Variations in clinical decision-making between cardiologists and cardiac surgeons; a case for management by multidisciplinary teams?

OBJECTIVE: To assess variations in decisions to revascularise patients with coronary heart disease between general cardiologists, interventional cardiologists and cardiac surgeons DESIGN: Six cases of coronary heart disease were presented at an open meeting in a standard format including clinical details which might influence the decision to revascularise. Clinicians (n = 53) were then asked to vote using an anonymous electronic system for one of 5 treatment options: medical, surgical (CABG), percutaneous coronary intervention (PCI) or initially medical proceeding to revascularisation if symptoms dictated. Each case was then discussed in an open forum following which clinicians were asked to revote. Differences in treatment preference were compared by chi squared test and agreement between groups and between voting rounds compared using Kappa. RESULTS: Surgeons were more likely to choose surgery as a form of treatment (p = 0.034) while interventional cardiologists were more likely to choose PCI (p = 0.056). There were no significant differences between non-interventional and interventional cardiologists (p = 0.13) in their choice of treatment. There was poor agreement between all clinicians in the first round of voting (Kappa 0.26) but this improved to a moderate level of agreement after open discussion for the second vote (Kappa 0.44). The level of agreement among surgeons (0.15) was less than that for cardiologists (0.34) in Round 1, but was similar in Round 2 (0.45 and 0.45 respectively) CONCLUSION: In this case series, there was poor agreement between cardiac clinical specialists in the choice of treatment offered to patients. Open discussion appeared to improve agreement. These results would support the need for decisions to revascularise to be made by a multidisciplinary panel

No relationship between left ventricular radial wall motion and longitudinal velocity and the extent and severity of noncompaction cardiomyopathy

<p>Abstract</p> <p>Background</p> <p>Noncompaction cardiomyopathy (NCCM) is characterized by a prominent trabecular meshwork and deep intertrabecular recesses. Although systolic dysfunction is common, limited information is available on differences in wall motion of the normal compacted and noncompacted segments. The purpose of this study was to assess radial wall motion and longitudinal wall velocity in patients with NCCM, according to the extent and severity of noncompaction.</p> <p>Methods</p> <p>The study comprised 29 patients in sinus rhythm (age 41 ± 15 years, 15 men), who fulfilled stringent diagnostic criteria for NCCM and compared to 29 age and gender matched healthy controls. Segmental radial wall motion of all compacted and noncompacted segments was assessed with the standard visual wall motion score index and longitudinal systolic (Sm) wall velocity with tissue Doppler imaging of the mitral annulus. For each LV wall a normalized Sm value was calculated. The extent and severity of NC in each LV segment was assessed both in a qualitative and quantitative manner.</p> <p>Results</p> <p>Heart failure was the primary clinical presentation in half of the patients. NCCM patients had a wall motion score index of 1.68 ± 0.43 and a normalized Sm of 82 ± 20%. The total and maximal noncompaction scores were not related to the wall motion score index and the normalized Sm. NCCM patients with and without heart failure had similar total and maximal noncompaction scores.</p> <p>Conclusions</p> <p>In NCCM patient's radial wall motion and longitudinal LV wall velocity is impaired but not related to the extent or severity of noncompaction.</p

Relationship of serum bilirubin concentration to kidney function and 24-hour urine protein in Korean adults

<p>Abstract</p> <p>Background</p> <p>The relationships among serum bilirubin concentration, kidney function and proteinuria have yet to be fully elucidated, nor have these relationships been investigated in Korean adults.</p> <p>Method</p> <p>We retrospectively reviewed the medical records of Korean adults who were evaluated at Kosin University Gospel Hospital (Busan, Republic of Korea) during a five-year period from January 2005 to December 2009. We evaluated the relationships among serum bilirubin concentration, estimated glomerular filtration rate (eGFR) and 24-hour urinary protein excretion in a sample of 1363 Korean adults aged 18 years or older.</p> <p>Results</p> <p>The values of eGFR <60 mL/min/1.73 m²and 24-hour urine albumin ≥150 mg/day were observed in 26.1% (n = 356) and 40.5% (n = 553) of subjects, respectively. Fasting glucose levels ≥126 mg/dL were observed in 44.9% (n = 612) of the total sample. After adjustment for potential confounding factors including demographic characteristics, comorbidities and other laboratory measures, total serum bilirubin was positively associated with eGFR and negatively associated with proteinuria both in the whole cohort and in a subgroup of diabetic individuals.</p> <p>Conclusions</p> <p>To our knowledge, this is the first hospital-based study specifically aimed at examining the relationships among serum total bilirubin concentration, 24-hour urine protein and kidney function in Korean adults. We demonstrated that serum total bilirubin concentration was negatively correlated with 24-hour urine protein and positively correlated with eGFR in Korean non-diabetic and diabetic adults.</p

Can a Multifaceted Intervention Including Motivational Interviewing Improve Medication Adherence, Quality of Life, and Mortality Rates in Older Patients Undergoing Coronary Artery Bypass Surgery? A Multicenter, Randomized Controlled Trial with 18-Month Follow-Up.

BACKGROUND: Patients undergoing coronary artery bypass graft (CABG) surgery are required to take a complex regimen of medications for extended periods, and they may have negative outcomes because they struggle to adhere to this regimen. Designing effective interventions to promote medication adherence in this patient group is therefore important. OBJECTIVE: The present study aimed to evaluate the long-term effects of a multifaceted intervention (psycho-education, motivational interviewing, and short message services) on medication adherence, quality of life (QoL), and mortality rates in older patients undergoing CABG surgery. METHODS: Patients aged over 65 years from 12 centers were assigned to the intervention (EXP; n = 144) or treatment-as-usual (TAU; n = 144) groups using cluster randomization at center level. Medication adherence was evaluated using the Medication Adherence Rating Scale (MARS), pharmacy refill rate, and lipid profile; QoL was evaluated using Short Form-36. Data were collected at baseline; 3, 6, and 18 months after intervention. Survival status was followed up at 18 months. Multi-level regressions and survival analyses for hazard ratio (HR) were used for analyses. RESULTS: Compared with patients who received TAU, the MARS, pharmacy refill rate, and lipid profile of patients in the EXP group improved 6 months after surgery (p < 0.01) and remained so 18 months after surgery (p < 0.01). QoL also increased among patients in the EXP group as compared with those who received TAU at 18 months post-surgery (physical component summary score p = 0.02; mental component summary score p = 0.04). HR in the EXP group compared with the TAU group was 0.38 (p = 0.04). CONCLUSION: The findings suggest that a multifaceted intervention can improve medication adherence in older patients undergoing CABG surgery, with these improvements being maintained after 18 months. QoL and survival rates increased as a function of better medication adherence. ClinicalTrials.gov NCT02109523

Concerns about the implantable cardioverter defibrillator: a determinant of anxiety and depressive symptoms independent of experienced shocks

Background: Patients with an implantable cardioverter clefibrillator (ICD) are at increased risk of anxiety disorders. In turn, anxiety has been identified as a precipitant of ventricular arrhythmias. Anxiety may in part be attributed to concerns about the ICD firing, but the relationship between ICD concerns, psychological morbidity, and shocks has not been systematically investigated. We examined the relative importance of experienced shocks versus subjective concerns about the ICD as determinants of anxiety and depressive symptoms in ICD patients. Methods: Consecutive surviving patients (n = 182, response rate = 82%) having had an ICD implanted between October 1998 and January 2003 at the Erasmus Medical Centre Rotterdam were asked to fill in the ICD Patient Concerns Questionnaire and the Hospital Anxiety and Depression Scale. Clinical variables were obtained from the patients' medical records. Results: A total of 55 (30%) patients had received a shock from the ICD. Although patients who had experienced a shock scored higher on ICD concerns, ICD concerns was the only independent determinant of anxiety (odds ratio 6.35, 95% CI 2.84-14.20) and depressive symptoms (odds ratio 2.29, 95% Cl 1.06-4.96) adjusting for shocks and all other factors. Conclusions: Patient concerns about the ICD may be an important indicator of psychosocial adjustment. Screening for lCD patient concerns using the ICD Patient Concerns Questionnaire may identify patients at risk for psychological morbidity after ICD implantation

Off-label gebruik van coronaire drug-eluting stents : Vóórkomen, veiligheid en effectiviteit in 'real world' klinische praktijk

Het gebruik van drug-eluting stents (DES) voor een ander doel dan het indicatiegebied (off-label gebruik), kan leiden tot een belasting van deze hulpmiddelen buiten de grenzen van het ontwerp en mogelijk tot verhoogde risico's. Anderzijds kan een dergelijke behandelmethode klinisch relevant zijn, een medisch erkende standaard worden en kan off-label gebruik belangrijk zijn voor verdere innovatie. Het gebruik van DES in patiënten met off-label kenmerken komt veelvuldig voor in de klinische praktijk. Gepubliceerde aantallen variëren wereldwijd tussen de 47% en 81% van alle patiënten die DES ontvangen. In één groot Nederlands cardiovasculair centrum werd off-label gebruik van DES geschat op 68% in 2002. Er werden geen gegevens op nationaal niveau in Nederland gevonden. De veelbelovende resultaten van DES voor on-label indicaties hebben geleid tot DES toepassingen in meer complexe situaties zoals meervoudige vaatafwijkingen, vaatafwijkingen bij een vertakking en diabetes. In sommige gevallen is het gebruik van DES de enige beschikbare optie voor behandeling. Voor onbeperkt gebruik van DES (dat zowel off-label als on-label indicaties omvat) geven individuele observationele studies geen sluitend beeld met betrekking tot veiligheidsaspecten in vergelijking met het gebruik van kale stents voor vergelijkbare indicaties. Er is echter ook een meta-analyse van observationele studies en gerandomiseerde klinische trials uitgevoerd door vooraanstaande onderzoekers. Hieruit lijkt onbeperkt gebruik van DES in vergelijking met kale stents niet te zijn geassocieerd met negatieve veiligheidsuitkomsten en wel met een hogere effectiviteit. Sommige nieuwe generatie DES zijn veiliger en hebben een hogere effectiviteit in vergelijking met de eerste generatie DES.Use of coronary drug-eluting stents (DES) for purposes other than their indications for use (off-label use) may push such devices beyond their design limits and thus potentially lead to increased risks. On the other hand, such use can be clinically relevant, treatment regimes may become a medically recognised standard and off-label use may be important for further innovation. Worldwide, the use of DES in patients with off-label characteristics is common in clinical practice, with frequencies varying from 47% to 81% of all patients. Offlabel use of DES in one large Dutch cardiovascular centre was estimated to be 68% in 2002. At a Dutch national level, no data could be found. Promising results of DES for on-label indications have led to the application of DES in more complex situations such as multiple lesions, lesions at bifurcations, and diabetes. In some cases, this is the only treatment option available. For unrestricted use of DES (covering off-label as well as on-label indications), there are no conclusive data from individual observational studies with regard to safety aspects compared with using a bare metal stent (BMS) for similar indications. However, in a meta-analysis by renowned investigators of observational studies and randomised clinical trials, unrestricted use of DES compared with BMS did not appear to be associated with adverse safety outcomes and was reported to be more effective. Some new-generation DES are more safe and effective when compared with first-generation DES.Dutch Health Care Inspectorat