Developments in the invasive diagnostic-therapeutic cascade of women and men with acute coronary syndromes from 2005 to 2011: a nationwide cohort study.

OBJECTIVES: To investigate for trends in sex-related differences in the invasive diagnostic-therapeutic cascade in a population of patients with acute coronary syndromes (ACS). DESIGN: A nationwide cohort study. SETTING: Administrative and clinical registries covering all hospitalisations, invasive cardiac procedures and deaths in the Danish population of 5.6 million inhabitants. PARTICIPANTS: We included 52,565 patients aged 30-90 years who were hospitalised with a first ACS from January 2005 to November 2011. Follow-up was 60 days from the day of index admission. MAIN OUTCOME MEASURES: Diagnostic coronary angiography, percutaneous coronary intervention or coronary artery bypass within 60 days of index admission. RESULTS: Women constituted 36%, were older, had more comorbidity and were less likely to be admitted to a hospital with cardiac catheterisation facilities than men. Mortality rates were similar for both sexes. Diagnostic coronary angiography was performed less frequently on women compared with men, both within 1 day (31% vs 42%; p<0.001) and within 60 days (67% vs 80%; p<0.001), yielding adjusted female-male HRs of 0.83 (0.79-0.87) and 0.86 (0.84-0.89), respectively.Among the 39,677 patients undergoing coronary angiography, non-obstructive coronary artery disease was more frequent among women than men (22% vs 9%; p<0.001). Women were less likely to undergo percutaneous coronary intervention (58% vs 72%; p<0.001) and coronary artery bypass (6% vs 11%, p<0.001) within 60 days than men, yielding adjusted HRs of 0.96 (0.92-0.99) and 0.81 (0.74-0.89), respectively. The sex-related differences were not attenuated over time for any of the invasive cardiac procedures (p values for trend >0.05). CONCLUSIONS: In this nationwide study, men were more likely to undergo an invasive approach than women when hospitalised with a first ACS--a difference persisting from 2005 to 2011. Future studies should focus on the potential mechanisms behind this differential treatment.

Emergency coronary artery bypass surgery after failed percutaneous transluminal coronary angioplasty.

Coronary complications caused by percutaneous transluminal coronary angioplasty (PTCA) may necessitate emergency coronary artery bypass grafting (CABG). In 1994-1998, 132 patients (1.5% of the patients registered in the Danish PTCA registry) underwent CABG within 24 h because of angioplasty complications. We reviewed the files of 86 patients who had emergency operations within 6 h and found that 35% suffered from 1-vessel disease. Fifty-eight percent were taken directly to the operating room from the cardiovascular laboratory, and 13% were given preoperative cardiovascular resuscitation. The vessels most frequently injured were the right coronary artery and the left anterior descending branch (LAD). The patients received a mean of 2.4 coronary bypasses each. Forty-three percent of the patients with lesions of the left main coronary artery and/or the LAD received a vein graft to the LAD. A perioperative Q-wave myocardial infarction developed in 51% of the patients. The in-hospital mortality rate was 12%. These results are inferior to those obtained after elective surgery. Local cardiothoracic backup is vital when PTCA is performed in an unselected patient group.

Influence of cuff size on blood pressure among schoolchildren.

In 236 schoolchildren aged 7-15 years arm blood pressure was measured using a semiautomatic technique. Three different cuffs were chosen among four cuffs with bladder sizes of either 6 x 20 cm, 9 x 27 cm, 12 x 35 cm or 15 x 43 cm. Ideal cuff size in each pupil was defined as the one in which the width of the bladder was closest to 40% of arm circumference. In all subjects ideal cuffs were tested along with two cuffs bigger or smaller than the ideal one. The study showed that "normal blood pressure" in relation to age depended on the cuff used. Using the ideal one, systolic blood pressure increased from 105 mmHg at 7 years of age to 117-119 mmHg at age 11, with no further increase at higher ages, while diastolic blood pressure was almost unchanged in the different age groups. Normal blood pressure curves constructed using the same cuff in all children showed a steeper increase in both systolic and diastolic blood pressure in relation to age compared to the curve based on the ideal cuff in all children. It is strongly recommended that future studies should take the best-suited cuff problem into consideration when planning studies among children. Some of the differences between previous published studies may be explained by the differences introduced by different cuff sizes.

[Coronary bypass surgery using the radial artery. An alternative in patients with varicose veins]. / Koronar bypass-operation med a. radialis. Et alternativ hos patienter med varicer.

Arterial revascularization of the heart with the radial artery was performed in twenty patients with varicosities of the lower legs. The patients all had a good functional result and were free of angina pectoris after the operation. None of the patients had complications from harvest of the radial artery. The patients were mobilized early, as no veins had been harvested from the legs.

The inflammatory cytokine response after autotransfusion of shed mediastinal blood.

BACKGROUND: The inflammatory response in patients undergoing cardiac surgery with cardiopulmonary bypass is well known and increased levels of inflammatory cytokines have been shown. High levels of cytokines have been reported in blood drained from the surgical field. The present study aimed to elucidate whether autotransfusion of shed mediastinal blood in itself causes increased cytokine levels in coronary artery bypass graft (CABG) patients. METHODS: A prospective, randomized controlled study was performed in 23 patients having elective uncomplicated CABG. Autotransfusion of shed mediastinal blood was done every hour for 18 h in group I. In group II, the shed mediastinal blood was accumulated for 4 h in the cardiotomy reservoir and then autotransfused every hour for the next 14 h. Plasma levels of tumour necrosis factor-alpha (TNFalpha) and interleukin (IL)-1alpha, IL-1beta, IL-6 were measured. In vitro study of cytokine production was performed with or without stimulation (phytohaemagglutinin (PHA) and Escherichia coli (E. coli) lipopolysaccharide (LPS)). RESULTS: We found high levels of IL-6 in the shed mediastinal blood. However, autotransfusion of shed mediastinal blood did not lead to increased level of cytokines (TNFalpha, IL-1alpha, IL-1beta and IL-6) in plasma in group I nor in group II. In vitro study showed activation of the leucocytes in the shed mediastinal blood with a significantly increased production of TNFalpha and IL-6 both in the stimulated and non-stimulated samples. CONCLUSION: Shed mediastinal blood contains high levels of IL-6. However, autotransfusion of shed mediastinal does not cause measurable elevations in plasma levels of IL-6. In vitro study shows that autotransfusion activates leucocytes, which may enhance production of inflammatory cytokines.

Impact of autotransfusion after coronary artery bypass grafting on oxygen transport.

BACKGROUND: Autotransfusion of shed mediastinal blood after coronary artery bypass grafting (CABG) has been shown to reduce the requirement for allogeneic blood. We have previously demonstrated in non-randomized studies that the oxygen capacity of shed mediastinal blood is similar to the patient's circulating blood and better than stored allogeneic blood. Therefore, we wanted to examine the influence of autotransfusion of shed mediastinal blood on oxygen transport capacity in patients undergoing CABG. METHODS: A prospective, randomized, controlled study involving 120 patients having elective, uncomplicated CABG was performed. The autotransfusion group received transfusion of shed mediastinal blood for 18 h. Both groups received allogeneic red cells if their hemoglobin concentration decreased below 5 mmol/L. Red blood cell 2,3-diphosphoglycerate (2,3-DPG) was measured preoperatively and at intervals up to the hospital discharged. Hemodynamic measurements as well as blood gas and hemoglobin measurements from samples of arterial and mixed venous blood were used for calculation of oxygen transport capacity. RESULTS: During the autotransfusion period only 2 patients (4%) in the autotransfusion group required allogeneic blood compared to 11 patients (20%) in the control group. The 2,3-DPG levels in the autotransfusion group were unchanged before and after autotransfusion (4.4 vs. 4.3 mumol/ml erythrocyte). In the control group, 2,3-DPG levels decreased from 4.3 to 3.9 mumol/ml erythrocyte during the same period. There were no differences in the other measured parameters for oxygen transport capacity between the groups. CONCLUSION: Autotransfusion of shed mediastinal blood conserves the 2,3-DPG level of the red blood cells, while transfusion of stored blood leads to a decrease in 2,3-DPG levels. Autotransfusion had no effect on hemodynamic parameters, oxygen delivery or oxygen extraction.

Cardiac enzymes and autotransfusion of shed mediastinal blood after myocardial revascularization.

BACKGROUND: Autotransfusion of shed mediastinal blood reduces blood requirement after coronary artery bypass grafting. Recently, two nonrandomized trials indicated that autotransfusion elevates the levels of cardiac enzymes after cardiac operations. METHODS: Prospective, randomized controlled studies involving 120 patients (study A) and 15 patients (study B) having elective uncomplicated coronary artery bypass grafting were performed. Autotransfusion of shed mediastinal blood was performed for 18 hours in the patients allocated to autotransfusion. Serum levels of cardiac enzymes were measured. In study B cardiac enzyme levels in shed mediastinal blood and circulating blood were measured 1 hour postoperatively. RESULTS: Cardiac enzyme levels were significantly elevated in the patients receiving autotransfusion. In patients with a perioperative myocardial infarction. The level of creatine kinase-MB was much higher than in the autotransfused patients without myocardial infarction. The level of cardiac enzymes was higher in shed mediastinal blood compared with circulating blood. CONCLUSIONS: Postoperative autotransfusion of shed mediastinal blood causes elevation of cardiac enzyme levels after coronary artery bypass grafting.

Efficacy and safety of dofetilide, a new class III antiarrhythmic agent, in acute termination of atrial fibrillation or flutter after coronary artery bypass surgery. Dofetilide Post-CABG Study Group.

Ninety-eight patients, who developed atrial fibrillation/flutter after coronary artery bypass grafting within 1-6 days after surgery, were included into a double-blind, placebo-controlled, randomized trial to assess the efficacy and safety of dofetilide. Patients were randomly allocated to dofetilide 4 micrograms/kg i.v. (n = 33), dofetilide 8 micrograms/kg i.v. (n = 32) or placebo (n = 33) given intravenously over 15 min at a constant infusion rate. Responders were defined as patients who converted to sinus rhythm at any time during the initial 3 h after the start of the infusion. The conversion rates were 24% (8/33) on placebo, 36% (12/33) on dofetilide 4 micrograms/kg, and 44% (14/32) on dofetilide 8 micrograms/kg. The P-values (two-tailed) were 0.27 for dofetilide 4 micrograms/kg vs. placebo, 0.11 for dofetilide 8 micrograms/kg vs. placebo, and 0.10 for dose-response relationship. Short episodes of aberrant ventricular conduction and ventricular tachycardia were seen separately in three subjects after dofetilide 8 micrograms/kg. No episodes of torsades de pointes were noted. No negative inotropic effect was noted. In conclusion, dofetilide was well tolerated, but the effects on atrial fibrillation/flutter did not attain statistical significance, possibly due to the high placebo conversion rate.

Autotransfusion after coronary artery bypass grafting halves the number of patients needing blood transfusion.

BACKGROUND: Several randomized studies about autotransfusion of shed mediastinal blood in patients undergoing coronary artery bypass grafting have resulted in divergent findings concerning reduction of the need for homologous blood transfusions. Most of these studies used less strict criteria for homologous blood transfusion than applied in daily clinical practice. METHODS: A prospective, randomized, controlled study involving 120 patients having elective, uncomplicated coronary artery bypass grafting was performed. The autotransfusion group received transfusion of shed mediastinal blood for 18 hours. Criteria for homologous blood transfusion were hemoglobin concentration less than 5.0 mmol/L in the intensive care unit and less than 5.5 mmol/L during the rest of the hospital stay. RESULTS: Twenty-eight percent of patients in the autotransfusion group received homologous blood transfusion versus 55% in the control group (p = 0.007). Ninety-five percent of the shed mediastinal blood was transfused. In the autotransfusion group, a total of 26 units of homologous blood was used versus 78 units in the control group (p < 0.001). CONCLUSIONS: Autotransfusion of shed mediastinal blood in patients undergoing elective, uncomplicated coronary artery bypass grafting halves the number of patients needing homologous blood and reduces the amount of homologous blood given.

Truncated GLP-1 (proglucagon 78-107-amide) inhibits gastric and pancreatic functions in man.

We studied the effect of intravenous infusion of synthetic truncated GLP-1 (proglucagon 78-107-amide) on fasting and postprandial gastric acid secretion, gastric emptying, and pancreatic secretion of trypsin and lipase in eight normal volunteers using marker dilution and aspiration technique. The infusion resulted in a plasma concentration of 110 +/- 14 pmol/liter (mean +/- SEM). Truncated GLP-1 significantly inhibited postprandial acid secretion by 43 +/- 11% in spite of unchanged plasma gastrin concentration. Gastric emptying rate decreased significantly; 50% emptying time increased from 16 +/- 2 min to 30 +/- 5 min. Postprandial trypsin and lipase outputs were significantly inhibited by 47 +/- 17% and 40 +/- 9% during truncated GLP-1 infusion. Pancreatic enzyme output was linearly correlated to gastric emptying, and truncated GLP-1 did not affect this relationship, suggesting that the effect on pancreatic secretion was secondary to the effect on gastric emptying. Postprandial insulin and glucagon concentrations were similar with and without truncated GLP-1 infusion in spite of significantly lower blood glucose levels (5.2 +/- 0.2 versus 3.7 +/- 0.3), indicating that GLP-1 stimulated insulin secretion and inhibited glucagon secretion. In conclusion, our results suggest that truncated GLP-1 act as a physiological inhibitor of gastric and pancreatic functions in man.

Fracture of a composite aortic graft. Case report.

Fracture of a valved composite graft was found 3 years after its implantation in the ascending aorta. This appears to be the first reported case of such fracture.

The effect of the cholecystokinin receptor antagonist MK-329 on meal-stimulated pancreaticobiliary output in humans.

To determine the physiological role of circulating cholecystokinin (CCK), the effect of the CCK receptor antagonist MK-329 on upper digestive processes was investigated in six normal volunteers after a mixed meal. In a double-blind, two-period, randomized crossover design, the subjects received either 10 mg MK-329 or placebo orally 3 hours 15 minutes before the meal, which contained 51CrCl3 as food marker. A five-lumen tube with the tip in the distal duodenum allowed continuous marker infusion (57Co-B12) and duodenal aspiration as well as recordings of antral and duodenal motility patterns via three pressure sensors. Postprandially, MK-329 caused a significant reduction of 30%-60% (P less than 0.05) in pancreatic trypsin output during the initial three 15-minute periods; thereafter, the output was virtually the same than after placebo. Thus, the integrated enzyme response was only reduced by 15% (NS) during the 3-hour period beginning 15 minutes after the meal. In contrast, gallbladder contraction, determined by total bile acid excretion, was inhibited by 77% (P less than 0.05), indicating a crucial role of CCK in regulating gallbladder motility. Except for the initial 30 minutes postprandially, MK-329 also induced a significant reduction in duodenal pH with mean values ranging from 3.5 +/- 0.2 to 4.1 +/- 0.3 compared with 4.5 +/- 0.3 to 5.0 +/- 0.4 after placebo (P less than 0.05), probably because of lowered secretion of pancreatic bicarbonate. Gastric emptying rate was significantly accelerated by MK-329 during the initial 75 minutes after the meal, but the time for 50% emptying did not differ from placebo [127.5 +/- 7.7 vs. 140.0 +/- 9.0 minutes (NS)]. No changes were observed in the motility pattern of the proximal duodenum after feeding. Whereas MK-329 only caused a slight increase of the basal plasma CCK concentrations, the postprandial levels were markedly enhanced. Peak concentrations were 10.0 +/- 1.3 vs. 4.0 +/- 0.5 pmol/L after placebo (P less than 0.001), and the integrated response exceeded the control value by 175% (P less than 0.01). The results suggest that circulating CCK is not an essential mediator of the postprandial pancreatic enzyme secretion in humans, whereas it plays a critical role in gallbladder emptying.

Mucosal/submucosal blood flow in the gut wall determined by local washout of 133Xenon.

A 133Xe washout technique for measuring the blood flow in the intestinal mucosa is introduced and evaluated. In 11 anaesthetized pigs a laparotomy was performed and the mucosal blood flow rate in the intestine of the pig was determined by a local epimucosal application of 133Xe. In both the colon and the small intestine the 133Xe washout plotted in a semilogarithmic diagram showed a multiexponential configuration. Histological examination and localization studies showed shunting by diffusion of 133Xe in the intestinal mucosa explaining the multiexponential configuration of the washout curve. Therefore the initial slope of the washout was used for measuring blood flow rate. Blood flow rate was simultaneously measured by microsphere entrapment technique. There was an excellent correlation between the blood flow rate determined by the two techniques the correlation coefficient R being 0.89 in the small intestine and 0.996 in the colon.

Mucosal/submucosal blood flow in the small intestine in pigs determined by local washout of 133Xe and microsphere techniques.

In 11 anaesthetized pigs a laparotomy was performed and the mucosal and submucosal blood flow rate in the small intestine of the pig was determined by a local application of 133Xe and by 6.5-microns radioactive microspheres. The 133Xe washout plotted in a semilogarithmic diagram showed a multiexponential configuration. As localization studies of 133Xe in the intestinal mucosa showed a constant high concentration of 133Xe in the luminal part of the mucosa due to shunting by diffusion, the initial slope of the 133Xe washout was used for blood flow determination in the mucosa/submucosa. There was a good relationship between blood flow determined by the two techniques. The correlation coefficient, R, between the two techniques was 0.89.

[Hemoglobin concentration prior to the 20th week of pregnancy correlated with complications in the third trimester]. / Haemoglobinkoncentration før 20. graviditetsuge korreleret til komplikationer i 3. trimester.

The haemodynamic changes in pregnancy result in decrease in haemoglobin and haematocrit. It has previously been demonstrated that absence of this decrease or even increase in the haemoglobin concentration (Hb) and haematocrit (Hct) values measured in the third trimester or late in the second trimester can be correlated to increased risk of development of hypertension, pre-eclampsia and intrauterine growth retardation. In the present investigation, the authors have investigated whether the abovementioned complications of pregnancy can also be correlated to high Hb and high Hct measured early in the third trimester. The investigation included 373 healthy pregnant women, 46 of whom had Hb greater than or equal to 8.3 mmol/l in the 13th-19th weeks. Complications of pregnancy occurred in 17.4% of the 46 women. Among the remaining 327 pregnant women with Hb less than 8.3 mmol/l, complications of pregnancy were observed in only 5.8%. This difference is significant. The blood volume increases by approximately 1.5 litre during pregnancy. The plasma volume increases by 50% from the seventh to the 32nd week and thereafter remains constant until delivery. The erythrocyte volume increases first from approximately the 16th week and increases by a total of 25%. The early increase in plasma volume results in a decrease in the haemoglobin concentration (Hb) and in the haematocrit (Hct) value. During the third trimester, Hb and Hct increase again as a result of the increased erythrocyte volume. A positive correlation has been demonstrated between the magnitude of the plasma volume in the third trimester and the birth weight and a negative correlation between Hb in the third trimester and the birth weight.(ABSTRACT TRUNCATED AT 250 WORDS)

Oxyntomodulin from distal gut. Role in regulation of gastric and pancreatic functions.

We studied the effects of intravenous infusion of synthetic oxyntomodulin (proglucagon 33-69), a potential hormone from the ileal mucosa, on fasting and postprandial gastric acid secretion, gastric emptying, gastroduodenal motility, and pancreatic secretion of trypsin and lipase measured simultaneously in six normal volunteers using multilumen tubes for infusion of markers, manometry, and aspiration of gastric and duodenal contents. The infusion resulted in plasma concentrations of 203 +/- 21 pmol/liter (mean +/- SEM) of oxyntomodulin, regarded as high but not unphysiological concentrations of the peptide. Oxyntomodulin almost abolished basal acid secretion and inhibited postprandial acid secretion by 35 +/- 10%. Gastric emptying decreased significantly; the time for 50% to leave the stomach increased from 17.3 +/- 2.2 min to 34.7 +/- 8.0 min. The postprandial gastroduodenal motility was massively inhibited by oxyntomodulin. Postprandial trypsin and lipase output was significantly inhibited by 56 +/- 12% and 42 +/- 11%, respectively, during oxyntomodulin infusion. However, pancreatic enzyme output was linearly related to gastric emptying and oxyntomodulin did not influence this relationship, suggesting that oxyntomodulins effect was due to its effect on gastric emptying. Oxyntomodulin seems to play an important role in the small intestinal inhibitory control of gastropancreatic functions.

Effect of low-dose exogenous secretin and somatostatin on pentagastrin-stimulated gastric acid secretion in man.

The inhibitory effect of intravenous infusion of secretin (0.05 CU kg-1h-1) and somatostatin (60 pmol kg-1h-1), given alone or in combination, on pentagastrin-stimulated (100 ng kg-1 h-1) acid secretion was studied in 10 healthy subjects. Secretin inhibited acid secretion by 54% (p less than 0.05), and somatostatin inhibited by 70% (p less than 0.05). The combined infusion of secretin and somatostatin decreased acid output by 64% (p less than 0.05). The differences between the three groups were not significant (p greater than 0.05). Median plasma concentrations of secretin and somatostatin were of the same magnitude as seen after duodenal acidification. The present study did not demonstrate any interaction between secretin and somatostatin in the inhibition of gastric acid secretion.

GLP-1 (glucagon-like peptide 1) and truncated GLP-1, fragments of human proglucagon, inhibit gastric acid secretion in humans.

Glucagon-like peptide 1 amide (GLP-1 amide), a predicted product of the glucagon gene (proglucagon 72-107-amide), and truncated GLP-1 (proglucagon 78-107-amide), recently isolated from porcine small intestine, were infused in doses of 100 and 400 ng/kg/hr and 12.5 and 50 ng/kg/hr, respectively, into eight volunteers to study pharmacokinetics and effects on pentagastrin-stimulated gastric acid secretion (plateau stimulation with pentagastrin at D50: 100 ng/kg/hr). The concentration of GLP-1 in plasma increased from 64 +/- 12 to 189 +/- 23 and 631 +/- 76 pmol/liter, respectively. The concentration of truncated GLP increased from approximately 7 pmol/liter to 28 +/- 3 pmol/liter during the high rate of infusion. A similar increase was seen in response to a mixed meal in eight normal volunteers. The metabolic clearance rate (MCR) of GLP-1 was 2.2 +/- 0.3 and 2.6 +/- 0.3 ml/kg/min, respectively, and the half-life in plasma was 17 +/- 2 min. The MCR of truncated GLP-1 was 13 +/- 2.8 ml/kg/min and the half-life 11.4 +/- 2.1 min. GLP-1 reduced the pentagastrin-stimulated acid secretion 16 +/- 9% during the low-rate infusion and 23 +/- 12% during the high rate (P less than 0.05). Truncated GLP-1 caused a 36 +/- 3% inhibition during the high infusion rate. Thus truncated GLP-1, a naturally occurring peptide, is a potent inhibitor of acid secretion in man and more so than GLP-1.

Oxyntomodulin: a potential hormone from the distal gut. Pharmacokinetics and effects on gastric acid and insulin secretion in man.

Synthetic oxyntomodulin, a predicted product of the glucagon gene, which is produced in the human lower intestinal mucosa, was infused in doses of 100 and 400 ng kg-1 h-1 into six volunteers to study its pharmacokinetics and effects on pentagastrin-stimulated gastric acid secretion (100 ng kg-1 h-1). The concentration of oxyntomodulin in plasma measured with a cross-reacting glucagon assay increased from 37 +/- 5 to 106 +/- 17 and 301 +/- 40 pmol l-1, respectively. The metabolic clearance rate was 5.2 +/- 0.7 ml kg-1 min-1 and the half-life in plasma was 12 +/- 1 min. Oxyntomodulin reduced the pentagastrin-stimulated acid secretion by 20 +/- 9% during the low-rate infusion (P less than 0.05) and by 76 +/- 10% during the high-rate infusion (P less than 0.05). In accordance with the homology with glucagon, there was a small, significant rise in plasma concentrations of insulin and insulin C-peptide during oxyntomodulin infusion. Oxyntomodulin may therefore be included among the potential incretins and enterogastrones in man.

Effect of a somatostatin analogue, SMS 201-995, on 133Xe clearance from colonic mucosa in unanesthetized man.

The effect of intravenous bolus injection of the somatostatin analogue SMS 201-995 on mucosal and submucosal blood flow was studied with the local 133Xe clearance technique in eight subjects. Mucosal and submucosal blood flow decreased by 33% after injection of SMS 201-995. These observations suggest that SMS 201-995, like somatostatin, inhibits splanchnic blood flow.