Implementation of an INR self-testing and self-management programme in common ambulatory private practice: our experience with 90 patients.

QUESTIONS UNDER STUDY: INR self-testing devices allow patients on vitamin K antagonists (VKA) to determine their INR and then have their VKA dose adapted by a physician (INR self-testing, ST) or adapt it themselves according to pre-established guidelines (INR self-management, SM). The safety, efficacy and advantages of ST and SM have been demonstrated, but their use remains limited. In an effort to improve the availability of ST and SM, we tested the hypothesis that implementing a teaching programme for ST and SM in a small structure in common ambulatory private practice is feasible, safe and can lead to high patient satisfaction. METHODS: Patients on long-term anticoagulation were assigned to a specific training programme. Patients used the CoaguChek (S then XS) INR testing system. Technical problems, adverse events and INR values were then recorded during the first year of follow-up and analysed. Patient satisfaction data were obtained via a specific questionnaire. RESULTS: 169 patients were referred and 90 included in the teaching programme. 80 performed SM and 10 performed ST. 54 patients (60%) returned the 1-year questionnaire with complete INR data available for 35 patients. The percentage of INR in the target range (target ± 0.5) was 60.6%. The rate of major adverse clinical events (MACE) was 3.7 per 100 patient-years. The main reported advantages were a reduction in visits to the INR testing facility and increased autonomy. There was better venous to capillary INR correlation with the CoaguChek XS than with the S (p <0.025). CONCLUSIONS: The development in a small structure in common ambulatory practice of a specific teaching programme made ST and SM available to a new patient population. It led to high patient satisfaction, significantly reducing the burden of VKA monitoring. These results were obtained while preserving the safety and efficacy standards of VKA treatment and favour greater expansion of ST and SM programmes.

Cardiac transplantation in a patient with emotionally triggered implantable cardioverter defibrillator storms.

The implantable cardioverter defibrillator (ICD) may be responsible for psychological disorders especially among patients experiencing multiple shocks. An associated hyperadrenergic state (e.g., anger, anxiety) may trigger malignant ventricular arrhythmias repeatedly treated by ICD shocks, entertaining a "vicious circle" often difficult to interrupt. Despite aggressive cardiac and psychological therapeutic efforts, this condition may be refractory, finally leading to heart transplantation, as described in this case report.

[Management of end-stage heart failure]. / Prise en charge de l'insuffisance cardiaque terminale.

Non-medical approaches to end-stage heart failure (ESHF) include heart transplantation, but also implantable cardioverter-defibrillators, cardiac resynchronization therapy and ventricular assist devices. These techniques might be used as a bridge to transplant, as a bridge to recovery or as destination therapy. Optimal medical therapy of ESHF should include an angiotensin-converting enzyme inhibitor, a beta-blocker and spironolactone. Risk stratification in ESHF allows to determine the individual prognosis of each patient with parameters such as echocardiographic criteria, peak exercise oxygen consumption, or plasma BNP levels. Heart transplantation is to be considered if the individual prognosis obtained after stratification is worse than the expected survival of transplant recipients.

Safety of low-dose spironolactone administration in chronic haemodialysis patients.

BACKGROUND: Prevention of cardiovascular diseases is essential in chronic haemodialysis patients. Recently, low-dose spironolactone has been shown to decrease cardiovascular mortality in patients with severe heart failure. However, since haemodialysis patients are prone to hyperkalaemia, a known side effect of spironolactone, this treatment is not used in this population. We performed a study to assess whether low-dose spironolactone (3 x 25 mg/week) could be administered without inducing hyperkalaemia in haemodialysis patients. METHODS: The study design included a 2-week baseline period, followed by a 4-week treatment period in which doses of spironolactone were started at 12.5 mg three times/week for 2 weeks, then increased to 25 mg three times/week, and followed by a 2-week wash-out period. Fourteen patients receiving low-dose spironolactone after each dialysis were compared with 21 haemodialysis patients (control group). RESULTS: Low-dose spironolactone did not change mean serum potassium (4.9 +/- 0.7 vs 4.9 +/- 0.3 mmol/l: control). The mean plasma canrenone level induced by administration of spironolactone 25 mg three times/week in the 14 treated patients was 13 +/- 5.3 ng/ml. Serum aldosterone was not significantly modified by the administration of spironolactone in these patients [before, median 0.35; interquartile range (IQR) 0.11-2.83 nmol/l vs after, median 0.22; IQR 0.12-0.60 nmol/l, NS]. Dietary potassium intake and the use of ion-exchange resin, angiotensin-converting enzyme inhibitors and beta-blockers were similar for the two groups throughout the study. CONCLUSION: This non-randomized and non-blinded study shows that administration of 25 mg spironolactone thrice weekly is not associated with an increased frequency of hyperkalaemia in haemodialysis patients when they are carefully monitored. More studies are required, however, before concluding that spironolactone administration is safe in the chronic haemodialysis population.

A prospective randomized controlled study on the efficacy and tolerance of two antilymphocytic globulins in the prevention of rejection in first-heart transplant recipients.

The usefulness of induction phase treatment in heart transplantation is a long-standing debate in the literature. Several centers report good short-term survival without such treatment, but no randomized trial addresses this question. If induction treatment is to be used, most centers prefer rabbit polyclonal antisera to OKT3. However, again, no randomized trial has compared the relative efficacy and tolerance of rabbit antisera. Fifty first-heart transplant recipients with standard triple immunosuppression were randomized to receive ATG Fresenius ( n=24) or Thymoglobulin Mérieux ( n=26) as an induction treatment and were followed for 1 year. The two groups were well matched for gender, age, pre-transplant diagnosis and ischemia time. Actuarial survival at 1 year was 87.5% in the Fresenius group and 84.6% in the Mérieux group (Fisher's exact test; P=1). The average number of rejection episodes per patient was comparable in both treatment groups (Fresenius: mean=2.63, SD=1.44; Mérieux: mean=2.46, SD=2.04). Mean time to first rejection was 48.9+/-37.2 days in the Fresenius group versus 59.6+/-54 days in the Mérieux group (Mann-Witney U-test: z=0.77; P=NS). The total number of rejections across all patients was also comparable (Fresenius: 63; Mérieux: 64) as well as the severity of rejection (seven moderate rejections out of a total of 63 in the Fresenius group and eight out of 64 in the Mérieux group). Eighteen Fresenius (75%) and 15 Mérieux (58%) patients suffered from at least one infection ( P=NS). The tolerance to treatment was excellent in both groups. Total lymphocyte count and all subsets of tested lymphocytes decreased rapidly after the introduction of either antiserum but was more pronounced and persisted for longer in the Mérieux group. ATG Fresenius or Thymoglobulin Mérieux as induction treatments in first-heart transplant recipients treated with standard immunosuppression have the same relative efficacy with regard to survival, acute rejection or infection rate, and are well tolerated.