansion up to leading-one-loop order. Agreement with available data is good at all energies. Our 2-parameter fit to all elastic $\gamma d$ data leads to values for the static isoscalar dipole polarizabilities which are in excellent agreement with the isoscalar Baldin sum rule. Taking this value as additional input, we find \alpha_E^s= (11.3+-0.7(stat)+-0.6(Baldin)) x 10^{-4} fm^3 and \beta_M^s = (3.2-+0.7(stat)+-0.6(Baldin)) x 10^{-4} fm^3 and conclude by comparison to the proton numbers that neutron and proton polarizabilities are essentially the same.Comment: 47 pages LaTeX2e with 20 figures in 59 .eps files, using graphicx. Minor modifications; extended discussion of theoretical uncertainties of polarisabilities extraction. Version accepted for publication in EPJ

Implications of serial measurements of natriuretic peptides in heart failure: insights from BIOSTAT‐CHF

No abstract available

Systolic heart failure

A 74-year-old man with a history of hypertension and myocardial infarction that occurred 5 years previously presents with breathlessness on exertion. His current medications include a statin and aspirin. On examination, his pulse is 76 beats per minute and regular, and his blood pressure is 121/74 mm Hg. There is jugular venous distention, lateral displacement of the apex beat, and edema in his lower limbs. The lung examination is normal. An echocardiogram shows left ventricular dilatation, globally reduced contractility, and an ejection fraction of 33%. How should his case be managed

Angiotensin inhibition in heart failure

Survival in patients with heart failure remains very poor, and is worse than that for most common cancers, including bowel cancer in men and breast cancer in women. The renin-angiotensin-aldosterone system (RAAS) is not completely blocked by angiotensin-converting enzyme (ACE) inhibition. Blockade of the RAAS at the AT1-receptor has the theoretical benefit of more effective blockade of the actions of angiotensin II. ACE inhibitors (ACE-Is) prevent the breakdown of bradykinin: this has been blamed for some of the unwanted effects of ACE-Is although bradykinin may have advantageous effects in heart failure. Consequently, ACE-Is and ARBs might be complementary or even additive treatments; recent trials have tested these hypotheses. The Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) programme compared the angiotensin receptor blocker (ARB) candesartan (target dose 32 mg once daily) to placebo in three distinct but complementary populations of patients with symptomatic heart failure. These were: patients with reduced left ventricular ejection fraction (LVEF) who were ACE-I-intolerant (CHARM-Alternative); patients with reduced LVEF who were being treated with ACE-Is (CHARM-Added); and patients with preserved left ventricular systolic function (CHARM-Preserved). There were substantial and statistically significant reductions in the primary composite end point (risk of cardiovascular death or hospital admission for heart failure) in CHARM-Alternative. This was also the case in CHARM-Added, supporting and extending the findings of Val-HeFT. In CHARM-Preserved, the effect of candesartan on the primary end point did not reach conventional statistical significance though hospital admission for heart failure was reduced significantly with candesartan. In the CHARM-Overall programme there was a statistically borderline reduction in all-cause mortality with a clear reduction in cardiovascular mortality. All-cause mortality was reduced by 12% in the two CHARM trials in patients with low LVEF. CHARM succeeded in answering a number of questions about the safety and efficacy of ARB use in heart failure. It showed evidence for a clinical benefit of candesartan both additive to and independent of ACE-I use. The benefits in terms of clinical outcomes were seen irrespective of β-blocker usage. Benefits in patients with preserved LVEF were shown in the proportion of patients hospitalised with worsening heart failure and in overall number of admissions for heart failure. Candesartan had expected effects on blood pressure and renal function, emphasising the need for careful patient monitoring