Mitchel L. Zoler, PhD

Major Findings: Women with congenital heart disease had a 12% rate of late cardiac events after pregnancy. The strongest independent risk factor for such an event was a cardiac event before or during pregnancy.

Data Source: Analysis of 318 women, with a total of 405 deliveries, at one center in Toronto.

Disclosures: Dr. Balint and her associates had no financial disclosures to report.

ORLANDO — During long-term follow-up after pregnancy, women with congenital heart disease had a 12% rate of late cardiac events in a series of 318 patients followed at one center for a median of 2.6 years.

The analysis also identified four clinical factors that flagged women with congenital heart disease who faced the highest risk for a late event (starting more than 6 months after delivery). Women with one of these risk factors had a 27% rate of long-term cardiac events, women with more than one had a 47% rate, whereas women with none of them had an 8% rate, Dr. Olga H. Balint said at the annual scientific sessions of the American Heart Association.

“We can use this data to discuss with patients” the risk they face from pregnancy, said Dr. Balint, a physician in the pregnancy and heart disease research program at the University of Toronto. The findings highlight the significance of cardiac events that occur before or during pregnancy, a factor that raised the risk for a late event by 2.5-fold independent of any other risk. “It's important to take into account a pregnancy event. These patients are most likely to need intervention after pregnancy.”

The other three significant independent risk factors for late cardiac events were as follows:

▸ Subpulmonary ventricular dysfunction, pulmonary regurgitation, or both, which conferred a 3.4-fold independent increased risk for a late event.

▸ Subaortic ventricular dysfunction (a left ventricular ejection fraction of less than 40%), which produced an independent threefold increased risk.

▸ Left heart obstruction, which linked with a 2.5-fold increased risk.

The late events, which occurred following 50 of the total 405 deliveries, were most frequently arrhythmia, with pulmonary edema as the next most common event. Three late events were cardiac arrest or death, and one was a stroke. This 12% rate of late cardiac events matched the 12% rate of cardiac events that preceded pregnancy and the 11% rate during pregnancy.

The analysis did not address how the late event rate in these women following pregnancy compared with the event rate that similar women with congenital heart disease would have had if they did not become pregnant, Dr. Balint noted. The women in the Toronto series had an average age of 28, and 66% were nulliparous prior to the index pregnancy. Dr. Balint stressed that parity was not a significant univariate risk factor for late cardiac events nor was it a significant risk factor in the multivariate analysis.

The most common congenital disease in the series was a shunt lesion, in 87 women, followed by tetralogy of Fallot in 70, aortic coarctation in 52, and congenital aortic stenosis in 45. The analysis did not include assessment of the treatment the women received during or after pregnancy. The pregnancies in the series occurred during 1995-2007.

These findings have increasing relevance to U.S. practice because the number of American women with congenital heart disease who became pregnant steadily rose during 1998-2006, according to data reported in a poster at the meeting.

Using data from nearly 38 million pregnant U.S. women hospitalized during that period and collected by the Nationwide Inpatient Sample, Dr. Omar K. Siddiqi and his associates found that during those 9 years the number of deliveries from women with congenital heart disease rose steadily by an overall 26%, reaching roughly 3,500 deliveries in both 2005 and 2006. The rate of increase was disproportionate to the rise in number of U.S. adults with congenital heart disease, which increased by about 11% during the same period.

Pregnant U.S. women with congenital heart disease during the study period matched their pregnant counterparts without congenital disease by their average age (27 years), but their risk for peripartum complications or death was far higher, said Dr. Siddiqi, a physician at the University of Pennsylvania in Philadelphia, and his associates. During the 9 years studied, pregnant women with congenital heart disease had a 22-fold increased risk for heart failure, an 11-fold increased risk for arrhythmia, a 31-fold increased risk for stroke, and a 12-fold increased risk for death, compared with pregnant women without congenital heart disease.

Major Findings: Women with congenital heart disease had a 12% rate of late cardiac events after pregnancy. The strongest independent risk factor for such an event was a cardiac event before or during pregnancy.

Data Source: Analysis of 318 women, with a total of 405 deliveries, at one center in Toronto.

Disclosures: Dr. Balint and her associates had no financial disclosures to report.

ORLANDO — During long-term follow-up after pregnancy, women with congenital heart disease had a 12% rate of late cardiac events in a series of 318 patients followed at one center for a median of 2.6 years.

The analysis also identified four clinical factors that flagged women with congenital heart disease who faced the highest risk for a late event (starting more than 6 months after delivery). Women with one of these risk factors had a 27% rate of long-term cardiac events, women with more than one had a 47% rate, whereas women with none of them had an 8% rate, Dr. Olga H. Balint said at the annual scientific sessions of the American Heart Association.

“We can use this data to discuss with patients” the risk they face from pregnancy, said Dr. Balint, a physician in the pregnancy and heart disease research program at the University of Toronto. The findings highlight the significance of cardiac events that occur before or during pregnancy, a factor that raised the risk for a late event by 2.5-fold independent of any other risk. “It's important to take into account a pregnancy event. These patients are most likely to need intervention after pregnancy.”

The other three significant independent risk factors for late cardiac events were as follows:

▸ Subpulmonary ventricular dysfunction, pulmonary regurgitation, or both, which conferred a 3.4-fold independent increased risk for a late event.

▸ Subaortic ventricular dysfunction (a left ventricular ejection fraction of less than 40%), which produced an independent threefold increased risk.

▸ Left heart obstruction, which linked with a 2.5-fold increased risk.

The late events, which occurred following 50 of the total 405 deliveries, were most frequently arrhythmia, with pulmonary edema as the next most common event. Three late events were cardiac arrest or death, and one was a stroke. This 12% rate of late cardiac events matched the 12% rate of cardiac events that preceded pregnancy and the 11% rate during pregnancy.

The analysis did not address how the late event rate in these women following pregnancy compared with the event rate that similar women with congenital heart disease would have had if they did not become pregnant, Dr. Balint noted. The women in the Toronto series had an average age of 28, and 66% were nulliparous prior to the index pregnancy. Dr. Balint stressed that parity was not a significant univariate risk factor for late cardiac events nor was it a significant risk factor in the multivariate analysis.

The most common congenital disease in the series was a shunt lesion, in 87 women, followed by tetralogy of Fallot in 70, aortic coarctation in 52, and congenital aortic stenosis in 45. The analysis did not include assessment of the treatment the women received during or after pregnancy. The pregnancies in the series occurred during 1995-2007.

These findings have increasing relevance to U.S. practice because the number of American women with congenital heart disease who became pregnant steadily rose during 1998-2006, according to data reported in a poster at the meeting.

Using data from nearly 38 million pregnant U.S. women hospitalized during that period and collected by the Nationwide Inpatient Sample, Dr. Omar K. Siddiqi and his associates found that during those 9 years the number of deliveries from women with congenital heart disease rose steadily by an overall 26%, reaching roughly 3,500 deliveries in both 2005 and 2006. The rate of increase was disproportionate to the rise in number of U.S. adults with congenital heart disease, which increased by about 11% during the same period.

Pregnant U.S. women with congenital heart disease during the study period matched their pregnant counterparts without congenital disease by their average age (27 years), but their risk for peripartum complications or death was far higher, said Dr. Siddiqi, a physician at the University of Pennsylvania in Philadelphia, and his associates. During the 9 years studied, pregnant women with congenital heart disease had a 22-fold increased risk for heart failure, an 11-fold increased risk for arrhythmia, a 31-fold increased risk for stroke, and a 12-fold increased risk for death, compared with pregnant women without congenital heart disease.

Major Findings: Women with congenital heart disease had a 12% rate of late cardiac events after pregnancy. The strongest independent risk factor for such an event was a cardiac event before or during pregnancy.

Data Source: Analysis of 318 women, with a total of 405 deliveries, at one center in Toronto.

Disclosures: Dr. Balint and her associates had no financial disclosures to report.

ORLANDO — During long-term follow-up after pregnancy, women with congenital heart disease had a 12% rate of late cardiac events in a series of 318 patients followed at one center for a median of 2.6 years.

The analysis also identified four clinical factors that flagged women with congenital heart disease who faced the highest risk for a late event (starting more than 6 months after delivery). Women with one of these risk factors had a 27% rate of long-term cardiac events, women with more than one had a 47% rate, whereas women with none of them had an 8% rate, Dr. Olga H. Balint said at the annual scientific sessions of the American Heart Association.

“We can use this data to discuss with patients” the risk they face from pregnancy, said Dr. Balint, a physician in the pregnancy and heart disease research program at the University of Toronto. The findings highlight the significance of cardiac events that occur before or during pregnancy, a factor that raised the risk for a late event by 2.5-fold independent of any other risk. “It's important to take into account a pregnancy event. These patients are most likely to need intervention after pregnancy.”

The other three significant independent risk factors for late cardiac events were as follows:

▸ Subpulmonary ventricular dysfunction, pulmonary regurgitation, or both, which conferred a 3.4-fold independent increased risk for a late event.

▸ Subaortic ventricular dysfunction (a left ventricular ejection fraction of less than 40%), which produced an independent threefold increased risk.

▸ Left heart obstruction, which linked with a 2.5-fold increased risk.

The late events, which occurred following 50 of the total 405 deliveries, were most frequently arrhythmia, with pulmonary edema as the next most common event. Three late events were cardiac arrest or death, and one was a stroke. This 12% rate of late cardiac events matched the 12% rate of cardiac events that preceded pregnancy and the 11% rate during pregnancy.

The analysis did not address how the late event rate in these women following pregnancy compared with the event rate that similar women with congenital heart disease would have had if they did not become pregnant, Dr. Balint noted. The women in the Toronto series had an average age of 28, and 66% were nulliparous prior to the index pregnancy. Dr. Balint stressed that parity was not a significant univariate risk factor for late cardiac events nor was it a significant risk factor in the multivariate analysis.

The most common congenital disease in the series was a shunt lesion, in 87 women, followed by tetralogy of Fallot in 70, aortic coarctation in 52, and congenital aortic stenosis in 45. The analysis did not include assessment of the treatment the women received during or after pregnancy. The pregnancies in the series occurred during 1995-2007.

These findings have increasing relevance to U.S. practice because the number of American women with congenital heart disease who became pregnant steadily rose during 1998-2006, according to data reported in a poster at the meeting.

Using data from nearly 38 million pregnant U.S. women hospitalized during that period and collected by the Nationwide Inpatient Sample, Dr. Omar K. Siddiqi and his associates found that during those 9 years the number of deliveries from women with congenital heart disease rose steadily by an overall 26%, reaching roughly 3,500 deliveries in both 2005 and 2006. The rate of increase was disproportionate to the rise in number of U.S. adults with congenital heart disease, which increased by about 11% during the same period.

Pregnant U.S. women with congenital heart disease during the study period matched their pregnant counterparts without congenital disease by their average age (27 years), but their risk for peripartum complications or death was far higher, said Dr. Siddiqi, a physician at the University of Pennsylvania in Philadelphia, and his associates. During the 9 years studied, pregnant women with congenital heart disease had a 22-fold increased risk for heart failure, an 11-fold increased risk for arrhythmia, a 31-fold increased risk for stroke, and a 12-fold increased risk for death, compared with pregnant women without congenital heart disease.

PHILADELPHIA — The Framingham risk score does a poor job of estimating future risk for cardiovascular disease events in patients with rheumatoid arthritis, according to a review of 550 unselected patients drawn from the general population.

Results from a second study reported at the annual meeting of the American College of Rheumatology suggested that adding three more risk markers (carotid disease assessment with ultrasound, erythrocyte sedimentation rate, and cumulative steroid dose) to the standard Framingham risk score (FRS) could significantly improve prognostic accuracy for coronary disease in patients with RA. And findings from a third study presented at the meeting indicated that treatment with methotrexate is an effective way to cut coronary disease risk in RA patients.

To assess the prognostic value of the FRS, Cynthia S. Crowson and her associates at the Mayo Clinic in Rochester, Minn., used data collected for the Rochester Epidemiology Project from residents of Olmsted County, Minn. They included 550 people who presented during 1988-2008 with incident RA that matched the 1987 RA criteria of the American College of Rheumatology and who also had no history of cardiovascular disease at the time of their initial RA diagnosis. The researchers calculated an FRS for each of these patients based on their medical records and using a revised FRS (introduced in 2008) that predicted risk for cardiovascular disease events including stroke and peripheral artery disease as well as coronary disease (Circulation 2008;117:743-53). The FRS estimates a person's risk for an event during the subsequent 10 years.

The Mayo researchers then compared the predicted rate of cardiovascular disease events against the actual rate observed during the first 10 years following RA diagnosis. The study group included 491 RA patients who were aged 30-74 years, and 59 others who were aged 75 years or older. The FRS is designed for application to adults younger than 75 years.

Among the 341 women aged 30-74 years, the average predicted event rate was 5%, and the actual observed rate was 11%. Among the 150 men in this age range, the predicted rate was 12% and the observed rate was 26%, Ms. Crowson, a biostatistician at the Mayo Clinic, reported in a poster. The researchers used a regression model to calculate a standard incidence ratio, in which the ratio of actual to expected events was 79% in women and 56% in men. Both differences were statistically significant. Further analysis showed that the largest differences between observed and expected rates were in women aged 55 years or older and in men aged 45 or older.

Although the FRS is not designed for use in people older than 74 years, Ms. Crowson and her associates applied the same analysis to the 59 RA patients in this age group. The results again showed a significant excess of observed events over expected events. In women, the observed event rate was 57%, compared with an expected 14% rate. In men, the observed rate was 87%, compared with an expected rate of 37%.

The findings “underscore the need for [a more] accurate tool to predict the risk of cardiovascular disease in RA patients,” the researchers concluded. They had no financial relationships to disclose.

One way to improve cardiovascular risk assessment in RA patients may be to add additional risk factors to the FRS. A poster presented by Dr. Inmaculada del Rincon, a rheumatologist at the University of Texas Health Sciences Center in San Antonio, and her associates explored one way to do this. They compared the correlation between standard FRS assessment and an enhanced assessment model for predicting the risk of acute coronary syndrome events in 599 RA patients. None of the patients in the study had a history of cardiovascular disease at the time the study began. During an average 5 years of follow-up, 66 patients had acute coronary syndrome events.

To enhance the predictive power of the FRS, they added measures of carotid plaque and intima-media thickness by carotid ultrasonography, erythrocyte sedimentation rate, and cumulative glucocorticoid dose. The analysis showed that the standard FRS accounted for 70% of the events observed in the patients. The three additional risk markers boosted this rate to 76%, a statistically significant improvement, reported Dr. del Rincon and her associates in their poster.

A third poster at the meeting reviewed the ability of treatment with methotrexate to reduce cardiovascular risk in RA patients. Dr. Janice Gupta, a rheumatologist at Tufts Medical Center in Boston, and her associates reviewed the medical literature for studies that compared the ability of methotrexate to lower cardiovascular events against other RA treatments. They identified six studies published during 2002-2007 that made this comparison. The studies involved a total of about 162,000 RA patients. The results showed a consistent pattern of reduced cardiovascular events in the patients who received methotrexate. The event risk was generally reduced by 15%–20%, compared with other RA treatments; the researchers did not calculate an overall summary risk-reduction rate.

Disclosures: None of the researchers had financial conflicts of interest.

PHILADELPHIA — The Framingham risk score does a poor job of estimating future risk for cardiovascular disease events in patients with rheumatoid arthritis, according to a review of 550 unselected patients drawn from the general population.

Results from a second study reported at the annual meeting of the American College of Rheumatology suggested that adding three more risk markers (carotid disease assessment with ultrasound, erythrocyte sedimentation rate, and cumulative steroid dose) to the standard Framingham risk score (FRS) could significantly improve prognostic accuracy for coronary disease in patients with RA. And findings from a third study presented at the meeting indicated that treatment with methotrexate is an effective way to cut coronary disease risk in RA patients.

To assess the prognostic value of the FRS, Cynthia S. Crowson and her associates at the Mayo Clinic in Rochester, Minn., used data collected for the Rochester Epidemiology Project from residents of Olmsted County, Minn. They included 550 people who presented during 1988-2008 with incident RA that matched the 1987 RA criteria of the American College of Rheumatology and who also had no history of cardiovascular disease at the time of their initial RA diagnosis. The researchers calculated an FRS for each of these patients based on their medical records and using a revised FRS (introduced in 2008) that predicted risk for cardiovascular disease events including stroke and peripheral artery disease as well as coronary disease (Circulation 2008;117:743-53). The FRS estimates a person's risk for an event during the subsequent 10 years.

The Mayo researchers then compared the predicted rate of cardiovascular disease events against the actual rate observed during the first 10 years following RA diagnosis. The study group included 491 RA patients who were aged 30-74 years, and 59 others who were aged 75 years or older. The FRS is designed for application to adults younger than 75 years.

Among the 341 women aged 30-74 years, the average predicted event rate was 5%, and the actual observed rate was 11%. Among the 150 men in this age range, the predicted rate was 12% and the observed rate was 26%, Ms. Crowson, a biostatistician at the Mayo Clinic, reported in a poster. The researchers used a regression model to calculate a standard incidence ratio, in which the ratio of actual to expected events was 79% in women and 56% in men. Both differences were statistically significant. Further analysis showed that the largest differences between observed and expected rates were in women aged 55 years or older and in men aged 45 or older.

Although the FRS is not designed for use in people older than 74 years, Ms. Crowson and her associates applied the same analysis to the 59 RA patients in this age group. The results again showed a significant excess of observed events over expected events. In women, the observed event rate was 57%, compared with an expected 14% rate. In men, the observed rate was 87%, compared with an expected rate of 37%.

The findings “underscore the need for [a more] accurate tool to predict the risk of cardiovascular disease in RA patients,” the researchers concluded. They had no financial relationships to disclose.

One way to improve cardiovascular risk assessment in RA patients may be to add additional risk factors to the FRS. A poster presented by Dr. Inmaculada del Rincon, a rheumatologist at the University of Texas Health Sciences Center in San Antonio, and her associates explored one way to do this. They compared the correlation between standard FRS assessment and an enhanced assessment model for predicting the risk of acute coronary syndrome events in 599 RA patients. None of the patients in the study had a history of cardiovascular disease at the time the study began. During an average 5 years of follow-up, 66 patients had acute coronary syndrome events.

To enhance the predictive power of the FRS, they added measures of carotid plaque and intima-media thickness by carotid ultrasonography, erythrocyte sedimentation rate, and cumulative glucocorticoid dose. The analysis showed that the standard FRS accounted for 70% of the events observed in the patients. The three additional risk markers boosted this rate to 76%, a statistically significant improvement, reported Dr. del Rincon and her associates in their poster.

A third poster at the meeting reviewed the ability of treatment with methotrexate to reduce cardiovascular risk in RA patients. Dr. Janice Gupta, a rheumatologist at Tufts Medical Center in Boston, and her associates reviewed the medical literature for studies that compared the ability of methotrexate to lower cardiovascular events against other RA treatments. They identified six studies published during 2002-2007 that made this comparison. The studies involved a total of about 162,000 RA patients. The results showed a consistent pattern of reduced cardiovascular events in the patients who received methotrexate. The event risk was generally reduced by 15%–20%, compared with other RA treatments; the researchers did not calculate an overall summary risk-reduction rate.

Disclosures: None of the researchers had financial conflicts of interest.

PHILADELPHIA — The Framingham risk score does a poor job of estimating future risk for cardiovascular disease events in patients with rheumatoid arthritis, according to a review of 550 unselected patients drawn from the general population.

Results from a second study reported at the annual meeting of the American College of Rheumatology suggested that adding three more risk markers (carotid disease assessment with ultrasound, erythrocyte sedimentation rate, and cumulative steroid dose) to the standard Framingham risk score (FRS) could significantly improve prognostic accuracy for coronary disease in patients with RA. And findings from a third study presented at the meeting indicated that treatment with methotrexate is an effective way to cut coronary disease risk in RA patients.

To assess the prognostic value of the FRS, Cynthia S. Crowson and her associates at the Mayo Clinic in Rochester, Minn., used data collected for the Rochester Epidemiology Project from residents of Olmsted County, Minn. They included 550 people who presented during 1988-2008 with incident RA that matched the 1987 RA criteria of the American College of Rheumatology and who also had no history of cardiovascular disease at the time of their initial RA diagnosis. The researchers calculated an FRS for each of these patients based on their medical records and using a revised FRS (introduced in 2008) that predicted risk for cardiovascular disease events including stroke and peripheral artery disease as well as coronary disease (Circulation 2008;117:743-53). The FRS estimates a person's risk for an event during the subsequent 10 years.

The Mayo researchers then compared the predicted rate of cardiovascular disease events against the actual rate observed during the first 10 years following RA diagnosis. The study group included 491 RA patients who were aged 30-74 years, and 59 others who were aged 75 years or older. The FRS is designed for application to adults younger than 75 years.

Among the 341 women aged 30-74 years, the average predicted event rate was 5%, and the actual observed rate was 11%. Among the 150 men in this age range, the predicted rate was 12% and the observed rate was 26%, Ms. Crowson, a biostatistician at the Mayo Clinic, reported in a poster. The researchers used a regression model to calculate a standard incidence ratio, in which the ratio of actual to expected events was 79% in women and 56% in men. Both differences were statistically significant. Further analysis showed that the largest differences between observed and expected rates were in women aged 55 years or older and in men aged 45 or older.

Although the FRS is not designed for use in people older than 74 years, Ms. Crowson and her associates applied the same analysis to the 59 RA patients in this age group. The results again showed a significant excess of observed events over expected events. In women, the observed event rate was 57%, compared with an expected 14% rate. In men, the observed rate was 87%, compared with an expected rate of 37%.

The findings “underscore the need for [a more] accurate tool to predict the risk of cardiovascular disease in RA patients,” the researchers concluded. They had no financial relationships to disclose.

One way to improve cardiovascular risk assessment in RA patients may be to add additional risk factors to the FRS. A poster presented by Dr. Inmaculada del Rincon, a rheumatologist at the University of Texas Health Sciences Center in San Antonio, and her associates explored one way to do this. They compared the correlation between standard FRS assessment and an enhanced assessment model for predicting the risk of acute coronary syndrome events in 599 RA patients. None of the patients in the study had a history of cardiovascular disease at the time the study began. During an average 5 years of follow-up, 66 patients had acute coronary syndrome events.

To enhance the predictive power of the FRS, they added measures of carotid plaque and intima-media thickness by carotid ultrasonography, erythrocyte sedimentation rate, and cumulative glucocorticoid dose. The analysis showed that the standard FRS accounted for 70% of the events observed in the patients. The three additional risk markers boosted this rate to 76%, a statistically significant improvement, reported Dr. del Rincon and her associates in their poster.

A third poster at the meeting reviewed the ability of treatment with methotrexate to reduce cardiovascular risk in RA patients. Dr. Janice Gupta, a rheumatologist at Tufts Medical Center in Boston, and her associates reviewed the medical literature for studies that compared the ability of methotrexate to lower cardiovascular events against other RA treatments. They identified six studies published during 2002-2007 that made this comparison. The studies involved a total of about 162,000 RA patients. The results showed a consistent pattern of reduced cardiovascular events in the patients who received methotrexate. The event risk was generally reduced by 15%–20%, compared with other RA treatments; the researchers did not calculate an overall summary risk-reduction rate.

Disclosures: None of the researchers had financial conflicts of interest.

Major Finding: The composite adverse event rate during up to 4 years of follow-up was 7.2% for stenting and 6.8% for endarterectomy, with the adverse event rate after stenting rising significantly higher than after surgery among patients older than 70 years.

Data Source: The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST), which randomized 2,502 patients with either symptomatic or asymptomatic carotid stenosis to treatment by endarterectomy or carotid stenting with embolic protection at 117 U.S. and Canadian sites.

Disclosures: CREST was funded by the National Institute of Neurological Disorders and Stroke. Dr. Clark and Dr. Brott said they had no other relevant disclosures.

SAN ANTONIO — The largest-ever, head-to-head comparison of stenting versus surgery for treating severe carotid artery stenosis showed a marked effect of age, with patients older than 70 having fewer adverse outcomes after carotid endarterectomy and patients younger than 70 having fewer complications following carotid angioplasty and stenting.

Although the highly anticipated results from the decade-long Carotid Revascularization Endarterectomy vs. Surgery Trial (CREST) seemed, in simplest terms, to show a dead heat between carotid stenting and surgery, the results reported at the International Stroke Conference actually revealed statistically significant and clinically important differences between the two treatments. (See box.)

The statistically significant interaction between patient age and outcome will likely play a major role when physicians and patients now decide which intervention to favor for a specific patient.

The CREST results also showed another significant difference between carotid surgery and stenting: Surgery led to a 1.2% increased absolute rate in the incidence of periprocedural myocardial infarctions, while stenting produced a 1.8% increase absolute rate of periprocedural strokes. This finding will force patients and their physicians to consider which complication they would rather risk.

The patients in CREST answered that question, at least in part, via another outcome measure. Assessment of patient physical and mental quality of life with the 36-item Short Form (SF-36) Health Survey a year after treatment showed that patients who developed new strokes, even “minor” strokes, had significant reductions from baseline in both their mental and physical well-being, while patients who developed new myocardial infarctions had, on average, no significant changes in their SF-36 mental and physical scores, Dr. Wayne M. Clark reported while presenting the CREST results.

“This study, at the bottom line, was an endorsement for surgery,” commented Dr. James C. Grotta, chairman of neurology at the University of Texas in Houston.

The CREST findings also renewed concerns about the appropriateness of any invasive intervention, be it stenting or surgery, for asymptomatic carotid stenosis. The findings raised questions about how CREST differed from another large comparison of stenting and surgery, the International Carotid Stenting Study (ICSS), the results of which also appeared online, coincidentally, on the same day as the CREST report (Lancet 2010 Feb. 26 [doi:10.1016/S0140-6736(10)60239-5

Some experts noted that the CREST stenting results came from selected, experienced operators and that it would be a leap to expect comparable results from less-experienced physicians.

CREST randomized 2,502 patients with either symptomatic carotid stenosis or asymptomatic, severe carotid stenosis (at least 60% blockage) at 108 sites in the United States and 9 in Canada. The patients' average age was 69 years, a third were women, and 47% were asymptomatic. The analysis showed no significant effect from gender or symptom status on outcomes.

Impact of Age

The age effect produced the sharpest distinction between stenting and surgery, and confirmed evidence that began emerging a few years ago that carotid stenting poses a special problem for elderly patients. “As we went into this [trial], most of us thought that the less invasive procedure would be best suited for the older patients,” said Dr. Thomas G. Brott, professor and director of neurology at the Mayo Clinic in Jacksonville, Fla., and co–principal investigator for CREST.

The problem has been attributed to the increased difficulty and danger of placing stents and embolic protection devices through elderly patients' tortuous and atherosclerotic arteries.

“It's likely that putting in the embolic protection device sets off strokes. Until we have more data to show whether or not the age effect is real, I will take it into account in my patients,” commented Dr. J. Donald Easton, a neurologist at the University of California, San Francisco.

“I'm tending to look at the age cut-point very carefully,” said Dr. Philip B. Gorelick, professor of neurology and rehabilitation and director of stroke research at the University of Illinois in Chicago.

Dr. Clark reported the age effect as a continuous variable, without specifying any point estimates. But based on the line graph he showed, patients who underwent stenting at age 65 had a roughly 20% reduced risk for an adverse perioperative or long-term outcome compared with those who underwent surgery. At age 60 the relative benefit from stenting was about 35%. At age 50, the rate of adverse outcomes after stenting was less than half the rate after endarterectomy.

The primary adverse-event measure in CREST was the composite rate of any stroke, myocardial infarction, or death during the 30 days following treatment plus the rate of any ipsilateral stroke during long-term follow-up of up to 4 years. This rate was 7.2% for stenting and 6.8% for endarterectomy, with similar rates of ipsilateral strokes occurring from 31 days to 4 years (2.0% vs. 2.4%).

In contrast to younger patients, at age 75, the rate of adverse outcomes after stenting rose by about 35% compared with surgery; at age 80, the adverse outcome rate was more than 50% higher with stenting than with surgery; and at age 85, the adverse event rate was roughly doubled by stenting. In patients who were 70 years old, the adverse event rates were essentially identical regardless of which procedure was used.

No Data on Asymptomatic Patients

The CREST results reported so far gave no details on how endarterectomy and stenting fared in asymptomatic patients, compared with patients who already had symptoms of carotid disease. In the absence of these data, several experts cautioned that the findings should not be taken as an endorsement of aggressive carotid interventions for asymptomatic patients, especially now that medical therapy has become so effective.

“It's worth revisiting the role of interventions in asymptomatic patients. Even low [adverse event] rates do not mean that everyone with an asymptomatic lesion needs to have endarterectomy or a stent,” Dr. Grotta said.

“We need to look carefully at the asymptomatic data. Asymptomatic patients walk a fine line. There is not much room for any additional morbidity and mortality,” Dr. Gorelick said.

“We think that a reasonable question to ask today, after a couple of decades of advancement in medical therapy, is whether in asymptomatic patients best medical therapy is the equal of carotid revascularization. That's something to investigate,” Dr. Brott said.

In contrast to CREST, the results from ICSS showed a clear benefit from endarterectomy over stenting. Experts offered several possible explanations for this difference.

Dr. Ralph L. Sacco, professor and chairman of neurology at the University of Miami, cited differences between the two studies: CREST enrolled both asymptomatic and symptomatic patients, while ICSS involved only symptomatic patients; CREST used a single stent and embolic protection device, while ICSS allowed participating physicians to use whichever device they wanted; and CREST had results during follow-up of as long as 4 years, while the ICSS report focused on outcomes within the first 120 days of treatment.

But perhaps the most important difference was that CREST included a lead-in phase for participating operators to hone their stenting skills, something that ICSS lacked.

“We had in CREST a very detailed credentialing process, including about 1,600 lead-in cases that were not included in the randomized trial,” noted Dr. Clark, a CREST participant and professor of medicine and director of the Oregon Stroke Center at the Oregon Health and Science University in Portland.

But the careful training phase of stent operators in CREST raised issues on the generalizability of the results.

“The results of this trial are not generalizable to the medical community as a whole,” said Dr. Mary E. Jensen, a professor of radiology at the University of Virginia in Charlottesville. “They should not be interpreted to mean that carotid stenting is ready to be rapidly adopted as a standard practice at every hospital. Other studies have shown that carotid stenting can be more dangerous than carotid endarterectomy if the operators lack the technical expertise and experience required to maintain a low complication rate. I hope that if the Centers for Medicare and Medicaid Services uses the CREST data to expand coverage [of carotid stenting], it will include a credentialing/training/competency requirement that matches CREST in addition to insisting that all patients are seen before and after by neurologists so that independent observation of complications occurs.”

“This is another reason we need comprehensive stroke centers,” Dr. Grotta said. “Part of the licensing of stroke centers is having acceptable complication rates for carotid surgery and stenting.”

Vitals

Source Elsevier Global Medical News

Major Finding: The composite adverse event rate during up to 4 years of follow-up was 7.2% for stenting and 6.8% for endarterectomy, with the adverse event rate after stenting rising significantly higher than after surgery among patients older than 70 years.

Data Source: The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST), which randomized 2,502 patients with either symptomatic or asymptomatic carotid stenosis to treatment by endarterectomy or carotid stenting with embolic protection at 117 U.S. and Canadian sites.

Disclosures: CREST was funded by the National Institute of Neurological Disorders and Stroke. Dr. Clark and Dr. Brott said they had no other relevant disclosures.

SAN ANTONIO — The largest-ever, head-to-head comparison of stenting versus surgery for treating severe carotid artery stenosis showed a marked effect of age, with patients older than 70 having fewer adverse outcomes after carotid endarterectomy and patients younger than 70 having fewer complications following carotid angioplasty and stenting.

Although the highly anticipated results from the decade-long Carotid Revascularization Endarterectomy vs. Surgery Trial (CREST) seemed, in simplest terms, to show a dead heat between carotid stenting and surgery, the results reported at the International Stroke Conference actually revealed statistically significant and clinically important differences between the two treatments. (See box.)

The statistically significant interaction between patient age and outcome will likely play a major role when physicians and patients now decide which intervention to favor for a specific patient.

The CREST results also showed another significant difference between carotid surgery and stenting: Surgery led to a 1.2% increased absolute rate in the incidence of periprocedural myocardial infarctions, while stenting produced a 1.8% increase absolute rate of periprocedural strokes. This finding will force patients and their physicians to consider which complication they would rather risk.

The patients in CREST answered that question, at least in part, via another outcome measure. Assessment of patient physical and mental quality of life with the 36-item Short Form (SF-36) Health Survey a year after treatment showed that patients who developed new strokes, even “minor” strokes, had significant reductions from baseline in both their mental and physical well-being, while patients who developed new myocardial infarctions had, on average, no significant changes in their SF-36 mental and physical scores, Dr. Wayne M. Clark reported while presenting the CREST results.

“This study, at the bottom line, was an endorsement for surgery,” commented Dr. James C. Grotta, chairman of neurology at the University of Texas in Houston.

The CREST findings also renewed concerns about the appropriateness of any invasive intervention, be it stenting or surgery, for asymptomatic carotid stenosis. The findings raised questions about how CREST differed from another large comparison of stenting and surgery, the International Carotid Stenting Study (ICSS), the results of which also appeared online, coincidentally, on the same day as the CREST report (Lancet 2010 Feb. 26 [doi:10.1016/S0140-6736(10)60239-5

Some experts noted that the CREST stenting results came from selected, experienced operators and that it would be a leap to expect comparable results from less-experienced physicians.

CREST randomized 2,502 patients with either symptomatic carotid stenosis or asymptomatic, severe carotid stenosis (at least 60% blockage) at 108 sites in the United States and 9 in Canada. The patients' average age was 69 years, a third were women, and 47% were asymptomatic. The analysis showed no significant effect from gender or symptom status on outcomes.

Impact of Age

The age effect produced the sharpest distinction between stenting and surgery, and confirmed evidence that began emerging a few years ago that carotid stenting poses a special problem for elderly patients. “As we went into this [trial], most of us thought that the less invasive procedure would be best suited for the older patients,” said Dr. Thomas G. Brott, professor and director of neurology at the Mayo Clinic in Jacksonville, Fla., and co–principal investigator for CREST.

The problem has been attributed to the increased difficulty and danger of placing stents and embolic protection devices through elderly patients' tortuous and atherosclerotic arteries.

“It's likely that putting in the embolic protection device sets off strokes. Until we have more data to show whether or not the age effect is real, I will take it into account in my patients,” commented Dr. J. Donald Easton, a neurologist at the University of California, San Francisco.

“I'm tending to look at the age cut-point very carefully,” said Dr. Philip B. Gorelick, professor of neurology and rehabilitation and director of stroke research at the University of Illinois in Chicago.

Dr. Clark reported the age effect as a continuous variable, without specifying any point estimates. But based on the line graph he showed, patients who underwent stenting at age 65 had a roughly 20% reduced risk for an adverse perioperative or long-term outcome compared with those who underwent surgery. At age 60 the relative benefit from stenting was about 35%. At age 50, the rate of adverse outcomes after stenting was less than half the rate after endarterectomy.

The primary adverse-event measure in CREST was the composite rate of any stroke, myocardial infarction, or death during the 30 days following treatment plus the rate of any ipsilateral stroke during long-term follow-up of up to 4 years. This rate was 7.2% for stenting and 6.8% for endarterectomy, with similar rates of ipsilateral strokes occurring from 31 days to 4 years (2.0% vs. 2.4%).

In contrast to younger patients, at age 75, the rate of adverse outcomes after stenting rose by about 35% compared with surgery; at age 80, the adverse outcome rate was more than 50% higher with stenting than with surgery; and at age 85, the adverse event rate was roughly doubled by stenting. In patients who were 70 years old, the adverse event rates were essentially identical regardless of which procedure was used.

No Data on Asymptomatic Patients

The CREST results reported so far gave no details on how endarterectomy and stenting fared in asymptomatic patients, compared with patients who already had symptoms of carotid disease. In the absence of these data, several experts cautioned that the findings should not be taken as an endorsement of aggressive carotid interventions for asymptomatic patients, especially now that medical therapy has become so effective.

“It's worth revisiting the role of interventions in asymptomatic patients. Even low [adverse event] rates do not mean that everyone with an asymptomatic lesion needs to have endarterectomy or a stent,” Dr. Grotta said.

“We need to look carefully at the asymptomatic data. Asymptomatic patients walk a fine line. There is not much room for any additional morbidity and mortality,” Dr. Gorelick said.

“We think that a reasonable question to ask today, after a couple of decades of advancement in medical therapy, is whether in asymptomatic patients best medical therapy is the equal of carotid revascularization. That's something to investigate,” Dr. Brott said.

In contrast to CREST, the results from ICSS showed a clear benefit from endarterectomy over stenting. Experts offered several possible explanations for this difference.

Dr. Ralph L. Sacco, professor and chairman of neurology at the University of Miami, cited differences between the two studies: CREST enrolled both asymptomatic and symptomatic patients, while ICSS involved only symptomatic patients; CREST used a single stent and embolic protection device, while ICSS allowed participating physicians to use whichever device they wanted; and CREST had results during follow-up of as long as 4 years, while the ICSS report focused on outcomes within the first 120 days of treatment.

But perhaps the most important difference was that CREST included a lead-in phase for participating operators to hone their stenting skills, something that ICSS lacked.

“We had in CREST a very detailed credentialing process, including about 1,600 lead-in cases that were not included in the randomized trial,” noted Dr. Clark, a CREST participant and professor of medicine and director of the Oregon Stroke Center at the Oregon Health and Science University in Portland.

But the careful training phase of stent operators in CREST raised issues on the generalizability of the results.

“The results of this trial are not generalizable to the medical community as a whole,” said Dr. Mary E. Jensen, a professor of radiology at the University of Virginia in Charlottesville. “They should not be interpreted to mean that carotid stenting is ready to be rapidly adopted as a standard practice at every hospital. Other studies have shown that carotid stenting can be more dangerous than carotid endarterectomy if the operators lack the technical expertise and experience required to maintain a low complication rate. I hope that if the Centers for Medicare and Medicaid Services uses the CREST data to expand coverage [of carotid stenting], it will include a credentialing/training/competency requirement that matches CREST in addition to insisting that all patients are seen before and after by neurologists so that independent observation of complications occurs.”

“This is another reason we need comprehensive stroke centers,” Dr. Grotta said. “Part of the licensing of stroke centers is having acceptable complication rates for carotid surgery and stenting.”

Vitals

Source Elsevier Global Medical News

Major Finding: The composite adverse event rate during up to 4 years of follow-up was 7.2% for stenting and 6.8% for endarterectomy, with the adverse event rate after stenting rising significantly higher than after surgery among patients older than 70 years.

Data Source: The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST), which randomized 2,502 patients with either symptomatic or asymptomatic carotid stenosis to treatment by endarterectomy or carotid stenting with embolic protection at 117 U.S. and Canadian sites.

Disclosures: CREST was funded by the National Institute of Neurological Disorders and Stroke. Dr. Clark and Dr. Brott said they had no other relevant disclosures.

SAN ANTONIO — The largest-ever, head-to-head comparison of stenting versus surgery for treating severe carotid artery stenosis showed a marked effect of age, with patients older than 70 having fewer adverse outcomes after carotid endarterectomy and patients younger than 70 having fewer complications following carotid angioplasty and stenting.

Although the highly anticipated results from the decade-long Carotid Revascularization Endarterectomy vs. Surgery Trial (CREST) seemed, in simplest terms, to show a dead heat between carotid stenting and surgery, the results reported at the International Stroke Conference actually revealed statistically significant and clinically important differences between the two treatments. (See box.)

The statistically significant interaction between patient age and outcome will likely play a major role when physicians and patients now decide which intervention to favor for a specific patient.

The CREST results also showed another significant difference between carotid surgery and stenting: Surgery led to a 1.2% increased absolute rate in the incidence of periprocedural myocardial infarctions, while stenting produced a 1.8% increase absolute rate of periprocedural strokes. This finding will force patients and their physicians to consider which complication they would rather risk.

The patients in CREST answered that question, at least in part, via another outcome measure. Assessment of patient physical and mental quality of life with the 36-item Short Form (SF-36) Health Survey a year after treatment showed that patients who developed new strokes, even “minor” strokes, had significant reductions from baseline in both their mental and physical well-being, while patients who developed new myocardial infarctions had, on average, no significant changes in their SF-36 mental and physical scores, Dr. Wayne M. Clark reported while presenting the CREST results.

“This study, at the bottom line, was an endorsement for surgery,” commented Dr. James C. Grotta, chairman of neurology at the University of Texas in Houston.

The CREST findings also renewed concerns about the appropriateness of any invasive intervention, be it stenting or surgery, for asymptomatic carotid stenosis. The findings raised questions about how CREST differed from another large comparison of stenting and surgery, the International Carotid Stenting Study (ICSS), the results of which also appeared online, coincidentally, on the same day as the CREST report (Lancet 2010 Feb. 26 [doi:10.1016/S0140-6736(10)60239-5

Some experts noted that the CREST stenting results came from selected, experienced operators and that it would be a leap to expect comparable results from less-experienced physicians.

CREST randomized 2,502 patients with either symptomatic carotid stenosis or asymptomatic, severe carotid stenosis (at least 60% blockage) at 108 sites in the United States and 9 in Canada. The patients' average age was 69 years, a third were women, and 47% were asymptomatic. The analysis showed no significant effect from gender or symptom status on outcomes.

Impact of Age

The age effect produced the sharpest distinction between stenting and surgery, and confirmed evidence that began emerging a few years ago that carotid stenting poses a special problem for elderly patients. “As we went into this [trial], most of us thought that the less invasive procedure would be best suited for the older patients,” said Dr. Thomas G. Brott, professor and director of neurology at the Mayo Clinic in Jacksonville, Fla., and co–principal investigator for CREST.

The problem has been attributed to the increased difficulty and danger of placing stents and embolic protection devices through elderly patients' tortuous and atherosclerotic arteries.

“It's likely that putting in the embolic protection device sets off strokes. Until we have more data to show whether or not the age effect is real, I will take it into account in my patients,” commented Dr. J. Donald Easton, a neurologist at the University of California, San Francisco.

“I'm tending to look at the age cut-point very carefully,” said Dr. Philip B. Gorelick, professor of neurology and rehabilitation and director of stroke research at the University of Illinois in Chicago.

Dr. Clark reported the age effect as a continuous variable, without specifying any point estimates. But based on the line graph he showed, patients who underwent stenting at age 65 had a roughly 20% reduced risk for an adverse perioperative or long-term outcome compared with those who underwent surgery. At age 60 the relative benefit from stenting was about 35%. At age 50, the rate of adverse outcomes after stenting was less than half the rate after endarterectomy.

The primary adverse-event measure in CREST was the composite rate of any stroke, myocardial infarction, or death during the 30 days following treatment plus the rate of any ipsilateral stroke during long-term follow-up of up to 4 years. This rate was 7.2% for stenting and 6.8% for endarterectomy, with similar rates of ipsilateral strokes occurring from 31 days to 4 years (2.0% vs. 2.4%).

In contrast to younger patients, at age 75, the rate of adverse outcomes after stenting rose by about 35% compared with surgery; at age 80, the adverse outcome rate was more than 50% higher with stenting than with surgery; and at age 85, the adverse event rate was roughly doubled by stenting. In patients who were 70 years old, the adverse event rates were essentially identical regardless of which procedure was used.

No Data on Asymptomatic Patients

The CREST results reported so far gave no details on how endarterectomy and stenting fared in asymptomatic patients, compared with patients who already had symptoms of carotid disease. In the absence of these data, several experts cautioned that the findings should not be taken as an endorsement of aggressive carotid interventions for asymptomatic patients, especially now that medical therapy has become so effective.

“It's worth revisiting the role of interventions in asymptomatic patients. Even low [adverse event] rates do not mean that everyone with an asymptomatic lesion needs to have endarterectomy or a stent,” Dr. Grotta said.

“We need to look carefully at the asymptomatic data. Asymptomatic patients walk a fine line. There is not much room for any additional morbidity and mortality,” Dr. Gorelick said.

“We think that a reasonable question to ask today, after a couple of decades of advancement in medical therapy, is whether in asymptomatic patients best medical therapy is the equal of carotid revascularization. That's something to investigate,” Dr. Brott said.

In contrast to CREST, the results from ICSS showed a clear benefit from endarterectomy over stenting. Experts offered several possible explanations for this difference.

Dr. Ralph L. Sacco, professor and chairman of neurology at the University of Miami, cited differences between the two studies: CREST enrolled both asymptomatic and symptomatic patients, while ICSS involved only symptomatic patients; CREST used a single stent and embolic protection device, while ICSS allowed participating physicians to use whichever device they wanted; and CREST had results during follow-up of as long as 4 years, while the ICSS report focused on outcomes within the first 120 days of treatment.

But perhaps the most important difference was that CREST included a lead-in phase for participating operators to hone their stenting skills, something that ICSS lacked.

“We had in CREST a very detailed credentialing process, including about 1,600 lead-in cases that were not included in the randomized trial,” noted Dr. Clark, a CREST participant and professor of medicine and director of the Oregon Stroke Center at the Oregon Health and Science University in Portland.

But the careful training phase of stent operators in CREST raised issues on the generalizability of the results.

“The results of this trial are not generalizable to the medical community as a whole,” said Dr. Mary E. Jensen, a professor of radiology at the University of Virginia in Charlottesville. “They should not be interpreted to mean that carotid stenting is ready to be rapidly adopted as a standard practice at every hospital. Other studies have shown that carotid stenting can be more dangerous than carotid endarterectomy if the operators lack the technical expertise and experience required to maintain a low complication rate. I hope that if the Centers for Medicare and Medicaid Services uses the CREST data to expand coverage [of carotid stenting], it will include a credentialing/training/competency requirement that matches CREST in addition to insisting that all patients are seen before and after by neurologists so that independent observation of complications occurs.”

“This is another reason we need comprehensive stroke centers,” Dr. Grotta said. “Part of the licensing of stroke centers is having acceptable complication rates for carotid surgery and stenting.”

Vitals

Source Elsevier Global Medical News

FORT LAUDERDALE, FLA. — Combining coronary artery catheterization and cardiac surgery in the same hospital admission was linked to a significantly increased risk for acute kidney injury (AKI), compared with performing the surgery during a second, later hospitalization, a single-center study of more than 600 patients showed.

AKI in cardiac surgery patients has been linked to significantly worse long-term survival. “If there is a way to safely manage patients medically between catheterization and surgery, that should be done, to mitigate the potential for acute kidney injury,” Dr. Robert S. Kramer said at the annual meeting of the Society of Thoracic Surgeons.

He acknowledged that some patients have urgent medical reasons to undergo cardiac surgery within days of their coronary catheterization. However, in many other cases, cardiac surgery becomes scheduled during the same hospital admission as catheterization because of convenience for the patient, the surgeon, or for other physicians involved with the case, Dr. Kramer, director of cardiac surgery research at Maine Medical Center in Portland, said in an interview.

The study reviewed 668 consecutive patients who underwent cardiac surgery subsequent to PCI at Maine Medical Center during 2008 who were not on dialysis and did not require emergency procedures while hospitalized. Surgery during a subsequent hospitalization was performed an average of 39 days after PCI in 211 patients, while in 457, surgery was performed an average of 3 days after PCI during the same hospitalization.

The patients' average age was 68 years and about a quarter were women. The immediate surgery patients had a significantly higher prevalences of coronary artery disease, MI during the week before surgery, LVEF of less than 40%, and elevated white cell count.

The rates of elective and urgent surgery, respectively, were 86% and 14% in the patients whose surgery was deferred for a second hospitalization, compared with 13% and 87% in patients who had their catheterization and surgery in a single hospitalization. Coronary bypass surgery alone occurred in 53% of the deferred patients and 60% of those with a single hospitalization, with the other surgeries divided between valve alone or valve plus bypass.

The incidence of AKI, defined as a creatinine measure that increased by at least 50% over baseline or that rose by at least 0.3 mg/dL over baseline, during or immediately after surgery was 34% in the patients hospitalized a second time for their surgery and 50% in those who had their surgery in their first hospitalization, a significant difference.

No other perioperative outcome parameters differed significantly between the two groups, including death, Q-wave MI, or stroke. The perioperative mortality rate was 2% in patients with deferred surgery and 4% in those with more immediate surgery.

In an analysis that adjusted for baseline demographic and clinical differences, patients with deferred surgery had a significant, 45% relative reduction in their rate of AKI, compared with patients with more immediate surgery.

Although the findings are strictly speaking just hypothesis generating, Dr. Kramer contended that the findings are compelling enough to warrant an immediate change in practice: limit cardiac surgery within a few days after catheterization to patients who clearly need rapid intervention.

Dr. Kramer said he had no disclosures relevant to this study.

◊ To see a video interview with Dr. Kramer, go to www.youtube.com/CardiologyNews

Limit cardiac surgery within a few days after catheterization to patients who clearly need rapid intervention.

Source DR. KRAMER

FORT LAUDERDALE, FLA. — Combining coronary artery catheterization and cardiac surgery in the same hospital admission was linked to a significantly increased risk for acute kidney injury (AKI), compared with performing the surgery during a second, later hospitalization, a single-center study of more than 600 patients showed.

AKI in cardiac surgery patients has been linked to significantly worse long-term survival. “If there is a way to safely manage patients medically between catheterization and surgery, that should be done, to mitigate the potential for acute kidney injury,” Dr. Robert S. Kramer said at the annual meeting of the Society of Thoracic Surgeons.

He acknowledged that some patients have urgent medical reasons to undergo cardiac surgery within days of their coronary catheterization. However, in many other cases, cardiac surgery becomes scheduled during the same hospital admission as catheterization because of convenience for the patient, the surgeon, or for other physicians involved with the case, Dr. Kramer, director of cardiac surgery research at Maine Medical Center in Portland, said in an interview.

The study reviewed 668 consecutive patients who underwent cardiac surgery subsequent to PCI at Maine Medical Center during 2008 who were not on dialysis and did not require emergency procedures while hospitalized. Surgery during a subsequent hospitalization was performed an average of 39 days after PCI in 211 patients, while in 457, surgery was performed an average of 3 days after PCI during the same hospitalization.

The patients' average age was 68 years and about a quarter were women. The immediate surgery patients had a significantly higher prevalences of coronary artery disease, MI during the week before surgery, LVEF of less than 40%, and elevated white cell count.

The rates of elective and urgent surgery, respectively, were 86% and 14% in the patients whose surgery was deferred for a second hospitalization, compared with 13% and 87% in patients who had their catheterization and surgery in a single hospitalization. Coronary bypass surgery alone occurred in 53% of the deferred patients and 60% of those with a single hospitalization, with the other surgeries divided between valve alone or valve plus bypass.

The incidence of AKI, defined as a creatinine measure that increased by at least 50% over baseline or that rose by at least 0.3 mg/dL over baseline, during or immediately after surgery was 34% in the patients hospitalized a second time for their surgery and 50% in those who had their surgery in their first hospitalization, a significant difference.

No other perioperative outcome parameters differed significantly between the two groups, including death, Q-wave MI, or stroke. The perioperative mortality rate was 2% in patients with deferred surgery and 4% in those with more immediate surgery.

In an analysis that adjusted for baseline demographic and clinical differences, patients with deferred surgery had a significant, 45% relative reduction in their rate of AKI, compared with patients with more immediate surgery.

Although the findings are strictly speaking just hypothesis generating, Dr. Kramer contended that the findings are compelling enough to warrant an immediate change in practice: limit cardiac surgery within a few days after catheterization to patients who clearly need rapid intervention.

Dr. Kramer said he had no disclosures relevant to this study.

◊ To see a video interview with Dr. Kramer, go to www.youtube.com/CardiologyNews

Limit cardiac surgery within a few days after catheterization to patients who clearly need rapid intervention.

Source DR. KRAMER

FORT LAUDERDALE, FLA. — Combining coronary artery catheterization and cardiac surgery in the same hospital admission was linked to a significantly increased risk for acute kidney injury (AKI), compared with performing the surgery during a second, later hospitalization, a single-center study of more than 600 patients showed.

AKI in cardiac surgery patients has been linked to significantly worse long-term survival. “If there is a way to safely manage patients medically between catheterization and surgery, that should be done, to mitigate the potential for acute kidney injury,” Dr. Robert S. Kramer said at the annual meeting of the Society of Thoracic Surgeons.

He acknowledged that some patients have urgent medical reasons to undergo cardiac surgery within days of their coronary catheterization. However, in many other cases, cardiac surgery becomes scheduled during the same hospital admission as catheterization because of convenience for the patient, the surgeon, or for other physicians involved with the case, Dr. Kramer, director of cardiac surgery research at Maine Medical Center in Portland, said in an interview.

The study reviewed 668 consecutive patients who underwent cardiac surgery subsequent to PCI at Maine Medical Center during 2008 who were not on dialysis and did not require emergency procedures while hospitalized. Surgery during a subsequent hospitalization was performed an average of 39 days after PCI in 211 patients, while in 457, surgery was performed an average of 3 days after PCI during the same hospitalization.

The patients' average age was 68 years and about a quarter were women. The immediate surgery patients had a significantly higher prevalences of coronary artery disease, MI during the week before surgery, LVEF of less than 40%, and elevated white cell count.

The rates of elective and urgent surgery, respectively, were 86% and 14% in the patients whose surgery was deferred for a second hospitalization, compared with 13% and 87% in patients who had their catheterization and surgery in a single hospitalization. Coronary bypass surgery alone occurred in 53% of the deferred patients and 60% of those with a single hospitalization, with the other surgeries divided between valve alone or valve plus bypass.

The incidence of AKI, defined as a creatinine measure that increased by at least 50% over baseline or that rose by at least 0.3 mg/dL over baseline, during or immediately after surgery was 34% in the patients hospitalized a second time for their surgery and 50% in those who had their surgery in their first hospitalization, a significant difference.

No other perioperative outcome parameters differed significantly between the two groups, including death, Q-wave MI, or stroke. The perioperative mortality rate was 2% in patients with deferred surgery and 4% in those with more immediate surgery.

In an analysis that adjusted for baseline demographic and clinical differences, patients with deferred surgery had a significant, 45% relative reduction in their rate of AKI, compared with patients with more immediate surgery.

Although the findings are strictly speaking just hypothesis generating, Dr. Kramer contended that the findings are compelling enough to warrant an immediate change in practice: limit cardiac surgery within a few days after catheterization to patients who clearly need rapid intervention.

Dr. Kramer said he had no disclosures relevant to this study.

◊ To see a video interview with Dr. Kramer, go to www.youtube.com/CardiologyNews

Limit cardiac surgery within a few days after catheterization to patients who clearly need rapid intervention.

Source DR. KRAMER

By the start of February, much of the American public had unofficially declared the influenza H1N1 pandemic of 2009-2010 over, even though as recently as Feb. 5 U.S. health officials continued to urge Americans to get vaccinated.

The U.S. population spoke with unrolled sleeves and averted nostrils. That's to say that during January, the period when the vaccine was available to all U.S. residents and not officially limited to just those in high risk groups, the pace of vaccination fell to the relatively low rate of about 9 million people immunized during the month. This was a significant drop compared with an average rate of about 20 million vaccinations per month from October through December, according to survey results and extrapolations made by the Centers for Disease Control and Prevention (CDC) in Atlanta.

Interest in the H1N1 vaccine in January ran parallel with the low level of H1N1 infection last month. During the final week of January, the CDC's sentinel system found that 1.9% of U.S. physician visits involved influenza, with virtually all identified strains H1N1, compared with a national baseline level “during the off season” of 2.3%, indicating infection rates were far from epidemic.

The prospects for much more H1N1 vaccine uptake seem dim, given results from a poll conducted Jan. 20-24 by the Harvard Opinion Research Program of Harvard University's School of Public Health. A telephone survey of more than 1,400 American adults found that 44% said the H1N1 outbreak was “over,” and “only 32%” had concern that they or someone in their immediate family might get sick from H1N1 during the next several months. The poll also found that 61% of respondents had not received the H1N1 vaccine and did not intend to get it in the future, with 37% of those polled saying their major reason for shunning the vaccine was that they did not think the H1N1 outbreak to be as serious now as public health officials once thought.

“The skepticism of this group indicates that, going forward, it may be difficult to get more movement in the percentage of adults vaccinated for H1N1,” said Robert J. Blendon, Sc.D., professor of health policy and political analysis at Harvard in Boston and director of the Opinion Research Program, in a written statement.

“The public aren't dummies. They figured out that despite the exhortations of the CDC to still get vaccinated [against H1N1], because the virus is still out there, at the moment it's a much quieter flu season than usual and so they are not lining up for vaccine,” said Dr. William Schaffner, professor and chairman of the department of preventive medicine at Vanderbilt University in Nashville. “In Tennessee, we have ample supplies of vaccine and few customers right now. The stock is not moving.”

Statistics show the H1N1 vaccine never caught on in the United States. The approximately 70 million Americans who got the vaccine through the end of January, 23% of the U.S. population according to CDC numbers, contrasts with 32% of American who received the seasonal 2009-2010 flu vaccine through mid-November 2009, according to a survey by the RAND Corporation. For the 2008-2009 season, RAND reported, 38% of American adults had received the seasonal flu vaccine as of March 2009.

What made the H1N1 vaccine so much less popular, despite an unprecedented public health campaign? (The federal government's widely publicized strategy was to swiftly buy and distribute up to 200 million doses of vaccine.)

Experts cite poor timing in the vaccine's availability last fall, confusion over who was to get the vaccine based on its limited early supply starting last October, and concerns about the vaccine's safety.

“The vaccine was too little too late in the public's mind,” said Dr. Gregory A. Poland, professor of medicine and director of the Vaccine Research group at Mayo Clinic in Rochester, Minn.

“Vaccine availability peaked just as the second wave of the pandemic diminished,” he said. The American public “waited and waited for [the vaccine], and when it become available they stopped hearing reports of cases.” Another important factor was the “underlying distrust and suspicion about vaccines, with many Americans believing the vaccine was too rushed, untested, and not safe.”

The striking difference in H1N1 vaccine uptake compared with the reception seasonal flu vaccine received in September through November isn't surprising because “people looked at the H1N1 vaccine differently,” Dr. Poland said in an interview.

“People are familiar with the seasonal vaccine and presumably more comfortable with its safety, drug stores and supermarkets heavily promoted [seasonal] flu shots, and most important, in contrast to H1N1, there was seasonal vaccine available to meet demand at the time vaccination was being heavily promoted. The public heeded the call to be vaccinated early,” said Katherine M. Harris, Ph.D., a senior economist at RAND Corp. and lead researcher on RAND's flu vaccine surveys.

Dr. Poland highlighted the tiered approach that targeted the earliest available H1N1 vaccine to high-risk people as another factor that dissipated momentum of the vaccination effort. “I don't think it works well on a public health level. It caused delay, and as a result we'll have tens of millions of H1N1 vaccine [doses] go to waste. If we had instead said first-come first-served I don't think we would have wasted as many doses.”

The major underlying problem appears to have been a mismatch between vaccine supply and demand.

“If I had to choose one element that slowed the whole thing down, it was that the bulk of the vaccine began to arrive between [Thanksgiving and Christmas], and there was a sense by then that H1N1 had peaked.,” said Dr. Schaffner.

Because the U.S. government totally funded H1N1 vaccine production, the sources in this article have no disclosures relevant to the topic.

'In Tennessee, we have ample supplies of vaccine and few customers right now. The stock is not moving.'

Source DR. SCHAFFNER

By the start of February, much of the American public had unofficially declared the influenza H1N1 pandemic of 2009-2010 over, even though as recently as Feb. 5 U.S. health officials continued to urge Americans to get vaccinated.

The U.S. population spoke with unrolled sleeves and averted nostrils. That's to say that during January, the period when the vaccine was available to all U.S. residents and not officially limited to just those in high risk groups, the pace of vaccination fell to the relatively low rate of about 9 million people immunized during the month. This was a significant drop compared with an average rate of about 20 million vaccinations per month from October through December, according to survey results and extrapolations made by the Centers for Disease Control and Prevention (CDC) in Atlanta.

Interest in the H1N1 vaccine in January ran parallel with the low level of H1N1 infection last month. During the final week of January, the CDC's sentinel system found that 1.9% of U.S. physician visits involved influenza, with virtually all identified strains H1N1, compared with a national baseline level “during the off season” of 2.3%, indicating infection rates were far from epidemic.

The prospects for much more H1N1 vaccine uptake seem dim, given results from a poll conducted Jan. 20-24 by the Harvard Opinion Research Program of Harvard University's School of Public Health. A telephone survey of more than 1,400 American adults found that 44% said the H1N1 outbreak was “over,” and “only 32%” had concern that they or someone in their immediate family might get sick from H1N1 during the next several months. The poll also found that 61% of respondents had not received the H1N1 vaccine and did not intend to get it in the future, with 37% of those polled saying their major reason for shunning the vaccine was that they did not think the H1N1 outbreak to be as serious now as public health officials once thought.

“The skepticism of this group indicates that, going forward, it may be difficult to get more movement in the percentage of adults vaccinated for H1N1,” said Robert J. Blendon, Sc.D., professor of health policy and political analysis at Harvard in Boston and director of the Opinion Research Program, in a written statement.

“The public aren't dummies. They figured out that despite the exhortations of the CDC to still get vaccinated [against H1N1], because the virus is still out there, at the moment it's a much quieter flu season than usual and so they are not lining up for vaccine,” said Dr. William Schaffner, professor and chairman of the department of preventive medicine at Vanderbilt University in Nashville. “In Tennessee, we have ample supplies of vaccine and few customers right now. The stock is not moving.”

Statistics show the H1N1 vaccine never caught on in the United States. The approximately 70 million Americans who got the vaccine through the end of January, 23% of the U.S. population according to CDC numbers, contrasts with 32% of American who received the seasonal 2009-2010 flu vaccine through mid-November 2009, according to a survey by the RAND Corporation. For the 2008-2009 season, RAND reported, 38% of American adults had received the seasonal flu vaccine as of March 2009.

What made the H1N1 vaccine so much less popular, despite an unprecedented public health campaign? (The federal government's widely publicized strategy was to swiftly buy and distribute up to 200 million doses of vaccine.)

Experts cite poor timing in the vaccine's availability last fall, confusion over who was to get the vaccine based on its limited early supply starting last October, and concerns about the vaccine's safety.

“The vaccine was too little too late in the public's mind,” said Dr. Gregory A. Poland, professor of medicine and director of the Vaccine Research group at Mayo Clinic in Rochester, Minn.

“Vaccine availability peaked just as the second wave of the pandemic diminished,” he said. The American public “waited and waited for [the vaccine], and when it become available they stopped hearing reports of cases.” Another important factor was the “underlying distrust and suspicion about vaccines, with many Americans believing the vaccine was too rushed, untested, and not safe.”

The striking difference in H1N1 vaccine uptake compared with the reception seasonal flu vaccine received in September through November isn't surprising because “people looked at the H1N1 vaccine differently,” Dr. Poland said in an interview.

“People are familiar with the seasonal vaccine and presumably more comfortable with its safety, drug stores and supermarkets heavily promoted [seasonal] flu shots, and most important, in contrast to H1N1, there was seasonal vaccine available to meet demand at the time vaccination was being heavily promoted. The public heeded the call to be vaccinated early,” said Katherine M. Harris, Ph.D., a senior economist at RAND Corp. and lead researcher on RAND's flu vaccine surveys.

Dr. Poland highlighted the tiered approach that targeted the earliest available H1N1 vaccine to high-risk people as another factor that dissipated momentum of the vaccination effort. “I don't think it works well on a public health level. It caused delay, and as a result we'll have tens of millions of H1N1 vaccine [doses] go to waste. If we had instead said first-come first-served I don't think we would have wasted as many doses.”

The major underlying problem appears to have been a mismatch between vaccine supply and demand.

“If I had to choose one element that slowed the whole thing down, it was that the bulk of the vaccine began to arrive between [Thanksgiving and Christmas], and there was a sense by then that H1N1 had peaked.,” said Dr. Schaffner.

Because the U.S. government totally funded H1N1 vaccine production, the sources in this article have no disclosures relevant to the topic.

'In Tennessee, we have ample supplies of vaccine and few customers right now. The stock is not moving.'

Source DR. SCHAFFNER

By the start of February, much of the American public had unofficially declared the influenza H1N1 pandemic of 2009-2010 over, even though as recently as Feb. 5 U.S. health officials continued to urge Americans to get vaccinated.

The U.S. population spoke with unrolled sleeves and averted nostrils. That's to say that during January, the period when the vaccine was available to all U.S. residents and not officially limited to just those in high risk groups, the pace of vaccination fell to the relatively low rate of about 9 million people immunized during the month. This was a significant drop compared with an average rate of about 20 million vaccinations per month from October through December, according to survey results and extrapolations made by the Centers for Disease Control and Prevention (CDC) in Atlanta.

Interest in the H1N1 vaccine in January ran parallel with the low level of H1N1 infection last month. During the final week of January, the CDC's sentinel system found that 1.9% of U.S. physician visits involved influenza, with virtually all identified strains H1N1, compared with a national baseline level “during the off season” of 2.3%, indicating infection rates were far from epidemic.

The prospects for much more H1N1 vaccine uptake seem dim, given results from a poll conducted Jan. 20-24 by the Harvard Opinion Research Program of Harvard University's School of Public Health. A telephone survey of more than 1,400 American adults found that 44% said the H1N1 outbreak was “over,” and “only 32%” had concern that they or someone in their immediate family might get sick from H1N1 during the next several months. The poll also found that 61% of respondents had not received the H1N1 vaccine and did not intend to get it in the future, with 37% of those polled saying their major reason for shunning the vaccine was that they did not think the H1N1 outbreak to be as serious now as public health officials once thought.

“The skepticism of this group indicates that, going forward, it may be difficult to get more movement in the percentage of adults vaccinated for H1N1,” said Robert J. Blendon, Sc.D., professor of health policy and political analysis at Harvard in Boston and director of the Opinion Research Program, in a written statement.

“The public aren't dummies. They figured out that despite the exhortations of the CDC to still get vaccinated [against H1N1], because the virus is still out there, at the moment it's a much quieter flu season than usual and so they are not lining up for vaccine,” said Dr. William Schaffner, professor and chairman of the department of preventive medicine at Vanderbilt University in Nashville. “In Tennessee, we have ample supplies of vaccine and few customers right now. The stock is not moving.”

Statistics show the H1N1 vaccine never caught on in the United States. The approximately 70 million Americans who got the vaccine through the end of January, 23% of the U.S. population according to CDC numbers, contrasts with 32% of American who received the seasonal 2009-2010 flu vaccine through mid-November 2009, according to a survey by the RAND Corporation. For the 2008-2009 season, RAND reported, 38% of American adults had received the seasonal flu vaccine as of March 2009.

What made the H1N1 vaccine so much less popular, despite an unprecedented public health campaign? (The federal government's widely publicized strategy was to swiftly buy and distribute up to 200 million doses of vaccine.)

Experts cite poor timing in the vaccine's availability last fall, confusion over who was to get the vaccine based on its limited early supply starting last October, and concerns about the vaccine's safety.

“The vaccine was too little too late in the public's mind,” said Dr. Gregory A. Poland, professor of medicine and director of the Vaccine Research group at Mayo Clinic in Rochester, Minn.

“Vaccine availability peaked just as the second wave of the pandemic diminished,” he said. The American public “waited and waited for [the vaccine], and when it become available they stopped hearing reports of cases.” Another important factor was the “underlying distrust and suspicion about vaccines, with many Americans believing the vaccine was too rushed, untested, and not safe.”

The striking difference in H1N1 vaccine uptake compared with the reception seasonal flu vaccine received in September through November isn't surprising because “people looked at the H1N1 vaccine differently,” Dr. Poland said in an interview.

“People are familiar with the seasonal vaccine and presumably more comfortable with its safety, drug stores and supermarkets heavily promoted [seasonal] flu shots, and most important, in contrast to H1N1, there was seasonal vaccine available to meet demand at the time vaccination was being heavily promoted. The public heeded the call to be vaccinated early,” said Katherine M. Harris, Ph.D., a senior economist at RAND Corp. and lead researcher on RAND's flu vaccine surveys.

Dr. Poland highlighted the tiered approach that targeted the earliest available H1N1 vaccine to high-risk people as another factor that dissipated momentum of the vaccination effort. “I don't think it works well on a public health level. It caused delay, and as a result we'll have tens of millions of H1N1 vaccine [doses] go to waste. If we had instead said first-come first-served I don't think we would have wasted as many doses.”

The major underlying problem appears to have been a mismatch between vaccine supply and demand.

“If I had to choose one element that slowed the whole thing down, it was that the bulk of the vaccine began to arrive between [Thanksgiving and Christmas], and there was a sense by then that H1N1 had peaked.,” said Dr. Schaffner.

Because the U.S. government totally funded H1N1 vaccine production, the sources in this article have no disclosures relevant to the topic.

'In Tennessee, we have ample supplies of vaccine and few customers right now. The stock is not moving.'

Source DR. SCHAFFNER

Implantable loop recorders play an increasingly important role in assessing patients for syncope, say several experts as well as the most recent syncope guidelines, released by the European Society of Cardiology last August.

Implantable loop recorders [ILRs], introduced for syncope assessment about a decade ago, “are steadily becoming more and more widely acknowledged as an important diagnostic device by arrhythmologists and other experts active in the investigation of unexplained syncope in daily practice,” said Dr. Panos E. Vardas, an electrophysiologist and professor of cardiology at the University of Crete, Greece, and president of the European Heart Rhythm Association.

“Patients with infrequent, short-duration, transient symptoms, recurring over weeks or months, are unlikely to be diagnosed by conventional Holter monitoring, since the likelihood of symptom-ECG correlation is very low. In such patients, following careful evaluation of the patient's history, physical examination and ECG, when syncopal episodes remain unexplained, ILRs are no longer implemented as a last option but earlier in the evaluation algorithm,” Dr. Vardas said in an interview.

“The main indications include repeated episodes of unexplained syncope, syncope with injury, and syncope with special kinds of loss of consciousness such as differentiating between cardiac syncope and epilepsy. Especially in the case of atrial fibrillation, in which some paroxysms also lead to syncope, I am expecting the use of ILRs will change the whole understanding we have of the natural history of the disease,” he said.

“Today, ILRs are the most valuable tool for the diagnosis of the arrhythmic mechanism of syncope,” and “are expected to become the gold standard for diagnosis of arrhythmic syncope,” said Dr. Richard Sutton, professor of clinical cardiology at Imperial College, London, and cochair of the European Society of Cardiology (ESC) task force that wrote the 2009 guidelines for diagnosing and managing syncope (Eur. Heart J. 2009;30:2631-71). “The new ESC guidelines for syncope attempt to bring the ILR into the forefront of investigation of syncope based on the experience reported in the literature,” Dr. Sutton said in a talk at the ESC annual meeting in Barcelona last August.

“ILRs are clearly underused,” said Dr. Christophe Leclercq, professor of cardiology and vascular diseases at Pontchaillou Hospital in Rennes, France. “I think that in patients with severe syncope, the role of ILRs will dramatically increase, improving the diagnosis of syncope and also avoiding misdiagnoses, such as epilepsy.”

Evidence for the utility of ILRs in distinguishing arrhythmogenic syncope and epilepsy came in a report at the last ESC annual meeting. Researchers from Manchester (England) Royal Infirmary studied 41 adult patients who had been tentatively diagnosed with epilepsy, but for whom further review by a neurologist raised doubt about their status.

All patients receive an ILR, and the researchers eventually identified seven patients (17%) who experienced a heartbeat stop of 4-89 seconds that caused their loss of consciousness.

Despite these views, other electrophysiologists remain skeptical that ILRs play a major part in syncope assessment. “We use ILRs in patients with infrequent episodes, maybe one or two over 18 months, and we probably use ILRs more than we did 5 years ago, but we put in perhaps six a year,” said Dr. S. Adam Strickberger, professor of medicine at Georgetown University in Washington, and head of electrophysiology at Washington Hospital Center.

ILRs are “a useful tool in only a small subset of patients, probably less than 5%,” he said in an interview. “Half of patients with syncope have a vasovagal cause,” and hence are not candidates for ILR assessment. Among the remaining syncope patients, a large fraction have a low ejection fraction that makes them immediate candidates for a defibrillator with no need for ILR assessment.

Dr. Strickberger agreed, however, that tilt table testing is rarely used today, and that electrophysiology testing of syncope patients has also dropped. A patient's history serves as the major starting point for syncope assessment, he said. Dr. Strickberger chaired the most recent American College of Cardiology and American Heart Association committee to issue a scientific statement on syncope assessment, in 2006 (J. Am. Coll. Cardiol. 2006;47:473-84).

An ILR, roughly the size of a memory stick, continuously records a patient's ECG onto a memory loop of about 20 minutes. Patients activate their recorders following an episode so that the prior 20 minutes of ECG recordings are preserved for later assessment to search for correlates between the syncope event and arrhythmia. Implantation of ILRs is subcutaneous on the chest, using local anesthesia, and does not require lead placement, making the process relatively noninvasive. ILRs have a battery life of up to 3 years.

Prolonged ECG monitoring to find disease-related ECG abnormalities is the biggest attraction of ILRs. The alternatives, Holter monitors and external loop recorders, are not practical for monitoring that might take months or years, and an in-hospital electrophysiology study carries no guarantee that an induced arrhythmia replicates the cause of spontaneous syncope.

According to the ESC guidelines, although ILRs have a “high initial cost … if symptom-ECG correlation can be achieved in a substantial number of patients … the implanted device may be more cost effective than a strategy using conventional investigation.”

The guidelines cite two class I indications (which means there is evidence for or general agreement that the procedure is effective and useful) for ILRs in assessing syncope: in the early phase of evaluating patients with recurrent syncope of uncertain origin who lack high-risk criteria but have a high likelihood of a recurrent episode during the ILR's battery life, and in high-risk patients whose initial evaluation did not identify a cause of syncope. An additional, more equivocal use of ILRs is to assess the role of bradycardia in patients with known or suspected reflex syncope prior to starting cardiac pacing.

“Tilt table testing is becoming less frequent, and electrophysiology studies should be exceptional,” Dr. Andrew D. Krahn said at the American Heart Associations scientific sessions last November in Orlando. The first and best tool for evaluating the likely cause of syncope is a detailed patient history, he added.

In addition to history, assessment of unexplained syncope is largely guided by left ventricular function, Dr. Krahn said. In patients with a left ventricular ejection fraction of less than 30%, the prime option is to forgo further testing and consider placing an implantable cardioverter defibrillator. In patients with better left ventricular function, ILRs serve as the ultimate arbiter for hard-to-assess patients.

In patients with an ejection fraction of more than 45%, tilt table testing may be appropriate if a vasovagal cause is suspected, said Dr. Krahn, an electrophysiologist in the arrhythmia service at the London (Ont.) Health Sciences Centre, and a member of the ESC syncope guidelines task force.

If an arrhythmia cause is the primary suspect, external monitoring is a potential first choice, and external monitoring might also follow a failed tilt table test. But if external monitoring fails to make the diagnosis, then an ILR is the next step, he said.

Dr. Vardas has been a speaker for Medtronic and St. Jude, companies that market ILRs. Dr. Sutton has received research grants from, and has been a consultant to, Medtronic. Dr. Leclercq has been a consultant to Medtronic and St. Jude. Dr. Strickberger has been a consultant to St. Jude. Dr. Krahn has received research grants from, and has been a consultant to, Transoma, a third company that had marketed an ILR. (Transoma went out of business late last year.)

The new European guidelines 'attempt to bring the ILR into the forefront of investigation of syncope.'

Source DR. SUTTON

Implantable loop recorders play an increasingly important role in assessing patients for syncope, say several experts as well as the most recent syncope guidelines, released by the European Society of Cardiology last August.

Implantable loop recorders [ILRs], introduced for syncope assessment about a decade ago, “are steadily becoming more and more widely acknowledged as an important diagnostic device by arrhythmologists and other experts active in the investigation of unexplained syncope in daily practice,” said Dr. Panos E. Vardas, an electrophysiologist and professor of cardiology at the University of Crete, Greece, and president of the European Heart Rhythm Association.

“Patients with infrequent, short-duration, transient symptoms, recurring over weeks or months, are unlikely to be diagnosed by conventional Holter monitoring, since the likelihood of symptom-ECG correlation is very low. In such patients, following careful evaluation of the patient's history, physical examination and ECG, when syncopal episodes remain unexplained, ILRs are no longer implemented as a last option but earlier in the evaluation algorithm,” Dr. Vardas said in an interview.

“The main indications include repeated episodes of unexplained syncope, syncope with injury, and syncope with special kinds of loss of consciousness such as differentiating between cardiac syncope and epilepsy. Especially in the case of atrial fibrillation, in which some paroxysms also lead to syncope, I am expecting the use of ILRs will change the whole understanding we have of the natural history of the disease,” he said.

“Today, ILRs are the most valuable tool for the diagnosis of the arrhythmic mechanism of syncope,” and “are expected to become the gold standard for diagnosis of arrhythmic syncope,” said Dr. Richard Sutton, professor of clinical cardiology at Imperial College, London, and cochair of the European Society of Cardiology (ESC) task force that wrote the 2009 guidelines for diagnosing and managing syncope (Eur. Heart J. 2009;30:2631-71). “The new ESC guidelines for syncope attempt to bring the ILR into the forefront of investigation of syncope based on the experience reported in the literature,” Dr. Sutton said in a talk at the ESC annual meeting in Barcelona last August.

“ILRs are clearly underused,” said Dr. Christophe Leclercq, professor of cardiology and vascular diseases at Pontchaillou Hospital in Rennes, France. “I think that in patients with severe syncope, the role of ILRs will dramatically increase, improving the diagnosis of syncope and also avoiding misdiagnoses, such as epilepsy.”

Evidence for the utility of ILRs in distinguishing arrhythmogenic syncope and epilepsy came in a report at the last ESC annual meeting. Researchers from Manchester (England) Royal Infirmary studied 41 adult patients who had been tentatively diagnosed with epilepsy, but for whom further review by a neurologist raised doubt about their status.

All patients receive an ILR, and the researchers eventually identified seven patients (17%) who experienced a heartbeat stop of 4-89 seconds that caused their loss of consciousness.

Despite these views, other electrophysiologists remain skeptical that ILRs play a major part in syncope assessment. “We use ILRs in patients with infrequent episodes, maybe one or two over 18 months, and we probably use ILRs more than we did 5 years ago, but we put in perhaps six a year,” said Dr. S. Adam Strickberger, professor of medicine at Georgetown University in Washington, and head of electrophysiology at Washington Hospital Center.

ILRs are “a useful tool in only a small subset of patients, probably less than 5%,” he said in an interview. “Half of patients with syncope have a vasovagal cause,” and hence are not candidates for ILR assessment. Among the remaining syncope patients, a large fraction have a low ejection fraction that makes them immediate candidates for a defibrillator with no need for ILR assessment.

Dr. Strickberger agreed, however, that tilt table testing is rarely used today, and that electrophysiology testing of syncope patients has also dropped. A patient's history serves as the major starting point for syncope assessment, he said. Dr. Strickberger chaired the most recent American College of Cardiology and American Heart Association committee to issue a scientific statement on syncope assessment, in 2006 (J. Am. Coll. Cardiol. 2006;47:473-84).

An ILR, roughly the size of a memory stick, continuously records a patient's ECG onto a memory loop of about 20 minutes. Patients activate their recorders following an episode so that the prior 20 minutes of ECG recordings are preserved for later assessment to search for correlates between the syncope event and arrhythmia. Implantation of ILRs is subcutaneous on the chest, using local anesthesia, and does not require lead placement, making the process relatively noninvasive. ILRs have a battery life of up to 3 years.

Prolonged ECG monitoring to find disease-related ECG abnormalities is the biggest attraction of ILRs. The alternatives, Holter monitors and external loop recorders, are not practical for monitoring that might take months or years, and an in-hospital electrophysiology study carries no guarantee that an induced arrhythmia replicates the cause of spontaneous syncope.

According to the ESC guidelines, although ILRs have a “high initial cost … if symptom-ECG correlation can be achieved in a substantial number of patients … the implanted device may be more cost effective than a strategy using conventional investigation.”

The guidelines cite two class I indications (which means there is evidence for or general agreement that the procedure is effective and useful) for ILRs in assessing syncope: in the early phase of evaluating patients with recurrent syncope of uncertain origin who lack high-risk criteria but have a high likelihood of a recurrent episode during the ILR's battery life, and in high-risk patients whose initial evaluation did not identify a cause of syncope. An additional, more equivocal use of ILRs is to assess the role of bradycardia in patients with known or suspected reflex syncope prior to starting cardiac pacing.

“Tilt table testing is becoming less frequent, and electrophysiology studies should be exceptional,” Dr. Andrew D. Krahn said at the American Heart Associations scientific sessions last November in Orlando. The first and best tool for evaluating the likely cause of syncope is a detailed patient history, he added.

In addition to history, assessment of unexplained syncope is largely guided by left ventricular function, Dr. Krahn said. In patients with a left ventricular ejection fraction of less than 30%, the prime option is to forgo further testing and consider placing an implantable cardioverter defibrillator. In patients with better left ventricular function, ILRs serve as the ultimate arbiter for hard-to-assess patients.

In patients with an ejection fraction of more than 45%, tilt table testing may be appropriate if a vasovagal cause is suspected, said Dr. Krahn, an electrophysiologist in the arrhythmia service at the London (Ont.) Health Sciences Centre, and a member of the ESC syncope guidelines task force.

If an arrhythmia cause is the primary suspect, external monitoring is a potential first choice, and external monitoring might also follow a failed tilt table test. But if external monitoring fails to make the diagnosis, then an ILR is the next step, he said.

Dr. Vardas has been a speaker for Medtronic and St. Jude, companies that market ILRs. Dr. Sutton has received research grants from, and has been a consultant to, Medtronic. Dr. Leclercq has been a consultant to Medtronic and St. Jude. Dr. Strickberger has been a consultant to St. Jude. Dr. Krahn has received research grants from, and has been a consultant to, Transoma, a third company that had marketed an ILR. (Transoma went out of business late last year.)

The new European guidelines 'attempt to bring the ILR into the forefront of investigation of syncope.'

Source DR. SUTTON

Implantable loop recorders play an increasingly important role in assessing patients for syncope, say several experts as well as the most recent syncope guidelines, released by the European Society of Cardiology last August.

Implantable loop recorders [ILRs], introduced for syncope assessment about a decade ago, “are steadily becoming more and more widely acknowledged as an important diagnostic device by arrhythmologists and other experts active in the investigation of unexplained syncope in daily practice,” said Dr. Panos E. Vardas, an electrophysiologist and professor of cardiology at the University of Crete, Greece, and president of the European Heart Rhythm Association.

“Patients with infrequent, short-duration, transient symptoms, recurring over weeks or months, are unlikely to be diagnosed by conventional Holter monitoring, since the likelihood of symptom-ECG correlation is very low. In such patients, following careful evaluation of the patient's history, physical examination and ECG, when syncopal episodes remain unexplained, ILRs are no longer implemented as a last option but earlier in the evaluation algorithm,” Dr. Vardas said in an interview.

“The main indications include repeated episodes of unexplained syncope, syncope with injury, and syncope with special kinds of loss of consciousness such as differentiating between cardiac syncope and epilepsy. Especially in the case of atrial fibrillation, in which some paroxysms also lead to syncope, I am expecting the use of ILRs will change the whole understanding we have of the natural history of the disease,” he said.

“Today, ILRs are the most valuable tool for the diagnosis of the arrhythmic mechanism of syncope,” and “are expected to become the gold standard for diagnosis of arrhythmic syncope,” said Dr. Richard Sutton, professor of clinical cardiology at Imperial College, London, and cochair of the European Society of Cardiology (ESC) task force that wrote the 2009 guidelines for diagnosing and managing syncope (Eur. Heart J. 2009;30:2631-71). “The new ESC guidelines for syncope attempt to bring the ILR into the forefront of investigation of syncope based on the experience reported in the literature,” Dr. Sutton said in a talk at the ESC annual meeting in Barcelona last August.

“ILRs are clearly underused,” said Dr. Christophe Leclercq, professor of cardiology and vascular diseases at Pontchaillou Hospital in Rennes, France. “I think that in patients with severe syncope, the role of ILRs will dramatically increase, improving the diagnosis of syncope and also avoiding misdiagnoses, such as epilepsy.”

Evidence for the utility of ILRs in distinguishing arrhythmogenic syncope and epilepsy came in a report at the last ESC annual meeting. Researchers from Manchester (England) Royal Infirmary studied 41 adult patients who had been tentatively diagnosed with epilepsy, but for whom further review by a neurologist raised doubt about their status.

All patients receive an ILR, and the researchers eventually identified seven patients (17%) who experienced a heartbeat stop of 4-89 seconds that caused their loss of consciousness.

Despite these views, other electrophysiologists remain skeptical that ILRs play a major part in syncope assessment. “We use ILRs in patients with infrequent episodes, maybe one or two over 18 months, and we probably use ILRs more than we did 5 years ago, but we put in perhaps six a year,” said Dr. S. Adam Strickberger, professor of medicine at Georgetown University in Washington, and head of electrophysiology at Washington Hospital Center.

ILRs are “a useful tool in only a small subset of patients, probably less than 5%,” he said in an interview. “Half of patients with syncope have a vasovagal cause,” and hence are not candidates for ILR assessment. Among the remaining syncope patients, a large fraction have a low ejection fraction that makes them immediate candidates for a defibrillator with no need for ILR assessment.

Dr. Strickberger agreed, however, that tilt table testing is rarely used today, and that electrophysiology testing of syncope patients has also dropped. A patient's history serves as the major starting point for syncope assessment, he said. Dr. Strickberger chaired the most recent American College of Cardiology and American Heart Association committee to issue a scientific statement on syncope assessment, in 2006 (J. Am. Coll. Cardiol. 2006;47:473-84).

An ILR, roughly the size of a memory stick, continuously records a patient's ECG onto a memory loop of about 20 minutes. Patients activate their recorders following an episode so that the prior 20 minutes of ECG recordings are preserved for later assessment to search for correlates between the syncope event and arrhythmia. Implantation of ILRs is subcutaneous on the chest, using local anesthesia, and does not require lead placement, making the process relatively noninvasive. ILRs have a battery life of up to 3 years.

Prolonged ECG monitoring to find disease-related ECG abnormalities is the biggest attraction of ILRs. The alternatives, Holter monitors and external loop recorders, are not practical for monitoring that might take months or years, and an in-hospital electrophysiology study carries no guarantee that an induced arrhythmia replicates the cause of spontaneous syncope.

According to the ESC guidelines, although ILRs have a “high initial cost … if symptom-ECG correlation can be achieved in a substantial number of patients … the implanted device may be more cost effective than a strategy using conventional investigation.”

The guidelines cite two class I indications (which means there is evidence for or general agreement that the procedure is effective and useful) for ILRs in assessing syncope: in the early phase of evaluating patients with recurrent syncope of uncertain origin who lack high-risk criteria but have a high likelihood of a recurrent episode during the ILR's battery life, and in high-risk patients whose initial evaluation did not identify a cause of syncope. An additional, more equivocal use of ILRs is to assess the role of bradycardia in patients with known or suspected reflex syncope prior to starting cardiac pacing.

“Tilt table testing is becoming less frequent, and electrophysiology studies should be exceptional,” Dr. Andrew D. Krahn said at the American Heart Associations scientific sessions last November in Orlando. The first and best tool for evaluating the likely cause of syncope is a detailed patient history, he added.

In addition to history, assessment of unexplained syncope is largely guided by left ventricular function, Dr. Krahn said. In patients with a left ventricular ejection fraction of less than 30%, the prime option is to forgo further testing and consider placing an implantable cardioverter defibrillator. In patients with better left ventricular function, ILRs serve as the ultimate arbiter for hard-to-assess patients.

In patients with an ejection fraction of more than 45%, tilt table testing may be appropriate if a vasovagal cause is suspected, said Dr. Krahn, an electrophysiologist in the arrhythmia service at the London (Ont.) Health Sciences Centre, and a member of the ESC syncope guidelines task force.

If an arrhythmia cause is the primary suspect, external monitoring is a potential first choice, and external monitoring might also follow a failed tilt table test. But if external monitoring fails to make the diagnosis, then an ILR is the next step, he said.

Dr. Vardas has been a speaker for Medtronic and St. Jude, companies that market ILRs. Dr. Sutton has received research grants from, and has been a consultant to, Medtronic. Dr. Leclercq has been a consultant to Medtronic and St. Jude. Dr. Strickberger has been a consultant to St. Jude. Dr. Krahn has received research grants from, and has been a consultant to, Transoma, a third company that had marketed an ILR. (Transoma went out of business late last year.)

The new European guidelines 'attempt to bring the ILR into the forefront of investigation of syncope.'

Source DR. SUTTON

FORT LAUDERDALE, FLA. — Later this year, coronary bypass patients will start steering their surgeon choices by the stars. A one- to three-star rating system for cardiac surgeons developed by the Society for Thoracic Surgeons will appear on a Consumer Reports Web site, probably beginning in June.

In a bold step toward getting outcomes-based rankings of surgeons out to the public in a user-friendly format, the society teamed with the Consumers Union, publisher of Consumer Reports, to disseminate rankings of U.S. programs offering coronary artery bypass grafting (CABG). The ranking data come from the Society of Thoracic Surgeons' (STS) Adult Cardiac Surgery Database, which currently gathers surgery and outcomes data from about 90% of practicing U.S. cardiac surgeons. The ranking will post at www.consumerreports.org/health

The STS leadership is soliciting formal consent from each of its practicing U.S. members; the process requires a physician's consent to place ratings for the practice on the site. The STS leadership first introduced the concept to its members last September, and since then has steadily promoted the idea. As of late January, almost 100 practices had signed releases, nearly 10% of the roughly 1,000 U.S. cardiac surgery practices that perform CABG. The Society's immediate goal is to have at least 300 consents on file by mid-March to ensure a robust start. Once that foundation exists, additional participation will likely follow, said Dr. Frederick L. Grover, chairman of the STS' council on quality, research, and patient safety and a recent former president of the group.

Each participating practice will receive star ratings in five categories: overall bypass surgery performance, patient survival, avoidance of complications, the extent to which the CABG program follows recommended surgical practice, and the extent of following recommended medications. Performance of each practice in these categories undergoes risk adjustment and assessment as a ratio of observed relative to expected performance.

Performance is then ranked relative to all other practices. Grading will be scaled so that most practices fall into the mid-range and receive two stars, while high-level performers will get three stars and the bottom tier receive one star, said Dr. Grover, professor and chairman of surgery at the University of Colorado, Denver.

The STS began contemplating public release of its data this way about a year ago, and contacted Consumers Union to flesh out a strategy. The effort shifted into a higher gear last summer when the STS leadership heard from other consumer groups that were planning their own release of CABG outcomes ratings based on administrative claims data, a source the STS considers much less reliable than its own database. Those contacts prompted the Society to speed up development and the timing of the roll-out of the project, Dr. Glover said in an interview.

In addition to giving the public information it likely wants, a second goal is to further spur surgeons who lag behind the field to improve. “If a program is at one star, hopefully it won't be for more than 1 year. The whole idea is to raise the bar for everyone,” he said.

“We think it's in the best interests of patients and our members,” Dr. Grover added. “It has risk, no doubt about it. Our members are obviously taking chances” by having the relative performance of their surgical practice and outcomes so openly displayed. “It will be interesting to see if it changes referral patterns.” The Society's bottom line is “the public has the right to know how we're doing,” Dr. Grover said.

FORT LAUDERDALE, FLA. — Later this year, coronary bypass patients will start steering their surgeon choices by the stars. A one- to three-star rating system for cardiac surgeons developed by the Society for Thoracic Surgeons will appear on a Consumer Reports Web site, probably beginning in June.

In a bold step toward getting outcomes-based rankings of surgeons out to the public in a user-friendly format, the society teamed with the Consumers Union, publisher of Consumer Reports, to disseminate rankings of U.S. programs offering coronary artery bypass grafting (CABG). The ranking data come from the Society of Thoracic Surgeons' (STS) Adult Cardiac Surgery Database, which currently gathers surgery and outcomes data from about 90% of practicing U.S. cardiac surgeons. The ranking will post at www.consumerreports.org/health

The STS leadership is soliciting formal consent from each of its practicing U.S. members; the process requires a physician's consent to place ratings for the practice on the site. The STS leadership first introduced the concept to its members last September, and since then has steadily promoted the idea. As of late January, almost 100 practices had signed releases, nearly 10% of the roughly 1,000 U.S. cardiac surgery practices that perform CABG. The Society's immediate goal is to have at least 300 consents on file by mid-March to ensure a robust start. Once that foundation exists, additional participation will likely follow, said Dr. Frederick L. Grover, chairman of the STS' council on quality, research, and patient safety and a recent former president of the group.

Each participating practice will receive star ratings in five categories: overall bypass surgery performance, patient survival, avoidance of complications, the extent to which the CABG program follows recommended surgical practice, and the extent of following recommended medications. Performance of each practice in these categories undergoes risk adjustment and assessment as a ratio of observed relative to expected performance.

Performance is then ranked relative to all other practices. Grading will be scaled so that most practices fall into the mid-range and receive two stars, while high-level performers will get three stars and the bottom tier receive one star, said Dr. Grover, professor and chairman of surgery at the University of Colorado, Denver.

The STS began contemplating public release of its data this way about a year ago, and contacted Consumers Union to flesh out a strategy. The effort shifted into a higher gear last summer when the STS leadership heard from other consumer groups that were planning their own release of CABG outcomes ratings based on administrative claims data, a source the STS considers much less reliable than its own database. Those contacts prompted the Society to speed up development and the timing of the roll-out of the project, Dr. Glover said in an interview.

In addition to giving the public information it likely wants, a second goal is to further spur surgeons who lag behind the field to improve. “If a program is at one star, hopefully it won't be for more than 1 year. The whole idea is to raise the bar for everyone,” he said.

“We think it's in the best interests of patients and our members,” Dr. Grover added. “It has risk, no doubt about it. Our members are obviously taking chances” by having the relative performance of their surgical practice and outcomes so openly displayed. “It will be interesting to see if it changes referral patterns.” The Society's bottom line is “the public has the right to know how we're doing,” Dr. Grover said.

FORT LAUDERDALE, FLA. — Later this year, coronary bypass patients will start steering their surgeon choices by the stars. A one- to three-star rating system for cardiac surgeons developed by the Society for Thoracic Surgeons will appear on a Consumer Reports Web site, probably beginning in June.

In a bold step toward getting outcomes-based rankings of surgeons out to the public in a user-friendly format, the society teamed with the Consumers Union, publisher of Consumer Reports, to disseminate rankings of U.S. programs offering coronary artery bypass grafting (CABG). The ranking data come from the Society of Thoracic Surgeons' (STS) Adult Cardiac Surgery Database, which currently gathers surgery and outcomes data from about 90% of practicing U.S. cardiac surgeons. The ranking will post at www.consumerreports.org/health

The STS leadership is soliciting formal consent from each of its practicing U.S. members; the process requires a physician's consent to place ratings for the practice on the site. The STS leadership first introduced the concept to its members last September, and since then has steadily promoted the idea. As of late January, almost 100 practices had signed releases, nearly 10% of the roughly 1,000 U.S. cardiac surgery practices that perform CABG. The Society's immediate goal is to have at least 300 consents on file by mid-March to ensure a robust start. Once that foundation exists, additional participation will likely follow, said Dr. Frederick L. Grover, chairman of the STS' council on quality, research, and patient safety and a recent former president of the group.

Each participating practice will receive star ratings in five categories: overall bypass surgery performance, patient survival, avoidance of complications, the extent to which the CABG program follows recommended surgical practice, and the extent of following recommended medications. Performance of each practice in these categories undergoes risk adjustment and assessment as a ratio of observed relative to expected performance.

Performance is then ranked relative to all other practices. Grading will be scaled so that most practices fall into the mid-range and receive two stars, while high-level performers will get three stars and the bottom tier receive one star, said Dr. Grover, professor and chairman of surgery at the University of Colorado, Denver.

The STS began contemplating public release of its data this way about a year ago, and contacted Consumers Union to flesh out a strategy. The effort shifted into a higher gear last summer when the STS leadership heard from other consumer groups that were planning their own release of CABG outcomes ratings based on administrative claims data, a source the STS considers much less reliable than its own database. Those contacts prompted the Society to speed up development and the timing of the roll-out of the project, Dr. Glover said in an interview.

In addition to giving the public information it likely wants, a second goal is to further spur surgeons who lag behind the field to improve. “If a program is at one star, hopefully it won't be for more than 1 year. The whole idea is to raise the bar for everyone,” he said.

“We think it's in the best interests of patients and our members,” Dr. Grover added. “It has risk, no doubt about it. Our members are obviously taking chances” by having the relative performance of their surgical practice and outcomes so openly displayed. “It will be interesting to see if it changes referral patterns.” The Society's bottom line is “the public has the right to know how we're doing,” Dr. Grover said.

PHILADELPHIA – Patients with systemic lupus erythematosus who are also diagnosed with depression were nearly four times more likely to have subclinical atherosclerosis than were lupus patients without depression in a cross-sectional study with 161 women with lupus.

“Depression may be a component of the 'lupus factor' that increases risk for cardiovascular disease,” Carol M. Greco, Ph.D., said at the annual meeting of the American College of Rheumatology. “Depressive symptoms may add to the inflammatory burden” of systemic lupus erythematosus, said Dr. Greco, a clinical psychologist at the lupus center of the University of Pittsburgh.

Finding evidence of a role for depression in causing atherosclerosis in patients with SLE is important because depression is a modifiable risk factor that can be targeted for intervention, she added. Her group's next step is to follow these interactions in a longitudinal clinical study.

To examine correlates of preclinical atherosclerosis in women with SLE, Dr. Greco and her associates studied 161 lupus patients with no history of a cardiovascular event. The women had enrolled in the HEARTS (Heart Effects on Atherosclerosis and Risk of Thrombosis in SLE) study at the University of Pittsburgh. At their baseline examination in 2001-2005, their average age was 50 years; 88% were white. Their average waist:hip ratio (a measure of adiposity) was 0.85, 55% were hypertensive, and 36% had a history of smoking. Their average duration of SLE was 16 years, with an average SLE disease activity index of 2.0. Two-thirds of the women received steroid treatment, and among these patients the median duration on a steroid was 10 years.

The researchers assessed depression with the 20-item CES-D (Centers for Epidemiologic Study–Depression) scale. In Dr. Greco's analysis, patients who scored 16 or higher on the CES-D were diagnosed with depression, and among the 161 patients in the study 27% met this criterion.

Depression might be relatively common among patients with SLE as a manifestation of central nervous system involvement of the disease, or because medications used to treat SLE may contribute to mood symptoms, Dr. Greco said.

The researchers diagnosed atherosclerosis by two measures: coronary artery calcium detected by electron beam CT, and carotid artery plaque visualized with ultrasound. Patients with either a coronary artery calcium Agatston score greater than zero or a carotid plaque index score of at least 1, or both, were considered to have atherosclerosis. In the study, 63% of the patients met this standard for having atherosclerosis.

Depression was among the strongest factors. Lupus patients with a CES-D score of 16 or higher had a significant and independent 3.85-fold greater risk for atherosclerosis, compared with patients without depression.

PHILADELPHIA – Patients with systemic lupus erythematosus who are also diagnosed with depression were nearly four times more likely to have subclinical atherosclerosis than were lupus patients without depression in a cross-sectional study with 161 women with lupus.

“Depression may be a component of the 'lupus factor' that increases risk for cardiovascular disease,” Carol M. Greco, Ph.D., said at the annual meeting of the American College of Rheumatology. “Depressive symptoms may add to the inflammatory burden” of systemic lupus erythematosus, said Dr. Greco, a clinical psychologist at the lupus center of the University of Pittsburgh.

Finding evidence of a role for depression in causing atherosclerosis in patients with SLE is important because depression is a modifiable risk factor that can be targeted for intervention, she added. Her group's next step is to follow these interactions in a longitudinal clinical study.

To examine correlates of preclinical atherosclerosis in women with SLE, Dr. Greco and her associates studied 161 lupus patients with no history of a cardiovascular event. The women had enrolled in the HEARTS (Heart Effects on Atherosclerosis and Risk of Thrombosis in SLE) study at the University of Pittsburgh. At their baseline examination in 2001-2005, their average age was 50 years; 88% were white. Their average waist:hip ratio (a measure of adiposity) was 0.85, 55% were hypertensive, and 36% had a history of smoking. Their average duration of SLE was 16 years, with an average SLE disease activity index of 2.0. Two-thirds of the women received steroid treatment, and among these patients the median duration on a steroid was 10 years.

The researchers assessed depression with the 20-item CES-D (Centers for Epidemiologic Study–Depression) scale. In Dr. Greco's analysis, patients who scored 16 or higher on the CES-D were diagnosed with depression, and among the 161 patients in the study 27% met this criterion.

Depression might be relatively common among patients with SLE as a manifestation of central nervous system involvement of the disease, or because medications used to treat SLE may contribute to mood symptoms, Dr. Greco said.

The researchers diagnosed atherosclerosis by two measures: coronary artery calcium detected by electron beam CT, and carotid artery plaque visualized with ultrasound. Patients with either a coronary artery calcium Agatston score greater than zero or a carotid plaque index score of at least 1, or both, were considered to have atherosclerosis. In the study, 63% of the patients met this standard for having atherosclerosis.

Depression was among the strongest factors. Lupus patients with a CES-D score of 16 or higher had a significant and independent 3.85-fold greater risk for atherosclerosis, compared with patients without depression.

PHILADELPHIA – Patients with systemic lupus erythematosus who are also diagnosed with depression were nearly four times more likely to have subclinical atherosclerosis than were lupus patients without depression in a cross-sectional study with 161 women with lupus.

“Depression may be a component of the 'lupus factor' that increases risk for cardiovascular disease,” Carol M. Greco, Ph.D., said at the annual meeting of the American College of Rheumatology. “Depressive symptoms may add to the inflammatory burden” of systemic lupus erythematosus, said Dr. Greco, a clinical psychologist at the lupus center of the University of Pittsburgh.

Finding evidence of a role for depression in causing atherosclerosis in patients with SLE is important because depression is a modifiable risk factor that can be targeted for intervention, she added. Her group's next step is to follow these interactions in a longitudinal clinical study.

To examine correlates of preclinical atherosclerosis in women with SLE, Dr. Greco and her associates studied 161 lupus patients with no history of a cardiovascular event. The women had enrolled in the HEARTS (Heart Effects on Atherosclerosis and Risk of Thrombosis in SLE) study at the University of Pittsburgh. At their baseline examination in 2001-2005, their average age was 50 years; 88% were white. Their average waist:hip ratio (a measure of adiposity) was 0.85, 55% were hypertensive, and 36% had a history of smoking. Their average duration of SLE was 16 years, with an average SLE disease activity index of 2.0. Two-thirds of the women received steroid treatment, and among these patients the median duration on a steroid was 10 years.

The researchers assessed depression with the 20-item CES-D (Centers for Epidemiologic Study–Depression) scale. In Dr. Greco's analysis, patients who scored 16 or higher on the CES-D were diagnosed with depression, and among the 161 patients in the study 27% met this criterion.

Depression might be relatively common among patients with SLE as a manifestation of central nervous system involvement of the disease, or because medications used to treat SLE may contribute to mood symptoms, Dr. Greco said.

The researchers diagnosed atherosclerosis by two measures: coronary artery calcium detected by electron beam CT, and carotid artery plaque visualized with ultrasound. Patients with either a coronary artery calcium Agatston score greater than zero or a carotid plaque index score of at least 1, or both, were considered to have atherosclerosis. In the study, 63% of the patients met this standard for having atherosclerosis.

Depression was among the strongest factors. Lupus patients with a CES-D score of 16 or higher had a significant and independent 3.85-fold greater risk for atherosclerosis, compared with patients without depression.

FORT LAUDERDALE, FLA. — Combining coronary artery catheterization and cardiac surgery in the same hospital admission was linked to a significantly increased risk for acute kidney injury, compared with performing the surgery during a second, later hospitalization, a single-center study of more than 600 patients showed.

Acute kidney injury (AKI) in cardiac surgery patients represents an important complication. Results from an earlier study linked it to significantly worse long-term survival, Dr. Robert S. Kramer said at the annual meeting of the Society of Thoracic Surgeons.

“If there is a way to safely manage patients medically between catheterization and surgery, that should be done, to mitigate the potential for acute kidney injury,” said Dr. Kramer, director of cardiac surgery research at Maine Medical Center in Portland. He acknowledged that some patients have urgent medical reasons to undergo cardiac surgery within days of their percutaneous coronary intervention (PCI), such as patients with an acute MI, life-threatening coronary anatomy, or another acute syndrome that mandates quick surgery. However, in many other cases, cardiac surgery becomes scheduled during the same hospital admission as PCI because of convenience for the patient, the surgeon, or other physicians involved with the case.

“We want cardiac surgeons to look at the whole picture and consider whether it would be better for the patient to go home and settle down if there is no reason to act right now,” he said in an interview. “We hypothesize that there may be an opportunity to reduce the incidence of acute kidney injury by moving patients who may be safely changed from the urgent to nonurgent category.”

The study reviewed 722 consecutive patients who underwent cardiac surgery subsequent to PCI at Maine Medical Center during 2008. The analysis excluded 41 patients who required emergency procedures while hospitalized, 5 who were on dialysis, and 8 who did not have cardiac catheterization in the days or weeks before their surgery, leaving 668 patients in the study. Surgery occurred during a subsequent hospitalization following catheterization in 211 patients, while in 457, surgery followed catheterization during the same hospitalization. Among patients with delayed surgery, the period between catheterization and surgery averaged 39 days. In patients who had both procedures in one admission, the delay between catheterization and surgery averaged 3 days.

The patients' average age was 68 years, and about a quarter were women. Patients with immediate surgery and those with delayed surgery were similar in the prevalence of most comorbidities and clinical characteristics. The immediate surgery patients had a significantly higher prevalence of coronary artery disease, 83% compared with 75%; a higher prevalence of MI during the week preceding surgery, 25% compared with 1%; a higher prevalence of a left ventricular ejection fraction of less than 40%, 14% compared with 8%; and a higher prevalence of an elevated white cell count.

The rates of elective and urgent surgery, respectively, were 86% and 14% in the patients whose surgery was deferred for a second hospitalization, compared with 13% and 87% in patients who had their catheterization and surgery in a single hospitalization. Coronary bypass surgery alone occurred in 53% of the deferred patients and 60% of those with a single hospitalization, with the other surgeries divided between valve alone or valve plus bypass.

The incidence of AKI during or immediately after surgery was 34% in the patients who came back to the hospital a second time for their surgery and 50% in those who had their surgery soon after their catheterization, a statistically significant difference. Dr. Kramer and his associates used an AKI definition devised by the AKI Network: a creatinine measure that increased by at least 50% over baseline or that rose by at least 0.3 mg/dL over baseline. All patients in the review had their serum creatinine levels measured at baseline and several times during and after surgery.

No other perioperative outcome parameters differed significantly between the two groups, including death, Q-wave MI, or stroke. The perioperative mortality rate was 2% in patients with deferred surgery and 4% in those with more immediate surgery.

In an analysis that adjusted for baseline demographic and clinical differences, patients with deferred surgery had a significant, 45% relative reduction in their rate of AKI, compared with patients with more immediate surgery.

Dr. Kramer and his associates documented the potential importance of AKI in a study they reported at the American Heart Association scientific sessions last November in Orlando. During 5-year follow-up of about 4,000 cardiac surgery patients, the survival rate was about 95% in patients who did not have any AKI perioperatively, compared with about 80% in those who experienced AKI.

“Creatinine levels and AKI are surrogates for bad epiphenomenon” in patients following cardiac surgery. “The kidney is the canary in the mine shaft,” Dr. Kramer said.

It's unclear what it is about scheduling cardiac surgery several days or weeks following coronary catheterization that cuts the risk of AKI. Contrast administered during coronary catheterization “is a major player, but other factors also play a role. It's not that the contrast clears, but contrast causes tubular injury that has to heal and does heal within a few days.” Based on other studies, he speculated that a delay of at least 5 days is ideal.

He cautioned that the finding was limited by the retrospective, single-center nature of the study. But it involved a relatively large number of patients, and creatinine level checks occurred prospectively and uniformly for all patients, eliminating potential ascertainment bias.

Although the findings are just hypothesis generating, Dr. Kramer contended that the findings are compelling enough to warrant an immediate change in practice: Limit cardiac surgery within a few days after catheterization to patients who clearly need rapid intervention.

Disclosures: Dr. Kramer said he had no disclosures relevant to this study.

A related video is at www.youtube.com/HospitalistNews

FORT LAUDERDALE, FLA. — Combining coronary artery catheterization and cardiac surgery in the same hospital admission was linked to a significantly increased risk for acute kidney injury, compared with performing the surgery during a second, later hospitalization, a single-center study of more than 600 patients showed.

Acute kidney injury (AKI) in cardiac surgery patients represents an important complication. Results from an earlier study linked it to significantly worse long-term survival, Dr. Robert S. Kramer said at the annual meeting of the Society of Thoracic Surgeons.

“If there is a way to safely manage patients medically between catheterization and surgery, that should be done, to mitigate the potential for acute kidney injury,” said Dr. Kramer, director of cardiac surgery research at Maine Medical Center in Portland. He acknowledged that some patients have urgent medical reasons to undergo cardiac surgery within days of their percutaneous coronary intervention (PCI), such as patients with an acute MI, life-threatening coronary anatomy, or another acute syndrome that mandates quick surgery. However, in many other cases, cardiac surgery becomes scheduled during the same hospital admission as PCI because of convenience for the patient, the surgeon, or other physicians involved with the case.

“We want cardiac surgeons to look at the whole picture and consider whether it would be better for the patient to go home and settle down if there is no reason to act right now,” he said in an interview. “We hypothesize that there may be an opportunity to reduce the incidence of acute kidney injury by moving patients who may be safely changed from the urgent to nonurgent category.”

The study reviewed 722 consecutive patients who underwent cardiac surgery subsequent to PCI at Maine Medical Center during 2008. The analysis excluded 41 patients who required emergency procedures while hospitalized, 5 who were on dialysis, and 8 who did not have cardiac catheterization in the days or weeks before their surgery, leaving 668 patients in the study. Surgery occurred during a subsequent hospitalization following catheterization in 211 patients, while in 457, surgery followed catheterization during the same hospitalization. Among patients with delayed surgery, the period between catheterization and surgery averaged 39 days. In patients who had both procedures in one admission, the delay between catheterization and surgery averaged 3 days.

The patients' average age was 68 years, and about a quarter were women. Patients with immediate surgery and those with delayed surgery were similar in the prevalence of most comorbidities and clinical characteristics. The immediate surgery patients had a significantly higher prevalence of coronary artery disease, 83% compared with 75%; a higher prevalence of MI during the week preceding surgery, 25% compared with 1%; a higher prevalence of a left ventricular ejection fraction of less than 40%, 14% compared with 8%; and a higher prevalence of an elevated white cell count.

The rates of elective and urgent surgery, respectively, were 86% and 14% in the patients whose surgery was deferred for a second hospitalization, compared with 13% and 87% in patients who had their catheterization and surgery in a single hospitalization. Coronary bypass surgery alone occurred in 53% of the deferred patients and 60% of those with a single hospitalization, with the other surgeries divided between valve alone or valve plus bypass.

The incidence of AKI during or immediately after surgery was 34% in the patients who came back to the hospital a second time for their surgery and 50% in those who had their surgery soon after their catheterization, a statistically significant difference. Dr. Kramer and his associates used an AKI definition devised by the AKI Network: a creatinine measure that increased by at least 50% over baseline or that rose by at least 0.3 mg/dL over baseline. All patients in the review had their serum creatinine levels measured at baseline and several times during and after surgery.

No other perioperative outcome parameters differed significantly between the two groups, including death, Q-wave MI, or stroke. The perioperative mortality rate was 2% in patients with deferred surgery and 4% in those with more immediate surgery.

In an analysis that adjusted for baseline demographic and clinical differences, patients with deferred surgery had a significant, 45% relative reduction in their rate of AKI, compared with patients with more immediate surgery.

Dr. Kramer and his associates documented the potential importance of AKI in a study they reported at the American Heart Association scientific sessions last November in Orlando. During 5-year follow-up of about 4,000 cardiac surgery patients, the survival rate was about 95% in patients who did not have any AKI perioperatively, compared with about 80% in those who experienced AKI.

“Creatinine levels and AKI are surrogates for bad epiphenomenon” in patients following cardiac surgery. “The kidney is the canary in the mine shaft,” Dr. Kramer said.

It's unclear what it is about scheduling cardiac surgery several days or weeks following coronary catheterization that cuts the risk of AKI. Contrast administered during coronary catheterization “is a major player, but other factors also play a role. It's not that the contrast clears, but contrast causes tubular injury that has to heal and does heal within a few days.” Based on other studies, he speculated that a delay of at least 5 days is ideal.

He cautioned that the finding was limited by the retrospective, single-center nature of the study. But it involved a relatively large number of patients, and creatinine level checks occurred prospectively and uniformly for all patients, eliminating potential ascertainment bias.

Although the findings are just hypothesis generating, Dr. Kramer contended that the findings are compelling enough to warrant an immediate change in practice: Limit cardiac surgery within a few days after catheterization to patients who clearly need rapid intervention.

Disclosures: Dr. Kramer said he had no disclosures relevant to this study.

A related video is at www.youtube.com/HospitalistNews

FORT LAUDERDALE, FLA. — Combining coronary artery catheterization and cardiac surgery in the same hospital admission was linked to a significantly increased risk for acute kidney injury, compared with performing the surgery during a second, later hospitalization, a single-center study of more than 600 patients showed.

Acute kidney injury (AKI) in cardiac surgery patients represents an important complication. Results from an earlier study linked it to significantly worse long-term survival, Dr. Robert S. Kramer said at the annual meeting of the Society of Thoracic Surgeons.

“If there is a way to safely manage patients medically between catheterization and surgery, that should be done, to mitigate the potential for acute kidney injury,” said Dr. Kramer, director of cardiac surgery research at Maine Medical Center in Portland. He acknowledged that some patients have urgent medical reasons to undergo cardiac surgery within days of their percutaneous coronary intervention (PCI), such as patients with an acute MI, life-threatening coronary anatomy, or another acute syndrome that mandates quick surgery. However, in many other cases, cardiac surgery becomes scheduled during the same hospital admission as PCI because of convenience for the patient, the surgeon, or other physicians involved with the case.

“We want cardiac surgeons to look at the whole picture and consider whether it would be better for the patient to go home and settle down if there is no reason to act right now,” he said in an interview. “We hypothesize that there may be an opportunity to reduce the incidence of acute kidney injury by moving patients who may be safely changed from the urgent to nonurgent category.”

The study reviewed 722 consecutive patients who underwent cardiac surgery subsequent to PCI at Maine Medical Center during 2008. The analysis excluded 41 patients who required emergency procedures while hospitalized, 5 who were on dialysis, and 8 who did not have cardiac catheterization in the days or weeks before their surgery, leaving 668 patients in the study. Surgery occurred during a subsequent hospitalization following catheterization in 211 patients, while in 457, surgery followed catheterization during the same hospitalization. Among patients with delayed surgery, the period between catheterization and surgery averaged 39 days. In patients who had both procedures in one admission, the delay between catheterization and surgery averaged 3 days.

The patients' average age was 68 years, and about a quarter were women. Patients with immediate surgery and those with delayed surgery were similar in the prevalence of most comorbidities and clinical characteristics. The immediate surgery patients had a significantly higher prevalence of coronary artery disease, 83% compared with 75%; a higher prevalence of MI during the week preceding surgery, 25% compared with 1%; a higher prevalence of a left ventricular ejection fraction of less than 40%, 14% compared with 8%; and a higher prevalence of an elevated white cell count.

The rates of elective and urgent surgery, respectively, were 86% and 14% in the patients whose surgery was deferred for a second hospitalization, compared with 13% and 87% in patients who had their catheterization and surgery in a single hospitalization. Coronary bypass surgery alone occurred in 53% of the deferred patients and 60% of those with a single hospitalization, with the other surgeries divided between valve alone or valve plus bypass.

The incidence of AKI during or immediately after surgery was 34% in the patients who came back to the hospital a second time for their surgery and 50% in those who had their surgery soon after their catheterization, a statistically significant difference. Dr. Kramer and his associates used an AKI definition devised by the AKI Network: a creatinine measure that increased by at least 50% over baseline or that rose by at least 0.3 mg/dL over baseline. All patients in the review had their serum creatinine levels measured at baseline and several times during and after surgery.

No other perioperative outcome parameters differed significantly between the two groups, including death, Q-wave MI, or stroke. The perioperative mortality rate was 2% in patients with deferred surgery and 4% in those with more immediate surgery.

In an analysis that adjusted for baseline demographic and clinical differences, patients with deferred surgery had a significant, 45% relative reduction in their rate of AKI, compared with patients with more immediate surgery.

Dr. Kramer and his associates documented the potential importance of AKI in a study they reported at the American Heart Association scientific sessions last November in Orlando. During 5-year follow-up of about 4,000 cardiac surgery patients, the survival rate was about 95% in patients who did not have any AKI perioperatively, compared with about 80% in those who experienced AKI.

“Creatinine levels and AKI are surrogates for bad epiphenomenon” in patients following cardiac surgery. “The kidney is the canary in the mine shaft,” Dr. Kramer said.

It's unclear what it is about scheduling cardiac surgery several days or weeks following coronary catheterization that cuts the risk of AKI. Contrast administered during coronary catheterization “is a major player, but other factors also play a role. It's not that the contrast clears, but contrast causes tubular injury that has to heal and does heal within a few days.” Based on other studies, he speculated that a delay of at least 5 days is ideal.

He cautioned that the finding was limited by the retrospective, single-center nature of the study. But it involved a relatively large number of patients, and creatinine level checks occurred prospectively and uniformly for all patients, eliminating potential ascertainment bias.

Although the findings are just hypothesis generating, Dr. Kramer contended that the findings are compelling enough to warrant an immediate change in practice: Limit cardiac surgery within a few days after catheterization to patients who clearly need rapid intervention.

Disclosures: Dr. Kramer said he had no disclosures relevant to this study.

A related video is at www.youtube.com/HospitalistNews

FORT LAUDERDALE, FLA. — Patients undergoing lung resection for non–small cell lung cancer had a 13% risk for developing a new atrial arrhythmia in a review of nearly 14,000 patients in a nationwide database involving 111 centers.

This rate confirms prior reports that atrial arrhythmias appeared in 10%–20% of patients following major noncardiac thoracic surgery. But the new finding is the first to be based on data from so many centers, and the first to focus on outcomes after a single type of thoracic surgery—lung resection for cancer—Dr. Mark W. Onaitis said at the annual meeting of the Society of Thoracic Surgeons.

The analysis identified four factors that significantly correlated with an increased risk for developing atrial arrhythmia after lung cancer surgery: more extensive resection (pneumonectomy or bilobectomy compared with lobectomy), increased age, male gender, and more advanced disease (clinical stage II or higher).

The new model could be used “to improve prognostic stratification, and for prospective prophylactic trials,” said Dr. Onaitis, a thoracic surgeon at Duke University in Durham, N.C.

Patients who developed a new-onset arrhythmia had significantly increased mortality; a higher incidence of several major morbidities, including pneumonia and stroke; and a significantly longer hospital stay. (See box.) During the 30 days following surgery, mortality was 6% in patients who developed an atrial arrhythmia, compared with 2% in those who did not—a significant difference.

The Society of Thoracic Surgeons General Thoracic Surgery Database for 2002–2008 included more than 14,000 patients who had lung resection for non–small cell lung cancer at 111 participating U.S. centers. Excluding patients with atrial arrhythmia prior to surgery left 13,904 patients, of whom 1,755 (13%) developed atrial arrhythmia during the 30 days following surgery.

Multivariate analysis revealed that pnemonectomy doubled the risk for development of atrial arrhythmia compared with lobectomy, while bilobectomy boosted the risk by 67% compared with single lobectomy. Each 10 years of increased age was linked to an 81% increased risk for arrhythmia, and men had a 60% increased risk compared with women. Patients with nodal disease, clinical stage II or greater, had a 28% increased risk for arrhythmia. The analysis also identified one protective feature: African Americans were 38% less likely to develop arrhythmia than were whites. These parameters together accounted for two-thirds of the variance in the rate of new-onset atrial arrhythmias.

Elsevier Global Medical News

My Take

Dissecting the Problem of Atrial Fibrillation After Lung Resection

Atrial fibrillation is consistently second only to duration of air leak as the major driver for length of stay after pulmonary resection. Because the downstream consequences of atrial fibrillation, such as stroke and other thromboembolic events, are so significant, and because its treatment is costly and associated with its own morbidity, perioperative atrial fibrillation may even exceed prolonged air leak as a health risk.

The relationship between postoperative atrial fibrillation and lung resection has long been explored in general thoracic surgery. For decades, colleagues have reportedly documented the incidence, especially following pneumonectomy, when it can occur in as many as a quarter or third of patients. The search for effective and simple prophylaxis has been difficult, even in the pneumonectomy patients known to be at highest risk. There is simply little convincing, multi-institutional–derived evidence that pharmacologic prophylaxis can reduce the risk.

Dr. Onaitis and his colleagues are to be congratulated for leveraging the STS database to begin to dissect this problem. They confirmed the importance of the problem by finding a threefold increase in 30-day mortality in patients who develop perioperative atrial fibrillation. Their simplified risk model allows physicians to stratify risk and better counsel patients. Unfortunately, the prognostic factors don't provide an opportunity to modify the risk. Perhaps the most beneficial outcome of this work will be to identify patients at highest risk who are the best candidates for pharmacologic prophylaxis in the hope of defining a signal of therapeutic efficacy.

FORT LAUDERDALE, FLA. — Patients undergoing lung resection for non–small cell lung cancer had a 13% risk for developing a new atrial arrhythmia in a review of nearly 14,000 patients in a nationwide database involving 111 centers.

This rate confirms prior reports that atrial arrhythmias appeared in 10%–20% of patients following major noncardiac thoracic surgery. But the new finding is the first to be based on data from so many centers, and the first to focus on outcomes after a single type of thoracic surgery—lung resection for cancer—Dr. Mark W. Onaitis said at the annual meeting of the Society of Thoracic Surgeons.

The analysis identified four factors that significantly correlated with an increased risk for developing atrial arrhythmia after lung cancer surgery: more extensive resection (pneumonectomy or bilobectomy compared with lobectomy), increased age, male gender, and more advanced disease (clinical stage II or higher).

The new model could be used “to improve prognostic stratification, and for prospective prophylactic trials,” said Dr. Onaitis, a thoracic surgeon at Duke University in Durham, N.C.

Patients who developed a new-onset arrhythmia had significantly increased mortality; a higher incidence of several major morbidities, including pneumonia and stroke; and a significantly longer hospital stay. (See box.) During the 30 days following surgery, mortality was 6% in patients who developed an atrial arrhythmia, compared with 2% in those who did not—a significant difference.

The Society of Thoracic Surgeons General Thoracic Surgery Database for 2002–2008 included more than 14,000 patients who had lung resection for non–small cell lung cancer at 111 participating U.S. centers. Excluding patients with atrial arrhythmia prior to surgery left 13,904 patients, of whom 1,755 (13%) developed atrial arrhythmia during the 30 days following surgery.

Multivariate analysis revealed that pnemonectomy doubled the risk for development of atrial arrhythmia compared with lobectomy, while bilobectomy boosted the risk by 67% compared with single lobectomy. Each 10 years of increased age was linked to an 81% increased risk for arrhythmia, and men had a 60% increased risk compared with women. Patients with nodal disease, clinical stage II or greater, had a 28% increased risk for arrhythmia. The analysis also identified one protective feature: African Americans were 38% less likely to develop arrhythmia than were whites. These parameters together accounted for two-thirds of the variance in the rate of new-onset atrial arrhythmias.

Elsevier Global Medical News

My Take

Dissecting the Problem of Atrial Fibrillation After Lung Resection

Atrial fibrillation is consistently second only to duration of air leak as the major driver for length of stay after pulmonary resection. Because the downstream consequences of atrial fibrillation, such as stroke and other thromboembolic events, are so significant, and because its treatment is costly and associated with its own morbidity, perioperative atrial fibrillation may even exceed prolonged air leak as a health risk.

The relationship between postoperative atrial fibrillation and lung resection has long been explored in general thoracic surgery. For decades, colleagues have reportedly documented the incidence, especially following pneumonectomy, when it can occur in as many as a quarter or third of patients. The search for effective and simple prophylaxis has been difficult, even in the pneumonectomy patients known to be at highest risk. There is simply little convincing, multi-institutional–derived evidence that pharmacologic prophylaxis can reduce the risk.

Dr. Onaitis and his colleagues are to be congratulated for leveraging the STS database to begin to dissect this problem. They confirmed the importance of the problem by finding a threefold increase in 30-day mortality in patients who develop perioperative atrial fibrillation. Their simplified risk model allows physicians to stratify risk and better counsel patients. Unfortunately, the prognostic factors don't provide an opportunity to modify the risk. Perhaps the most beneficial outcome of this work will be to identify patients at highest risk who are the best candidates for pharmacologic prophylaxis in the hope of defining a signal of therapeutic efficacy.

FORT LAUDERDALE, FLA. — Patients undergoing lung resection for non–small cell lung cancer had a 13% risk for developing a new atrial arrhythmia in a review of nearly 14,000 patients in a nationwide database involving 111 centers.

This rate confirms prior reports that atrial arrhythmias appeared in 10%–20% of patients following major noncardiac thoracic surgery. But the new finding is the first to be based on data from so many centers, and the first to focus on outcomes after a single type of thoracic surgery—lung resection for cancer—Dr. Mark W. Onaitis said at the annual meeting of the Society of Thoracic Surgeons.

The analysis identified four factors that significantly correlated with an increased risk for developing atrial arrhythmia after lung cancer surgery: more extensive resection (pneumonectomy or bilobectomy compared with lobectomy), increased age, male gender, and more advanced disease (clinical stage II or higher).

The new model could be used “to improve prognostic stratification, and for prospective prophylactic trials,” said Dr. Onaitis, a thoracic surgeon at Duke University in Durham, N.C.

Patients who developed a new-onset arrhythmia had significantly increased mortality; a higher incidence of several major morbidities, including pneumonia and stroke; and a significantly longer hospital stay. (See box.) During the 30 days following surgery, mortality was 6% in patients who developed an atrial arrhythmia, compared with 2% in those who did not—a significant difference.

The Society of Thoracic Surgeons General Thoracic Surgery Database for 2002–2008 included more than 14,000 patients who had lung resection for non–small cell lung cancer at 111 participating U.S. centers. Excluding patients with atrial arrhythmia prior to surgery left 13,904 patients, of whom 1,755 (13%) developed atrial arrhythmia during the 30 days following surgery.

Multivariate analysis revealed that pnemonectomy doubled the risk for development of atrial arrhythmia compared with lobectomy, while bilobectomy boosted the risk by 67% compared with single lobectomy. Each 10 years of increased age was linked to an 81% increased risk for arrhythmia, and men had a 60% increased risk compared with women. Patients with nodal disease, clinical stage II or greater, had a 28% increased risk for arrhythmia. The analysis also identified one protective feature: African Americans were 38% less likely to develop arrhythmia than were whites. These parameters together accounted for two-thirds of the variance in the rate of new-onset atrial arrhythmias.

Elsevier Global Medical News

My Take

Dissecting the Problem of Atrial Fibrillation After Lung Resection

Atrial fibrillation is consistently second only to duration of air leak as the major driver for length of stay after pulmonary resection. Because the downstream consequences of atrial fibrillation, such as stroke and other thromboembolic events, are so significant, and because its treatment is costly and associated with its own morbidity, perioperative atrial fibrillation may even exceed prolonged air leak as a health risk.

The relationship between postoperative atrial fibrillation and lung resection has long been explored in general thoracic surgery. For decades, colleagues have reportedly documented the incidence, especially following pneumonectomy, when it can occur in as many as a quarter or third of patients. The search for effective and simple prophylaxis has been difficult, even in the pneumonectomy patients known to be at highest risk. There is simply little convincing, multi-institutional–derived evidence that pharmacologic prophylaxis can reduce the risk.

Dr. Onaitis and his colleagues are to be congratulated for leveraging the STS database to begin to dissect this problem. They confirmed the importance of the problem by finding a threefold increase in 30-day mortality in patients who develop perioperative atrial fibrillation. Their simplified risk model allows physicians to stratify risk and better counsel patients. Unfortunately, the prognostic factors don't provide an opportunity to modify the risk. Perhaps the most beneficial outcome of this work will be to identify patients at highest risk who are the best candidates for pharmacologic prophylaxis in the hope of defining a signal of therapeutic efficacy.