Showing papers by "Kim A. Eagle published in 1998"

Guidelines for the management of patients with valvular heart disease: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease)

Abstract: This executive summary and recommendations appears in the November 3, 1998, issue of Circulation . The guidelines in their entirety, including the ACC/AHA Class I, II, and III recommendations, are published in the November 1, 1998, issue of the Journal of the American College of Cardiology . Reprints of both the full text and the executive summary and recommendations are available from both organizations. During the past 2 decades, major advances have occurred in diagnostic techniques, the understanding of natural history, and interventional cardiological and surgical procedures for patients with valvular heart disease. The information base from which to make clinical management decisions has greatly expanded in recent years, yet in many situations, management issues remain controversial or uncertain. Unlike many other forms of cardiovascular disease, there is a scarcity of large-scale multicenter trials addressing the diagnosis and treatment of valvular disease from which to derive definitive conclusions, and the literature represents primarily the experiences reported by single institutions in relatively small numbers of patients. The Committee on Management of Patients With Valvular Disease was given the task of reviewing and compiling this information base and making recommendations for diagnostic testing, treatment, and physical activity. These guidelines follow the format established in previous American College of Cardiology/American Heart Association (ACC/AHA) guidelines for classifying indications for diagnostic and therapeutic procedures: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment IIa. Weight of evidence/opinion is in favor of usefulness/efficacy IIb. Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful and in some cases …

Elderly patients receive less aggressive medical and invasive management of unstable angina: potential impact of practice guidelines.

Abstract: Background The Agency for Health Care Policy and Research (AHCPR) released a practice guideline on the diagnosis and management of unstable angina in 1994. Objective To examine practice variation across the age spectrum in the management of patients hospitalized with unstable angina 2 years before release of the AHCPR guideline. Design Retrospective cohort. Setting Urban academic hospital. Patients All nonreferral patients diagnosed as having unstable angina who were hospitalized directly from the emergency department to the intensive care or telemetry unit between October 1, 1991, and September 30, 1992. Measurements Percentage of eligible patients receiving medical treatment concordant with 8 important AHCPR guideline recommendations. Results Half of the 280 patients were older than 66 years; women were older than men on average (70 vs 64 years; P P P P 2 , P Conclusions Older patients were less likely to receive standard therapies for unstable angina before release of the 1994 AHCPR guideline. Patients presenting with congestive heart failure also received care that was more discordant with guideline recommendations. The AHCPR guideline allows identification of patients who receive nonstandard care and, if applied to those patients with the greatest likelihood to benefit, could lead to improved health care delivery.

A randomized controlled trial of information-giving to patients referred for coronary angiography: effects on outcomes of care.

Abstract: OBJECTIVE: To assess the impact of providing an educational videotape, 'Treatment Choices for Ischaemic Heart Disease: a Shared Decision-Making Program Videotape,' to patients referred for coronary angiography compared with standard patient-physician decision making (usual care). STUDY DESIGN: Randomized controlled clinical trial. SETTING: University Hospital and Veterans Affairs Hospital. PATIENTS: A consecutive sample of 217 patients referred for coronary angiography were randomized to receive 'usual care' or to receive the videotape in addition to standard patient physician decision making (videotape): 109 completed the study (50% completion rate). MAIN OUTCOME MEASURES: Knowledge of coronary artery disease, satisfaction, self-reported physical and mental health functioning, and the proportion of patients who were referred for coronary revascularization. RESULTS: Compared with patients who received 'usual care,' those who received the videotape were more knowledgeable (mean score 83 vs. 58%; P < 0.0001) but less satisfied with their treatment (79 vs. 88%; P = 0.038). There were no significant differences between the videotape and 'usual care' groups with respect to satisfaction with the decision making process (mean score 73 vs. 77%; P = 0.37), satisfaction with the decision made (mean score 73 vs. 78%; P = 0.28), physical functioning (38 vs. 38%; P = 0.76), mental health functioning (49 vs. 49%; P = 0.94), or in referral for coronary revascularization (OR 0.60; 95% CI 0.22-1.65; P = 0.33). CONCLUSION: Although the educational videotape increased patients' knowledge level, it was associated with a decrease in their level of satisfaction with treatment. Before there is wide-spread dissemination of this technology, advocates should demonstrate its effectiveness in everyday practice.

Fortnightly review: Secondary prevention in acute myocardial infarction

Abstract: Acute myocardial infarction affects hundreds of thousands of people each year. Around a quarter die, half of them before reaching a hospital. Survivors are at increased risk of recurrent myocardial infarctions or cardiac death, with a 10% death rate in the first year after discharge and a subsequent annual death rate of 5%—six times that in people of the same age who do not have coronary artery disease. Whereas aggressive management of the acute infarction has been enthusiastically adopted, far less attention has been given to preventive strategies. Though most doctors agree with the importance of secondary prevention, the results of studies suggest that many patients are currently not being given optimal preventive care. Since most patients after acute myocardial infarction are routinely followed up in primary care, general practitioners must be fully informed and participate in treatment strategies designed for the secondary prevention of coronary artery disease. We conducted a Medline search for all articles on acute myocardial infarction dating from January 1980 to August 1997, with particular emphasis on secondary prevention in acute myocardial infarction. We scanned all of these reports, which numbered more than 3000. In this review we have also incorporated current standard practice at the University of Michigan, Ann Arbor, for managing myocardial infarction. Several controlled trials in more than 35 000 survivors of myocardial infarction have shown the benefit of long term treatment with β blockers in reducing the incidence of recurrent myocardial infarction, sudden death, and all cause mortality (table 1).1-8 β Blockers reduce myocardial workload and oxygen consumption by reducing the heart rate, blood pressure, and contractility, and they increase the threshold for ventricular fibrillation. A meta-analysis of such treatment in patients who have had myocardial infarctions shows a 20% reduction in long term mortality and a 34% reduction in …

Neural network assessment of perioperative cardiac risk in vascular surgery patients.

Abstract: Neural networks were developed to predict perioperative cardiac complications with data from 567 vascular surgery patients. Neural network scores were based on cardiac risk factors and dipyridamole thallium results. These scores were converted into likelihood ratios that predicted cardiac risk. The prognostic accuracy of the neural networks was similar to that of logistic regression models (ROC areas 76.0% vs 75.8%), but their calibration was better. Logistic regression overestimated event rates in a group of high-risk patients (predicted event rate, 64%; observed rate 30%; n=50, p<0.001). On a validation set of 514 patients, the neural networks still had ROC similar areas to those of logistic regression (68.3% vs 67.5%), but logistic regression again overestimated event rates for a group of high-risk patients. The calibration difference was reflected in the Hosmer-Lemeshow chi-square statistic (18.6 for the neural networks, 45.0 for logistic regression). The neural networks successfully estimated perioperative cardiac risk with better calibration than comparable logistic regression models.

Frequency, Predictors, and Appropriateness of Blood Transfusion After Percutaneous Coronary Interventions

Abstract: Increased awareness of the risks of blood-borne infections has recently led to profound changes in the practice of transfusion medicine. These changes include, among others, the development of guidelines by the American College of Physicians (ACP) for transfusion. Although the incidence and predictors of vascular complications of percutaneous interventions have been well defined, there are currently no data on frequency, risk factors, and appropriateness of blood transfusions. We performed a retrospective analysis of 628 consecutive percutaneous coronary revascularization procedures. Predictors of blood transfusion were identified using multivariate logistic regression analysis. Appropriateness of transfusions was determined using modified ACP guidelines. Transfusions were administered after 8.9% of interventions (56 of 628). Multivariate analysis identified age >70 years, female gender, procedure duration, coronary stenting, acute myocardial infarction, postprocedural use of heparin and intra-aortic balloon pump placement as independent predictors of blood transfusions (all p <0.05). According to the ACP guidelines, 36 of 56 patients (64%) received transfusions inappropriately. Transfusion reactions (fever) occurred in 10% of patients who received tranfusions appropriately and in 5% of patients who received tranfusions inappropriately. The estimated additional costs per procedure related to transfusions were $551 and $419, respectively. In conclusion, unnecessary transfusions were performed frequently after percutaneous coronary interventions. Application of available guidelines could reduce the number of unnecessary transfusions, thus avoiding exposure of patients to additional risks and reducing procedural costs.

Impact of a Simple Inexpensive Quality Assurance Effort on Physician's Choice of Thrombolytic Agents and Door-to-Needle Time: Implication for Costs of Management

Abstract: The objective of this study were to assess the impact of a quality assurance effort on the door-to-needle time and the choice of thrombolytic agent for the management of acute myocardial infarction in the emergency department The study design involved a prospective collection of data on a series of consecutive patients who received a thrombolytic agent for a presumed acute myocardial infarction The study was carried out in the emergency department of a major university urban tertiary care center A total of 349 patients were studied from September 1989 to March 1994 The quality assurance program began in 1989 and included chart review of all patients receiving thrombolytic therapy, with special attention to all patients with door-to-needle times >60 minutes to identify causes for delay Feedback was directed to pharmacy, nursing, and physician staff Biannual reports were distributed throughout the hospital and the emergency department Nursing-specific feedback led to the development of protocols for all aspects of the delivery of thrombolytic agents The choice of thrombolytic agent was not dictated by the protocol, but the physician staff was continuously updated on the results of the latest clinical trials comparing one thrombolytic agent with another The mean age was 58 years for men and 67 years for women in this cohort consisting of 78% men and 22% women Thirty-seven percent of the myocardial infarctions were in an anterior location and 56% were in an inferior location The median duration of chest pain before presentation to the emergency department was 120 minutes Hospital mortality was 3% Median door-to-needle time fell from 46 (1989–1991) to 36 (1992–1994) minutes, P 60 minutes decreased from 35% (1989–1991) to 16% (1992–1994) minutes, P < 00001 Corresponding with the ISIS-3 report, there was a significant increase in the proportion of patients receiving streptokinase over the first 3 years of the study (P < 00001), which changed to a trend toward increased utilization of tissue plasminogen activator with the GUSTO report in the final 6 months of the study In conclusion, a quality assurance program led to a significant reduction in the door-to-needle time, and recent megatrials were found to influence the choice of thrombolytic agent used

Evaluating and improving the delivery of heart care: the University of Michigan experience.

Abstract: With increasing pressure to curb escalating costs in medical care, there is particular emphasis on the delivery of cardiovascular services, which account for a substantial portion of the current healthcare dollar spent in the United States. A variety of tools were used to improve performance at the University of Michigan Health System, one of the oldest university-affiliated hospitals in the United States. The tools included initiatives to understand outcomes after coronary bypass operations and coronary angioplasty through use of proper risk-adjusted models. Critical pathways and guidelines were implemented to streamline care and improve quality in interventional cardiology, management of myocardial infarction, and preoperative assessment of patients undergoing vascular operations. Strategies to curb unnecessary costs included competitive bidding of vendors for expensive cardiac commodities, pharmacy cost reductions, and changes in nursing staff. Methods were instituted to improve guest services and partnerships with the community in disease prevention and health promotion.

Sudden Death in a 55-Year-Old Woman With Systemic Lupus Erythematosus

Abstract: A 55-year-old woman with systemic lupus erythematosus (SLE) and hypertension was admitted for evaluation of a 1-week history of dyspnea and pleuritic chest pain. SLE was diagnosed 3 years ago and manifested as rash, recurrent angioedema, and arthritis. Maintenance therapy with continuous prednisone (10 to 50 mg/d) and briefly with methotrexate for 1 year controlled disease manifestations. Two months before admission, she developed increasing fatigue and malaise. One week before admission, a mild, nonproductive cough and chills were noted. Over the next several days, she developed progressively increasing dyspnea on exertion and bilateral, sharp, anterior chest pain that worsened with inspiration, supine position, and movement. The remainder of the past medical history was notable only for a miscarriage. Family history was unremarkable. The patient was a retired bookkeeper. She had smoked one-half pack of cigarettes per day for 20 years and had 1 alcoholic drink per day. There was no history of illicit drug abuse. Medications at the time of admission were prednisone 10 mg and sustained release nifedipine 60 mg daily. The patient was allergic to penicillin. On physical examination, the patient was in moderate respiratory distress. Blood pressure was 160 to 180 over 90 to 105 mm Hg, heart rate was 120 bpm, respiratory rate was 30 to 40 breaths per minute, and temperature was 99.1°F. The neck veins were flat. Lung sounds were decreased halfway up on the left and one third of the way up on the right. No evidence of consolidation was noted. A loud, 3-component pericardial friction rub was heard. No murmur or gallop was appreciated. A pulsus paradoxus was not present. No active synovitis or joint findings were noted. Pertinent laboratory findings on admission are noted in the Table⇓. The ECG on admission showed sinus tachycardia at 120 bpm. View this table: Table 1. Laboratory Values …

Neural networks, logistic regression, and calibration: a reply.

Abstract: have commented about the model calibration, neural network design, and logistic regression models in our study, which used neural networks to predict perioperative cardiac risk.2 2 They maintain that the likelihood-ratio calculations were invalid unless the neural network scores had normal distributions for patients with and without cardiac events.' However, in our study we examined these distributions and they were indeed normal. Obtaining likelihood ratios from neural networks was described as a superfluous step because neural networks can provide logistic probabilities.' However, many neural network designs do not provide such probabilities. Different transfer functions may produce neural network outputs greater than one or less than zero.