Efficacy criteria and cholesterol targets for LDL apheresis.

Low density lipoprotein (LDL) apheresis is now accepted as the treatment of choice for patients with homozygous familial hypercholesterolaemia and for heterozygotes with cardiovascular disease refractory to lipid-lowering drug therapy. However, a paucity of evidence has meant that detailed guidance on the extent of cholesterol reduction required to prevent the onset or progression of cardiovascular disease in these high risk patients is lacking. This review defines criteria for expressing the efficacy of apheresis, proposes target levels of total and LDL cholesterol for homozygotes and heterozygotes based on recent follow-up studies and suggests a scheme for monitoring cardiovascular disease in these patients. Establishing a uniform approach to data collection would facilitate the setting up of national or multi-national registers and might eventually provide the information needed to formulate evidence-based guidelines for LDL apheresis.

LDL-apheresis: indications and clinical experience in a tertiary cardiac centre.

OBJECTIVE: To determine the efficacy and safety of liposorber D low-density lipoprotein (LDL) apheresis system in high-risk cardiac patients. DESIGN: Retrospective analysis of 466 treatments undertaken in eight patients with coronary heart disease. Five patients had severe heterozygous familial hypercholesterolaemia (FH), one had severe hypertriglyceridaemia and two were cardiac transplant recipients with FH intolerant to statins. Acute reductions during single sessions and preprocedural long-term changes in lipoprotein subfractions, laboratory safety parameters, adverse events and clinical outcome were recorded. RESULTS: In 352 treatments performed in seven patients, acute reductions averaged 52.8% (standard deviation: 8.61%) for total cholesterol (TC), 61.8% (10.13%) for LDL-cholesterol (LDL-C), 21.1% (9.66%) for high-density lipoprotein cholesterol (HDL-C), 71.1% (median) for lipoprotein (a) [Lp(a)] and 44.5% (14.42%) for triglycerides (p < 0.05). Long-term reductions of TC, LDL-C, Lp(a) and triglycerides by 18.1%, 21.7%, 9.4% (median) and 19.8%, respectively, were achieved. HDL-C was increased by 7.5%. Results from the patient with severe hypertriglyceridaemia were analysed separately because of markedly elevated TC and triglycerides. Technical and clinical complications were mild and showed an incidence of 16.65% and 12.45% respectively. The most common clinical event was transient hypotension (5.8%), whereas vascular access difficulties (11.3%) represented a common technical problem. All patients demonstrated clinical improvement. However, two patients treated via a central line developed septicaemia, resulting in endocarditis in one of them. CONCLUSION: Liposorber D is a simple, safe and effective modality in reducing atherogenic lipoproteins in dyslipidaemic high-risk cardiac patients. The treatment via an arteriovenous fistula is the preferred vascular access in this type of patient.

Survival to discharge following open chest cardiac compression (OCCC). A 4-year retrospective audit in a cardiothoracic specialist centre--Royal Brompton and Harefield NHS Trust, United Kingdom.

OBJECTIVE: To review the use of Open Chest Cardiac Compression (OCCC) techniques in postcardiac surgical patients in one specialist cardiothoracic centre in the UK. METHODS: A 4-year retrospective audit (April 1995--March 1999) of all cardiac arrest victims and resuscitation practice across two specialist cardiothoracic hospitals. Audit outcomes related to initial survival and survival to discharge, arrest rhythm, reasons for resternotomy, surgical procedure prior to resternotomy and time elapsed from original surgery to resternotomy. RESULTS: Seventy-two patients (adult and paediatric) suffering cardiac arrest received OCCC following cardiac surgery. Thirty-three patients initially survived (46%) and 12 patients survived to discharge (17%). DISCUSSION AND RECOMMENDATIONS: In the absence of current European Resuscitation Council guidelines, we adopted recommendations for resternotomy to be performed after 5 min of unsuccessful conventional CPR and OCCC initiated. An adapted ERC algorithm incorporating these recommendations can provide much needed direction in postcardiac surgery cardiac arrest victims.

Does resuscitation training affect outcome from cardiac arrest?

It is established that basic life support (BLS) is performed inadequately by both nursing and medical staff and that the ability to retain these skills, once trained, is low. In addition, the initial success rate from cardiopulmonary arrest is poor. By implementing the advanced life support (ALS) course and providing frequent updates on resuscitation skills and management, it is expected that cardiac arrest outcome results should improve. This data is from a 4 year audit of in-hospital cardiac arrest within an adult patient group between January 1993 and December 1996. The average return response of all audit forms was 86.5%. The total sample consisted of 367 separate arrests where the initial rhythm was documented as either ventricular fibrillation (VF)/ventricular tachycardia (VT) (58.3%), asystole (21.7%), electromechanical dissociation (EMD) (7.0%) and other (13.0%). Initial success was defined as return of spontaneous circulation (ROSC). This was achieved in 75.0% of all resuscitation attempts. Within the VF/VT group, successful outcome remained consistent over the 4-year period with an ROSC of 85%. Successful outcome remained consistent in the EMD group, however, the number of arrests was small. Within the asystole group, initial survival increased from 47.5% in 1993-1994 to 67.5% in 1995-1996. These results suggest that BLS and ALS training may only have an impact on initial survival from cardiac arrest.

Nursing practice. To visit--or not to visit.

In many settings, restrictions remain on visiting times in hospitals and in particular in coronary care units. This paper questions the appropriateness of restricted visiting times, examines relevant literature on the subject, and describes a small-scale project conducted in the author's own unit. The results of the study suggested that visiting times needed to be reviewed if the well-being of patients was to be enhanced.