Percutaneous coronary intervention without on site surgical back-up; two-years registry of a large Dutch community hospital.

AIMS: To assess safety and efficacy of off-site percutaneous coronary intervention (PCI) in The Dutch invasive cardiovascular system. METHODS AND RESULTS: Descriptive single centre registry of elective and emergency PCI. Setting is a Dutch community hospital, 40 km north of Amsterdam, with an adherent population of 400,000 people. A Clinical follow up of Major Adverse Cardiac and Cerebral Events (MACCE) at 30 days post PCI is performed. The total number of participants eligible for PCI was 781 of whom 545 were men and 236 women. During a two-year period 781 PCI's were performed of which 298 were emergency and 483 elective. Acute complications occurred in 2.1% of participants. MACCE-free was 86.9% in the group with AMI and 95.8% in the elective group. CONCLUSIONS: Off-site PCI is feasible and safe in The Netherlands on the condition that specific key factors for success are taken into consideration.

[Nurse practitioner equally as good as a resident in the treatment of stable patients after recent myocardial infarction, but with more patient satisfaction]. / 'Nurse practitioner' even bekwaam als assistent-geneeskundige voor de behandeling van stabiele patiënten na een recent myocardinfarct, maar met meer tevredenheid bij patiënten.

OBJECTIVE: To determine the feasibility and efficacy ofa nurse-led clinic for stable patients recovering from a recent myocardial infarction, as opposed to a resident-led clinic. DESIGN: Randomized study. METHOD: Over a period of 1 year, data on the treatment and complications of 200 consecutive infarction patients were collected. The patients were randomized on transfer from the coronary-care unit to the cardiology ward. Subsequently, these patients were treated by a registered nurse practitioner (n = 97) or by a resident (n = 103), both of whom were under the direct supervision of the attending cardiologist. Degree of satisfaction was scored by the patients on a 0-10 point scale. RESULTS: The patients in both groups were predominantly men (75%) with a mean age of 63 years. Risk factors and cardiac histories were comparable in both groups as were the location of the infarction and the nature of the acute treatment. No significant differences between the groups were found in the main endpoints: mortality (0%), re-infarctions (2%) or length ofstay. However, patients treated by the nurse practitioner expressed a significantly higher score in the satisfaction study. CONCLUSION: The treatment of stable postmyocardial infarction patients in a nurse-practitioner-led clinic post was found to be feasible and effective with a significantly higher level of patient satisfaction.

Validity of conjoint analysis to study clinical decision making in elderly patients with aortic stenosis.

OBJECTIVE: Written case simulations are increasingly being used to investigate clinical decision making. Our study was designed to determine the validity of written case simulations within a conjoint analysis approach. STUDY DESIGN AND SETTING: We developed a series of 32 written case simulations that differed with respect to nine clinical characteristics. These case simulations represented elderly patients with aortic stenosis. The clinical characteristics varied according to a fractional factorial design. We analyzed retrospectively all consecutive patients of 70 years of age or older with an aortic stenosis in three university hospitals. RESULTS: 34 cardiologists from three Dutch hospitals gave their treatment advice to each of these case simulations on a six-point scale (ranging from 'certainly no' to 'certainly yes' to surgical treatment). We compared the influence that the clinical characteristics had on the responses to these case simulations with their influence on the actual treatment decision for 147 actual patients in the same three hospitals. We found a strong agreement. This agreement was only slightly affected by the cut-off value used to dichotomize the treatment advice into a recommendation in favor of or against surgical treatment. CONCLUSION: Written case simulations reflect well how clinicians are influenced by specific clinical characteristics of their patients.

Glossopharyngeal neuralgia with syncope: a case report.

We present the case of a 60-year-old woman with known glossopharyngeal neuralgia who was admitted to hospital because of recurrent syncopes associated with episodes of painful sensations in the caudal region of her tongue. Rhythm observation showed prolonged asystole, which was accompanied by a loss of consciousness. The asystole was preceded by an episode of pain. We concluded that the bradyarrhythmia and syncopes where associated with the glossopharyngeal neuralgia. Because of the life-threatening condition, we inserted a permanent dual-chamber pacing device. After implantation of the pacemaker, the patient had no further syncopes, although she still complained of episodic tongue pain.

The role of predicted intracranial bleeding risk in the choice of reperfusion strategy in patients with acute myocardial infarction.

OBJECTIVES: Intracranial haemorrhage after thrombolytic therapy for acute myocardial infarction occurs in 0.5-3% of patients. Prediction models have been developed to predetermine the intracranial bleeding risk, but have rarely been used for assigning the optimal reperfusion strategy. This might result in the use of thrombolytic therapy when primary PTCA would be preferable. METHODS: Prospective data were gathered in 1365 candidates for reperfusion therapy. Risk of intracranial haemorrhage was determined with a risk score derived from large-scale clinical trials. Patients were divided into three groups based on their risk of intracranial haemorrhage: <1%, 1-3% and >3% and stratified by age. RESULTS: An intracranial bleeding risk exceeding 3% was found in 120 patients (9%). These high-risk patients were often treated with thrombolysis (87%). Intracranial bleeding actually occurred in four out of 120 patients (3.3%) in this highest risk group, while no bleeding occurred in the other risk groups. CONCLUSION: The actual incidence of intracranial bleeding is similar to the predicted bleeding risk in high-risk patients. These high-risk patients are predominantly older than 70 years. Nearly all patients exceeding a 3% risk of intracranial haemorrhage were treated with thrombolytic therapy. Primary angioplasty should be preferred in patients aged over 70 years since success rates of direct PTCA are no worse in elderly compared with younger patients.