Warfarin for non-rheumatic atrial fibrillation: five year experience in a district general hospital.

OBJECTIVES: To assess the long term efficacy of and risks associated with computer aided oral anticoagulation for non-rheumatic atrial fibrillation (NRAF) in a district hospital setting. DESIGN: Retrospective, age stratified, event driven clinical database analysis. SETTING: District general hospital. PARTICIPANTS: 739 patients receiving warfarin for NRAF between 1996 and 2001. Patients were selected from an anticoagulation database through appropriate filter settings. MAIN OUTCOME MEASURES: Anticoagulation control (international normalised ratio (INR)) and hospitalisations for bleeding complications, thromboembolic events, and stroke. RESULTS: Over 1484 patient-years, computer assisted anticoagulation was uncontrolled in 38.3% of patients (INR < 2.0 or > 3.0). No significant differences in INR control were observed with respect to patient age (< 65, 65-75, and > 75 years), although to achieve adequate control of anticoagulation, the frequency of testing increased significantly with age. Annual risks of bleeding complications, thromboembolism, and stroke were 0.76%, 0.35%, and 0.84%, respectively. No significant differences in these events were observed between the three age groups studied. Patients who had thromboembolic events and haemorrhagic complications were significantly more likely to have been under-anticoagulated (INR < 2.0) and over-anticoagulated (INR > 3.0), respectively, at the time of their clinical event. CONCLUSIONS: Computerised long term oral anticoagulation for NRAF in a community setting of elderly and diverse patients is safe and effective. Anticoagulation control, bleeding events, thromboembolic episodes, and stroke rates are directly comparable with those reported in major clinical trials. The authors therefore support the strategy of rate control with long term oral anticoagulation for NRAF in general clinical practice.

Troponin I, laboratory issues, and clinical outcomes in a district general hospital: crossover study with "traditional" markers of myocardial infarction in a total of 1990 patients.

AIMS: Review of the clinical outcomes and practical issues of replacing traditional cardiac enzymes with troponin I (cTnI) in a district general hospital. METHODS: Crossover study of three sequential three month stages during which serial cardiac enzymes were replaced with a single cTnI measurement available at three set times within 24 hours for the duration of the second three month stage. The study was carried out in a 630 bed district general hospital with 1990 admissions of suspected cardiac ischaemia over the study period as a whole. Account was taken of seasonal factors. RESULTS: The introduction of troponin was associated with 8.5% more patients with non-ischaemic heart disease (IHD) being discharged on the day after admission, saving approximately 107 bed days each year. Approximately 50% more patients were diagnosed with myocardial infarction during the cTnI stage. There was no increase in readmission within one month or early death with cTnI. Approximately 3% false positive and 1.5% false negative cTnI results were recorded. All false positive cTnI results were coding errors or attributable to known assay interference effects. All false negatives were potentially explained by sample timing factors. The lack of standardisation in troponin assay services impacts clinically. CONCLUSION: Younger patients without IHD were discharged earlier during the cTnI stage in apparent safety. Blood sample timing needs to be verified when cTnI is used as an adjunct to early discharge. There were no unexplained false positives or negatives. Standardisation related issues arose.

Recurring febrile illness in a slaughterhouse worker.

A slaughterhouse worker presented with fever and a pleuropericardial effusion. Conventional microbiology failed to identify the responsible organism. However, DNA sequencing definitively identified Campylobacter fetus ssp fetus, which is rare in immunocompetent individuals. Prolonged treatment was required to eradicate the infection.

Haemodynamic deterioration after treatment with adenosine.

A 26 year old woman presented with a narrow complex tachycardia with a rate of 210 beats/min. Adenosine converted this to atrial fibrillation with a rate of 280 beats/min with associated haemodynamic deterioration that needed electrical cardioversion.

The use of intra-aortic balloon counterpulsation in malignant ventricular arrhythmias.

We describe a patient with recurrent ventricular arrhythmias post anterior myocardial infarction who stabilised following intra-aortic balloon counterpulsation. Antiarrhythmic drugs and continuous ventricular pacing were ineffective. The possible mechanisms of the improvement with counterpulsation and other treatment options are discussed.