[Prospective study on conciliation of medication in orthopaedic patients]. / Estudio prospectivo de conciliación de medicación en pacientes de traumatología.

OBJECTIVES: To identify and resolve discrepancies between the medications prescribed when patients are admitted to hospital and the medication usually taken by selected patients, adapting the prescriptions to the pharmacotherapeutic guidelines and the clinical con- dition of the patient. METHOD: A prospective study in which patients over the age of 65 with at least one chronic disease in addition to the reason for hospitalisation in the orthopaedic department were selected. Pharmacists reviewed the treatments 24-48 hours after hospitalisation, comparing the order for medication sent to the pharmacy with the clinical history and patient interview. The following data were collected : patient name, age, gender, reason for hospitalisation, comorbidities, drugs, discrepancies, recommendation and acceptance. RESULTS: During a four-month period, 84 patients were included (23.5% of all the patients admitted to the orthopaedic service), aged 75.40 +/- 10.63 years. 47.6% presented three or more chronic diseases and took 8.14 +/- 2.95 drugs. A total of 120 discrepancies were detected in 60 patients (71.43% of those selected): 71 unjustified discrepancies and 49 justified discrepancies. Among the unjustified discrepancies, the majority were due to the omission of a drug followed by dosing errors, frequency, timetables, route or method of administration. The acceptance of the pharmaceutical recommendation was 88.73%. CONCLUSIONS: The action of the pharmacist, as part of the multidisciplinary team, resolved the discrepancies in the medication on admitting the patients selected.

Cardioversion-induced fulminant ischaemic hepatitis.

Ischaemic hepatitis, although infrequent, should be considered as a cause of fulminant hepatitis in patients with congestive heart failure. Ischaemic hepatitis is characterized by a marked rise in transaminases occurring within 24-48 h of circulatory failure. Cardioversion of atrial fibrillation to sinus rhythm is associated with an increase in cardiac output in most patients; however, a transient reduction in cardiac output may occur in more than one-third of patients, and may therefore induce ischaemic hepatitis. This is the first report of fulminant ischaemic hepatitis as a complication of cardioversion of atrial fibrillation.

The differing prognostic utility of exercise radionuclide ventriculography in coronary artery disease patients with and without prior myocardial infarction.

UNLABELLED: Previous studies have documented the prognostic utility of left ventricular ejection fraction response to exercise primarily in populations without prior myocardial infarction. We undertook a study to assess the prognostic utility of exercise left ventricular ejection fraction and segmental wall motion response during exercise radionuclide ventriculography in coronary artery disease patients with and without prior myocardial infarction. METHODS: We examined the comparative prognostic utility of left ventricular ejection fraction and segmental wall motion response during upright bicycle exercise radionuclide ventriculography in 419 coronary artery disease patients with (n = 217) and without (n = 202) prior myocardial infarction using univariate and multivariate hierarchical regression analyses. RESULTS: During an average followup period of 61 months, 96 patients (23%) suffered cardiac events, including 55/217 (25%) of the patients with prior myocardial infarction and 41/200 (21%) of the patients without prior myocardial infarction (p = ns). Both cumulative Kaplan-Meier survival analyses and stepwise hierarchical Cox survival analyses demonstrated that peak left ventricular ejection fraction < 55% was a significant predictor of cardiac events in patients without prior myocardial infarction (p = 0.04), whereas an exercise wall motion worsening score > or = 2 was a significant predictor in patients with a prior myocardial infarction (p = 0.0001). CONCLUSIONS: The prognostic utility of exercise radionuclide ventriculography variables differ according to the presence or absence of prior myocardial infarction. Global function, assessed by peak left ventricular ejection fraction, adds the greatest prognostic information in patients without prior myocardial infarction, whereas regional function, assessed by exercise wall motion worsening, is the best predictor among patients with prior myocardial infarction.

Detection and significance of myocardial ischemia in women versus men within six months of acute myocardial infarction or unstable angina. The Multicenter Myocardial Ischemia Research Group.

Ischemia detection after an acute coronary event predicts subsequent cardiac events. However, gender-related aspects in the prevalence and prognostic significance of ischemia detection after an acute coronary event have not been reported. Noninvasive tests, which included resting 12-lead electrocardiogram (ECG), 24-hour ambulatory ECG, exercise ECG, and thallium-201 stress scintigraphy were performed in 936 stable patients (224 women and 712 men) 1 to 6 months (average 2.7) after an acute coronary event (i.e., myocardial infarction or unstable angina). Primary end points during an average follow-up of 23 months included cardiac death, nonfatal myocardial infarction, and unstable angina, while restricted end points included the first 2. Ischemia detection was significantly less frequent among women than among men on 24-hour ambulatory ECG, exercise ECG, and thallium-201 stress scintigraphy. Primary end points occurred in 19.2% of women and in 19% of men, and restricted end points occurred in 5.8% of women versus 8%. of men (p = NS). Cox analyses revealed that gender and its interaction with each of the ischemia tests did not contribute to the prediction of the primary or restricted end points. We conclude that in stable patients 1 to 6 months after an acute coronary event, ischemia detection by noninvasive tests was significantly less prevalent in women than in men. However, subsequent cardiac event rates in women were similar to those observed in men, and there was no gender-ischemic detection interaction regarding subsequent events.

Gender-related differences in exercise ventricular function among healthy subjects and patients.

Increasing numbers of women are undergoing noninvasive stress testing for coronary artery disease evaluation. Limited information is available regarding the presence, magnitude, and importance of gender-related differences in exercise ventriculography among the heterogeneous population of patients referred for noninvasive stress testing. Patients referred for exercise radionuclide ventriculography between 1979 and 1986 were evaluated, including 175 patients with a likelihood of coronary artery disease, 59 patients with angiographically normal coronary arteries, and 419 patients with coronary artery disease. Overall, women demonstrated higher resting left ventricular ejection fraction and lower delta left ventricular ejection fraction response to exercise compared with men. Although left ventricular response to exercise correlated with the underlying severity of coronary artery disease in both women and men, fewer women demonstrated a delta left ventricular ejection fraction >5 percent despite a lower prevalence of multivessel coronary artery disease compared with men. We conclude that gender-related differences in left ventricular response to exercise are present in a wide range of patients referred for testing.

The limited efficacy of exercise radionuclide ventriculography in assessing prognosis of women with coronary artery disease.

Increasing numbers of women are undergoing stress testing for coronary artery disease evaluation. Limited study is available as to its efficacy in women. Four hundred nineteen patients with coronary artery disease (74 women and 345 men) referred for exercise radionuclide ventriculography between 1979 and 1986 were evaluated in a prospective cohort evaluation with 5-year follow-up. Exercise radionuclide ventriculographic variables were analyzed and compared between women and men. The prognostic efficacy of exercise radionuclide ventriculography was assessed separately for women and men among patients with coronary artery disease by Kaplan-Meier cumulative survival curves, univariate Cox regression analyses, and hierarchical stepwise Cox regression analyses. Overall, women demonstrated higher resting and peak left ventricular ejection fraction response to exercise than men. Ninety-six of 419 patients (23%) had cardiac events at 5-year follow-up. Although left ventricular response to exercise conveyed prognostic information in the combined and male populations (multivariate hierarchical analyses chi-square 11, p = 0.001 for delta left ventricular ejection fraction and chi-square 10, p = 0.002 for worsening exercise wall motion score), these variables were not found to be prognostically useful in women. Women with coronary artery disease demonstrated a worsened functional status, evidenced by greater compromise of exercise capacity, despite having less extensive anatomic disease than their male counterparts. We conclude that sex-related differences in left ventricular response to exercise limit the prognostic utility of exercise ventriculography in women with coronary artery disease.

Automatic quantification of ejection fraction from gated myocardial perfusion SPECT.

UNLABELLED: We have developed a completely automatic algorithm to quantitatively measure left ventricular ejection fraction (LVEF) from gated 99mTc-sestamibi myocardial perfusion SPECT images. METHODS: The algorithm operates in the three-dimensional space and uses gated short-axis image volumes. It segments the left ventricle (LV), estimates and displays endocardial and epicardial surfaces for all gating intervals in the cardiac cycle, calculates the relative left ventricular cavity volumes and derives the global EF from the end-diastolic and end-systolic volume, all without operator interaction. The algorithm for measuring LVEF was tested in 65 clinical patients undergoing 16-interval and 8-interval rest-gated SPECT and validated against first-pass radionuclide ventriculography. RESULTS: Automatic segmentation and contouring of the LV was successful in 65/65 (100%) of the studies. Agreement between EFs measured from 8-interval gated SPECT and EFs calculated from first-pass data was high (y = 2.44 + 1.03x, r = 0.909, p < 0.001, s.e.e. = 6.87). Agreement between EF values measured from 16-interval and 8-interval gated SPECT was excellent (y = -2.7 + 0.97x, r = 0.988, p < 0.001, s.e.e. = 2.65), the latter being on average lower by 3.71 percentage points. CONCLUSION: Our automatic method is rapid and highly agrees with conventional radionuclide measurements of EF, thus providing clinically useful additional information to complement myocardial perfusion studies.

Ischemic threshold during two exercise testing protocols and during ambulatory electrocardiographic monitoring.

OBJECTIVES: The aim of this study was to examine the dependence of the ischemic threshold during exercise testing on the exercise protocol employed and to determine the relation between the ischemic thresholds observed during exercise and during daily activity. BACKGROUND: The ischemic threshold (heart rate at 1-mm ST segment depression) during daily activity has been reported to be lower than that observed during exercise testing. Recent reports have hypothesized that this difference is probably dependent on the exercise protocol employed. METHODS: Twenty-two patients with known coronary artery disease, not receiving antianginal medications, were evaluated by repeated exercise testing according to the Bruce and the modified Davidson protocols and by 48-h ambulatory electrocardiographic monitoring. RESULTS: Although the heart rate at 1-mm ST segment depression was somewhat lower with the Davidson than with the Bruce protocol (112 +/- 14 vs. 115 +/- 14 beats/min), the rate-pressure product at 1-mm ST segment depression was similar during the two protocols (16,900 +/- 4,000 vs. 17,700 +/- 3,600). The mean heart rate (100 + 12 beats/min) at 1-mm ST segment depression during ambulatory ischemic episodes (n = 137) was significantly lower than that observed during both exercise protocols (p < 0.001 for both comparisons). CONCLUSIONS: Exercise-induced ischemia occurs at a relatively fixed threshold that is mainly dependent on myocardial oxygen demand and is independent of the exercise protocol employed. Ischemia on ambulatory monitoring, however, occurs at a much more variable threshold that is commonly lower than that observed during exercise and is therefore dependent on other factors in addition to increased demand.

Circadian variations in ischemic threshold and their relation to the occurrence of ischemic episodes.

BACKGROUND: The occurrence of ischemic episodes during daily activity has been reported to exhibit a bimodal circadian distribution, yet its relation to the ischemic threshold (heart rate at 1-mm ST segment depression) has not been explored. METHODS AND RESULTS: To determine whether the ischemic threshold during daily activity exhibits a circadian pattern that might relate to the frequency of occurrence of ischemic episodes, we studied the time of occurrence and the heart rate at onset of ischemia in 1,371 ischemic episodes recorded in 41 patients with stable coronary disease, positive exercise testing, and repeated ischemic episodes during ambulatory ECG monitoring (AEM). All patients had 7 days of AEM; 23 were off any anti-ischemic therapy, while 18 were on low dose of beta-blockers. The occurrence of ischemic episodes exhibited the typical bimodal circadian distribution with a prominent peak between 7:00 and 11:00 AM and a second less prominent peak between 6:00 and 9:00 PM. The threshold of myocardial ischemia exhibited a different single-peaked circadian distribution; it was lowest between 1:00 and 3:00 AM and highest between 10 AM and 1 PM. Time series analyses indicated a strong hour-by-hour trend of each of the two circadian distributions, whereas the two series cross-correlated maximally at a lag of zero hours (p < 0.01), indicating a complex interplay between myocardial oxygen demand and supply in determining the occurrence of ischemic episodes during daily activity. The morning increase in the frequency of ischemic episodes could not be attributed to a reduced threshold but rather to an increase in demand. The low threshold at night-time might probably indicate that the mechanism of ischemia during these hours is reduced coronary flow due to increased coronary tone. Secondary analyses for several predefined patients' subsets gave similar results. Patients who received low-dose beta-blockers maintained the bimodal circadian distribution of the occurrence of ischemic episodes, whereas the ischemic threshold exhibited a constant pattern with no circadian changes. CONCLUSIONS: Our results demonstrate that myocardial oxygen demand is a major determinant of daily ischemia, yet changes in the ischemic threshold that probably reflect dynamic changes in coronary tone play also an important role. The relative contribution of increased demand and decreased threshold to the genesis of ischemic episodes during daily activity can be assessed by AEM and may help to optimize medical therapy.

Usefulness of severity of myocardial ischemia on exercise testing in predicting the severity of myocardial ischemia during daily activities.

To determine the relation between myocardial ischemic indexes on exercise testing and on ambulatory Holter recording, 60 patients with stable coronary artery disease who exhibited an ischemic response to both testing procedures were studied. All patients performed a Bruce protocol exercise test and underwent 24-hour Holter recording within 2 weeks without antianginal medications. Mean exercise duration was 7.4 +/- 2.8 minutes, mean heart rate at 1-mm ST depression was 118 +/- 20 beats/min and mean maximal ST depression during exercise was 2.2 +/- 1 mm. During Holter recording the average number of ischemic episodes was 4.7 +/- 2.6 per patient, mean duration of daily ischemia was 62 +/- 54 minutes, mean maximal ST depression was 3.2 +/- 1.3 mm and average heart rate at 1-mm ST depression was 93 +/- 17 beats/min. Overall, the correlations between ischemic indexes on both testing procedures were very weak (mean r2 = 0.054). The only exercise variable that had a significant correlation (p less than 0.05) with all Holter variables was heart rate at 1-mm ST depression, yet it correlated very weakly (0.064 less than or equal to r2 less than or equal to 0.125) with most Holter covariates and had a better correlation (r2 = 0.256) only with average heart rate at 1-mm ST depression during Holter. Thus, ischemic indexes on exercise testing cannot accurately predict ischemic indexes on ambulatory Holter recording in patients with stable coronary artery disease who exhibit ischemic changes on both tests.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in myocardial ischemic threshold during daily activities.

This study assesses the variations in myocardial ischemic threshold (heart rate at the onset of ischemia) during daily activities in patients with ischemic episodes on Holter monitoring. Eighty patients with known coronary artery disease, positive treadmill stress test results and greater than or equal to 2 ischemic episodes during a 24-hour period of Holter monitoring were studied. The lowest and the highest ischemic thresholds were determined for each patient. The mean lowest ischemic threshold was 85 beats/min, and the mean highest ischemic threshold was 109 beats/min. The highest ischemic threshold was identical to ischemic threshold values noted during exercise. Of the 895 ischemic episodes, 654 (74%) were preceded by a moderate (greater than 10%) increase in heart rate. The variability of ischemic threshold (difference in percentage between the highest and lowest ischemic thresholds) increased with the number of ischemic episodes (range 2 to 60%). However, in different patients with a similar number of ischemic episodes, different variability was observed. These differences in ischemic thresholds are probably indirect indicators of the vasomotor activity of the coronary arteries in different patients.

Prognostic significance of ischemic episodes in patients with previous myocardial infarction.

This study assessed the prognostic significance of ischemic changes during daily activity as recorded by ambulatory electrocardiographic monitoring in a group of 224 low-risk postinfarction patients. Of the 224 patients studied, 74 (33%) had transient ischemic episodes on Holter monitoring. During the 28 months of follow-up the frequency of cardiac events (cardiac death, reinfarction, hospitalization for unstable angina, balloon angioplasty or coronary bypass surgery) was 51% among those with ischemic episodes on Holter monitoring, compared with 12% in those without such changes (p less than 0.0001). The 74 patients with positive results in their exercise tests and Holter monitoring had a 51% event rate, compared with 20% among the 44 patients with a positive exercise test result but negative Holter results (p less than 0.001). The event rate in those without ischemic changes either on the exercise test or on Holter was only 8.5%. Among patients with good (greater than 40%) or reduced (less than 40%) left ventricular ejection fraction, those with transient ST depression on Holter had a significantly higher cardiac event rate compared with those without it. A similar event rate was found in patients with only silent, only symptomatic and with silent and symptomatic ischemic episodes.

Use of streptokinase for lysis of a mobile left ventricular thrombus--report of a case and review of the literature.

One-third of patients with acute anterior wall infarction develop left ventricular apical thrombi. Mobile thrombi carry the highest risk of systemic embolization, particularly in the early phase after the acute infarction. We report here on a young patient in whom a protruding and mobile left ventricular thrombus was detected on two-dimensional echocardiogram 1 week after an acute antero-septal infarction. Intravenous administration of relatively low doses of streptokinase was followed within 14 h by complication-free resolution and disappearance of the thrombus.