Acute & Interventional Cardiology 2002; Volume 9: pages AIC 1- AIC 32

September 2002 Br J Cardiol (Acute Interv Cardiol) 2002;9(1):AIC 32

Pergolide and coronary artery dissection

Annalise Geldenhuys, Tony Mourant, Trevor Johnston, John Glynn

Abstract

This report describes a 48-year-old woman with Parkinson"s disease who developed coronary artery dissection. We believe that dissection in this patient was probably caused by treatment with the anti-Parkinsonian drug pergolide....

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September 2002 Br J Cardiol (Acute Interv Cardiol) 2002;9(1):AIC 26–AIC 31

The evolving role of the cardiac inotrope, enoximone, in heart failure

Liam J Cormican, A Craig Davidson

Abstract

Chronic heart failure is a progressive syndrome which continues to have high rates of morbidity and mortality. Heart failure rates are increasing in parallel with the ageing population, as are rates of hospitalisation for acute episodes of decompensated failure. Little progress has been made in the medical management of such episodes. Positive inotropes, including selective phosphodiesterase III inhibitors, are associated with increased mortality when administered over the long term. Now newer approaches, using selective agents such as enoximone orally at lower doses alone or in combination with carefully titrated beta1-selective adrenergic blockade, may provide a more favourable outcome in terms of symptom management, functional status and improved survival. Trials are underway to determine whether this is the case. Published trials with enoximone and protocols for forthcoming trials are reviewed....

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September 2002 Br J Cardiol (Acute Interv Cardiol) 2002;9(1):AIC 20–AIC 25

Volumetric haemodynamic monitoring and continuous pulse contour analysis – an untapped resource for coronary and high dependency care units?

Tushar V Saluhke, Duncan LA Wyncoll

Abstract

Critically ill patients in the coronary care or high dependency units (CCU, HDU) need accurate assessment of their haemodynamic status to guide fluid or vasoactive drug therapy. Both central venous pressure and pulmonary artery occlusion pressure are poor guides to cardiac filling and pulmonary oedema, and using a pulmonary artery catheter often fails to improve clinical outcome. The PiCCO system is a relatively new and less invasive approach to cardiac monitoring. It has been used extensively in intensive care and is reviewed in this article. This approach uses thermo-dilution techniques to reliably calculate volumetric measurements of cardiac preload and cardiac output, and can provide continuous real-time cardiac output and stroke volume variation measurements through pulse contour analysis. The reliability and accuracy of this method has drastically refined fluid and vasopressor management of the hypotensive patient and the management and prevention of pulmonary oedema. This method of measuring cardiac output correlates well with gold standard methods of cardiac output calculation and has been validated in adults and children. The PiCCO system can be an invaluable tool in the optimisation of the circulation in cardiac, medical and surgical patients commonly seen in the CCU and HDU....

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September 2002 Br J Cardiol (Acute Interv Cardiol) 2002;9(1):AIC 19

Are waiting times for coronary artery bypass graft surgery longer than they should be? Implications of the NICE guidelines for coronary artery stents

Stephen Large

Abstract

Tryfonidis, Prendergast and Curzen present their findings of work designed to answer the very pertinent question "Are waiting times for coronary artery bypass grafting (CABG) longer than they should be?". This question requires some reflection before we review the authors’ work and comments....

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September 2002 Br J Cardiol (Acute Interv Cardiol) 2002;9(1):AIC 13–AIC 17

Are waiting times for coronary artery bypass graft surgery longer than they should be? Implications of the NICE guidelines for coronary artery stents

Marios Tryfonidis, Brian Prendergast, Nicholas Curzen

Abstract

The objective of this study was to test the hypothesis that some patients on the routine waiting list for coronary artery bypass (CABG) surgery are suitable for percutaneous coronary intervention (PCI), as suggested in the NICE appraisal of coronary artery stents. A retrospective analysis was performed of 100 consecutive patients who had recently undergone CABG surgery from the routine waiting list in a tertiary cardiothoracic centre. The coronary angiograms of these patients were reviewed by an interventional cardiologist and a cardiac surgeon to assess patients’ potential suitability for PCI. The mean total waiting time from being listed for angiography to having CABG surgery was 18.7 months. The mean delay from angiography to CABG surgery was 13.5 months. Of the 100-patient cohort, 70 were referred by a non-interventional cardiologist and 30 by an interventionalist (ratio 2.3:1). Fifteen patients were deemed potentially suitable for PCI after angiographic review. Of these, 13 (87%) were referred by a non-interventional cardiologist without angiographic review by an interventional specialist. The majority (86%) of the 15 patients deemed potentially suitable for PCI had single or double vessel coronary artery disease, in contrast to the population as a whole (38%). These data suggest (a) that current CABG waiting lists could be reduced by up to 15% if coronary angiograms were reviewed by an interventional cardiologist in addition to a consultant cardiothoracic surgeon and (b) that referral arrangements should be adopted to facilitate such a review. The clinical implications of these data could be fully assessed by rolling out prospectively to other groups in the Coronary Heart Disease Collaborative....

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September 2002 Br J Cardiol (Acute Interv Cardiol) 2002;9(1):AIC 11

Will league tables have an adverse effect on the practice of coronary revascularisation in the UK?

Nick Curzen

Abstract

Within the last year we have witnessed the advent of public scrutiny of the results of surgical coronary revascularisation. The methodology em-ployed in order to achieve this scrutiny was flawed, as was the way the inadequate and incomplete results were presented to the general public. Data were presented without careful critical appraisal of what the figures actually meant. Little or no account was taken of context, risk assessment or case mix. This was either because of ignorance upon the part of those involved in publication or because of an inadequate level of concern for accuracy. In either case it was irresponsible. Inevitably, to make matters worse, any attempt to explain the fallibility of the presented figures and the flaws in their interpretation has lead to the charge of having something to hide....

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League tables, risk assessment and an opportunity to improve standards

September 2002 Br J Cardiol (Acute Interv Cardiol) 2002;9(1):AIC 5–AIC 10

League tables, risk assessment and an opportunity to improve standards

Stephen Westaby

Abstract

The implications of the Secretary of State’s approval of the introduction of league tables for cardiac surgeons are discussed. Surgeons are to be ranked according to mortality rates for first-time coronary artery bypass graft operations. It is questionable whether anybody will gain from this information: the focus of surgeons’ attention is transferred from patient care to self-preservation. The introduction of league tables in New York State has resulted in surgeons being reluctant to operate on higher risk patients and in secondary referrals of patients out of the State. League tables also encourage the manipulation of risk factor status. Many factors other than the individual surgeon’s skill influence the quality of care and patient outcomes. These factors include the patient’s status, the timing of surgery, the surgical team, equipment in the operating room and post-operative care. An alternative to the punitive process of public reporting is the application of continuous quality improvement to healthcare. This starts from the position that most negative outcomes are due not to individual failures but to failures of process and systems....

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