Medical Europe

Global Cardiovascular Health

2011-10-03T17:53:00.003+02:00

Urgent Need for an Intersectoral Approach
Abstract

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with more than 80% of CVD deaths occurring in low- and middle-income countries (LMICs).
There have been several calls for action to address the global burden of CVD, but there remains insufficient investment in and implementation of CVD prevention and disease management efforts in LMICs.
To catalyze the action needed to control global CVD, the Institute of Medicine recently produced a report, Promoting Cardiovascular Health in the Developing World A Critical Challenge to Achieve Global Health.
This paper presents a commentary of the Institute of Medicine's report, focusing specifically on the intersectoral nature of intervention approaches required to promote global cardiovascular health.
We describe 3 primary domains of intervention to control global CVD:
1) policy approaches
2) health communication programs
3) healthcare delivery interventions.
We argue that the intersectoral nature of global CVD interventions should ideally occur at 2 levels: first, all 3 domains of intervention must be activated and engaged simultaneously, rather than only 1 domain at a time; and second, within each domain, a synergistic combination of interventions must be implemented. A diversity of public and private sector actors, representing multiple sectors such as health, agriculture, urban planning, transportation, finance, broadcasting, education, and the food and pharmaceutical industries, will be required to collaborate for policies, programs, and interventions to be optimally aligned. Improved control of global CVD is eminently possible but requires an intersectoral approach involving a diversity of actors and stakeholders.

Introduction
Cardiovascular disease (CVD) is well established as one of the leading causes of death worldwide, with more than 80% of all CVD-related deaths now occurring in low- and middle-income countries (LMICs). There have been several calls for action to address the global burden of CVD, but there remains insufficient investment in and implementation of CVD prevention and disease management efforts in LMICs.
To catalyze the action needed to control global CVD, the Institute of Medicine has produced a report entitled Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health.[5] A key feature of the committee's report is that the interventions to control global CVD should be intersectoral, extending beyond the direct domain of the health sector to involve multiple sectors of society, both public and private, and at both the population and individual levels.
This paper presents a commentary of the Institute of Medicine's report specifically related to the intervention approaches that can be pursued, focusing on the intersectoral nature of these interventions that is required to promote global cardiovascular health. Macro-level, intersectoral interventions are often difficult to implement successfully. Therefore, the challenge will be to adopt innovative and robust implementation approaches that take into account specific characteristics of the sociopolitical environment in different countries to find the optimal opportunities for success.

The determinants of the global CVD epidemic are multifactorial. Although the proximate risk factors for CVD are biological (hypertension, dyslipidemia, and diabetes) and behavioral (diet, physical activity, and tobacco), these risk factors are influenced by more "upstream" and "structural" factors such as globalization, demographic change, sociopolitical determinants, social inequality, education, and cultural norms.Thus, an intersectoral approach is required to address the multifactorial etiology of CVD.

Policy strategies at the global, national, and local levels have great potential for creating environments that enable individuals to make and maintain healthful choices. Policy tools include financial, legal, regulatory, and trade measures. Tobacco control is a well-established success story of CVD-related policy and demonstrates the impact possible from adopting an intersectoral approach.
In particular, the World Health Organization Framework Convention on Tobacco Control, the first international treaty dedicated to a health issue, emphasizes the importance of simultaneous implementation of comprehensive tobacco policies. These include taxation on tobacco products, smoking bans in public places, restrictions on tobacco advertising, counteradvertising, regulations on packaging and labeling of tobacco products, public awareness campaigns, health education initiatives, tobacco cessation services, restrictions on tobacco trade and sales, and support for alternative economic activities for tobacco producers. Similar intersectoral policy approaches can be applied to food and agriculture policy, environmental legislation, and urban planning, all of which have profound impact on the choices available to individuals regarding healthy behaviors.
Intersectoral and comprehensive policy approaches are not without their risks and difficulties. Creating collaboration and agreement among different government agencies and institutions is not always straightforward. In addition, developing policy is insufficient: implementation and enforcement is critical and often requires negotiation, compromise, creative financing, and transparent accountability. Despite the successes of the Framework Convention on Tobacco Control, more than 20% of signatory countries have yet to establish a national tobacco-control coordinating mechanism, and implementation of tobacco control policies remains a challenge in many countries.

Health communication programs, which enhance the knowledge, motivation, and skills of individuals and their communities, are by necessity intersectoral, involving multiple partners and stakeholders. Health communication initiatives can involve the mass media and other large-scale public communication strategies as well as communication programs implemented in community settings.
Successful communication programs recognize that health behaviors are influenced by socioeconomic, political, and cultural factors, and that interventions are required at multiple interdependent settings and levels. Thus, a combination of mass media, social marketing, community mobilization, empowerment and participatory approaches, enhancement of knowledge and behavior diffusion networks, and access to healthy choices can potentially maximize individuals' capacity to act on increased knowledge and awareness. For instance, community-based health communication interventions related to dietary changes are especially successful when individuals simultaneously have increased access to healthy food choices. Targeted communication strategies that are coordinated and aligned with the implementation of policy strategies have the potential to not only promote healthy behaviors but also build public support for policy changes. However, care must be taken in targeting, designing, and implementing both mass media and community-based health communication initiatives, as the evidence for the effectiveness of targeting multiple risk factors and affecting cardiovascular disease outcomes is not conclusive, and there have been limited evaluations in LMICs.
Evaluation of communication efforts in both mass media and community settings, as well as further research using innovative and novel communication strategies, are required to determine the optimal approach in LMICs.

Interventions to improve healthcare delivery—such as strengthening health systems, improving quality of care, optimizing human resources for health, establishing secure supply chains of drugs and technology, and promoting equitable access to care—are crucial to improve the preventive, diagnostic, therapeutic, and rehabilitative services available to the population. Rather than focusing on vertical, disease-specific programs, a "diagonal" approach should be pursued in which CVD-related healthcare delivery should be integrated into a broad-based approach to health systems' strengthening and promotion of primary care services.
Involvement of multiple stakeholders, including the private sector such as pharmaceutical and device companies, will be required to work toward equitable access to affordable health services, essential medicines, diagnostics, and technologies for prevention and treatment of CVD.
To maximize the effectiveness of interventions to improve healthcare delivery (both clinical and behavioral), they should be implemented in the context of broader population-level policy changes and community-level programs.

In summary, each domain of intervention—policy approaches, health communication programs, and healthcare delivery—is likely to have maximal positive impact when an intersectoral approach is undertaken. In addition, the effectiveness of these 3 domains of intervention can be further enhanced when interventions are synergistically linked across domains and mutually reinforced.
Thus, coordination of interventions among these 3 domains is critical to creating enabling environments, maximizing healthy choices, and empowering individuals to adopt health-promoting behaviors. Given the significant and growing burden of CVD in LMICs, and in light of the upcoming United Nations high-level, head-of-state meeting at the General Assembly in September 2011, which will focus on chronic noncommunicable diseases, it is particularly timely and important to recognize the need for intersectoral interventions to promote cardiovascular health as a critical component of global health initiatives in general.

Source: J Am Coll Cardiol. 2011;58(12):1208-1210. 2011 Elsevier Science, Inc.

Cooling May Benefit Children After Cardiac Arrest

2010-11-11T11:02:00.000+01:00

When the heart is stopped and restarted, the patient's life may be saved but the brain is often permanently damaged. Therapeutic hypothermia, a treatment in which the patient's body temperature is lowered and maintained several degrees below normal for a period of time, has been shown to mitigate these harmful effects and improve survival in adults.

Now, in the first large-scale multicenter study of its kind, physician-scientists are evaluating the effectiveness of the technique in infants and children. Offered in the greater New York metropolitan area solely by Columbia University Medical Center researchers at NewYork-Presbyterian/Morgan Stanley Children's Hospital, the Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) trial is funded by the National Heart, Lung and Blood Institute, part of the National Institutes of Health.

"A tragedy no matter how it happens, cardiac arrest can occur in children either as a complication from a serious medical condition or due to an accident or sudden illness. While arrest in children is rare, currently no other therapies have been shown to improve their chances of recovering," says Dr. Charles Schleien, a pediatrician and anesthesiologist at NewYork-Presbyterian/Morgan Stanley Children's Hospital and executive vice chairman of pediatrics and professor of pediatrics and anesthesiology at Columbia University College of Physicians and Surgeons. "In this study we are aiming to see whether therapeutic hypothermia can give these children a better chance at survival and long-term quality of life."

According to a 2008 review of pediatric cardiopulmonary resuscitation in the journal Pediatrics, about 16,000 children suffer cardiac arrest each year in the United States.

Study participants will be randomly selected to either have their body cooled through therapeutic hypothermia or maintained at normal body temperature. In both groups, body heat will be adjusted using special temperature-control blankets. Those receiving hypothermia will have their body temperature reduced to between 89.6º and 93.2º Fahrenheit for two days, then slowly increased to a normal body temperature and maintained for another three days.

Co-led by Dr. Frank W. Moler at the University of Michigan C.S. Mott Children's Hospital and Dr. Michael Dean at the University of Utah, the six-year study involves a total of 34 study sites in North America.

Cardiac Arrest and Therapeutic Hypothermia

During cardiac arrest, the body's blood supply is interrupted and cells are deprived of oxygen. This stresses the body, causing the release of toxic compounds that can overwhelm the organs and result in long-term brain injury. Therapeutic hypothermia slows the body's production of these compounds, reducing risk for brain injury. The therapy has been used successfully in adult cardiac arrest patients and has been shown beneficial for newborns who have received insufficient oxygen at birth.

Source: NewYork-Presbyterian Hospital

The Year's Major Event In Cardiovascular Medicine: ESC Congress 2010

2010-07-10T10:49:00.000+02:00

The European Society of Cardiology Congress 2010, the world's biggest international meeting in Cardiology will be held in Stockholm, Sweden, from 28 August to 1 September 2010.

The spotlight of ESC Congress 2010 will be coronary artery disease (CAD), 'from genes to outcome', which the chairperson of this year's program committee, Professor Fausto Pinto, describes as still the number one cause of death in the developed world. 'What we'll be seeing in this year's program,' he says, 'is how developments in basic science are now being translated into clinical progress in the early diagnosis and treatment of CAD. This is an area which involves the laboratory and the clinic, and a range of specialists which includes technicians and nurses, family doctors and consultant cardiologists. They will all play a part in this year's program.'

Last year's ESC Congress in Barcelona attracted almost 32,000 registered participants (as well as 750 registered press), making it the largest medical meeting in the world; this year's event promises a similar attendance.
New fpr 2010 is a one-day program on Saturday 28 August for primary care physicians and nurses. The program is open to all but has been designed with Scandinavians in mind, and this too may provide much local interest. The congress's opening press conference will also take place on this Saturday, at 9.00 am.
ESC Congress 2010 promises once again to be the world's major event in cardiovascular medicine.

Source:
ESC Press Office
European Society of Cardiology

ESC Supports 'appropriate' Use Of Nuclear Imaging Technology

2010-03-25T11:15:00.000+01:00

Cardiac nuclear imaging and computed tomography angiography (CCTA) still have an important role to play in cardiac disease diagnosis, say experts from the European Society of Cardiology (ESC).

Following the recent publications (1,2,3) highlighting potential dangers of ionising radiation resulting from imaging testing, the ESC experts feel that it is important to voice support of the technology. "We want to reassure the public that for individual patients the benefits of receiving an accurate diagnosis are likely to far outweigh the small potential risks involved in having a scan," said Professor Juhani Knuuti, of the ESC Working Group on Nuclear Cardiology and Cardiac CT, from Turku University Hospital (Turku, Finland). "The most fundamental question that clinicians need to ask themselves is whether a test is appropriate for the individual patient, and whether that patient will derive benefit from it."

It needs to be remembered, he added, that tests like CCTA are used to select patients for invasive procedures that themselves carry risks. "Any procedure is a balance of risks and benefits. What has been overlooked in recent publications is the risk of cardiovascular disease going untreated, which can even result in immediate sudden death. The potential risks of imaging tests are small relative to the diagnostic information obtained," said Knuuti.

"We have real concerns that following the publicity around the papers, the public may avoid these tests out of fear and that authorities might create unjustified recommendations for imaging use. They need to appreciate that radiation is a single aspect of the risks involved, and that these are really useful tests for cardiologists. Everything needs to be considered in the wider context," said Knuuti.

Papers highlighting the risks

Last year the problems of radiation exposure in patients undergoing medical imaging procedures were raised in three papers in major journals.

A Science Advisory statement from the American Heart Association Committee on Cardiac Imaging wrote that between 1980 and 2006 the collective dose from medical uses of radiation received by the US population increased by more than 700%. The paper, published in Circulation, added that in 2006 CTTA accounted for around 50 % of the collective dose(1).

A NEJM paper, by Reza Fazel and colleagues, from Emory University School of Medicine (Atlanta, Georgia), reviewed the radiation exposure of nearly one million US adults, aged 18 to 64(2). The investigators found that 69 % of participants had undergone at least one imaging procedure associated with radiation, and that the mean cumulative dose was 2.4 mSv per subject per year. "Our finding, that in some patients worrisome radiation doses from imaging procedures can accumulate over time, underscores the need to improve their use," wrote the authors, adding that strategies for optimizing and ensuring appropriate use of the procedures in general should be introduced.

A paper in JAMA by Jorg Hausleiter and colleagues, from Klinik an der Technischen Universitat, (Munich, Germany) reviewed the radiation dose of CCTA from 50 study centres(3).Results revealed an estimated median radiation dose corresponding to 12mSv, and furthermore found a six fold difference in the dose delivered between the highest and lowest centres. "Improved education of physicians and technicians performing CCTA on these dose-saving strategies might be considered to keep the radiation dose 'as low as reasonably achievable' in every patient undergoing CCTA," concluded the authors.

Radiation exposure risks put in context

It is important", said Knuuti, for the public to try to achieve an understanding of exactly what the potential increased cancer risk might involve. "The difficulty involved here is that the risks are so small that you'd never be able to detect them in clinical trials unless you recruited millions of subjects and followed them for the rest of their lifetimes," said Knuuti, adding that the current risk estimates have been derived from studies of atomic bomb survivors.

One study that helps put the risk of imaging into perspective suggests that living with a smoker (i.e. being a passive smoker) causes a 20 times higher risk of fatal cancer(4) than undergoing one CCTA scan (10 mSv). Another study suggests that the risk of having a fatal pedestrian traffic accident is three times higher than the risk of developing fatal cancer after one CCTA scan(5).

Cancer risks also need be considered in relation to the patient's age at the time of undergoing the investigation. "For patients with chest pain over the age of 60 years the radiation risks involved are unlikely to have consequences since it takes anyway decades to develop potential adverse events," said Knuuti, adding that the estimated risks would be greater for younger patients.

The way forward, said Knuuti, is to introduce strategies that reduce the radiation dose received by patients undergoing investigations. The PROTECTION 1 study, for example, showed that reducing the tube voltage from 120 kV to 100 kV resulted in a 53 % reduction in the median radiation dose for CCTA(6) "In the last five years the radiation dose from CCTA has been reduced from 20 to 30 mSv to 1-5 mSv. So the current dose is much lower than these papers are leading us to believe," he added.

Furthermore, additional efforts need to be undertaken to ensure appropriate use of imaging tests in different patient populations. "Studies undertaken in the US have suggested that one third of tests are being undertaken in patients where there is not a good indication," said Knuuti.

Source: European Society of Cardiology (ESC)

Tiny heart pump

2009-11-05T10:21:00.000+01:00

Cardiologists at the University of Illinois Medical Center are using a new heart pump that can be inserted without the need for surgery and allows them to treat high-risk patients with a procedure to unblock their heart arteries.

The recently FDA-approved device was used to assist in three angioplasty procedures at the Medical Center last week.

Patients with the worst blockages are often the sickest, making it too dangerous to treat their coronary artery blockages with standard angioplasty or even with a bypass operation, says Dr. Adhir Shroff, assistant professor of cardiology at the UIC College of Medicine.

Shroff and his partners, Dr. Mladen Vidovich, assistant professor of cardiology, and Dr. John Kao, assistant professor of medicine, performed these procedures using the Abiomed Impella 2.5 ventricular assist device, which has been used only about 1,000 times in the country.

"Often these patients, who may have complicating conditions like cancer, renal failure, severe lung disease, or heart failure, are poor candidates for more invasive procedures like bypass surgery and are left with few options," said Shroff. "We only proceed with high-risk angioplasties after reviewing the patients with our heart surgeons."

Angioplasty is done by threading a thin, flexible tube, or catheter, into the coronary arteries through a small opening in a leg artery. It is much less invasive than open heart surgery, but has been largely restricted to managing low- to middle-risk patients.

The Impella heart pump makes it possible for cardiologists to offer the less invasive procedure to high-risk patients. "Our ability to continuously maintain blood flow will decrease complications during these high-risk cases where the patient had no other options to fix their heart arteries," Shroff said.

The Impella system uses a narrow catheter, which is threaded up from the groin, through the ascending aorta, and into the left ventricle. From this position, the Impella pumps blood from within the heart into the aorta, supplementing the weakened pumping of the patient's heart. The pump itself is smaller than a number-2 pencil eraser. Although it provides a large portion of the heart's work, it is silent and virtually imperceptible to the patient.

The Impella can be regulated during angioplasty to maintain blood flow, giving the physician the time needed to remove the blockage. If the patient needs further support, the Impella can be continued while the patient moves up to the ICU and until the heart is able to take on the task.

"We have created a seamless transition from the cath lab to the ICU," Shroff said. "We could not have done this without the collaboration of everyone who sees these patients as they move through the hospital, from the emergency room to the cath lab to the ICU. This exceptional effort on everyone's part, especially Nursing Services and the Cath Lab staff, allows UIC to offer the best possible care for patients with heart disease."

Source: University of Illinois at Chicago

World First New DeBakey VAD impanted in Heidelberg

2009-08-19T11:24:00.005+02:00

At the end of July 2009, a team of cardiac surgeons headed by Professor Dr. Matthias Karck, Director of the Department of Cardiac Surgery at Heidelberg University Hospital, was the first in the world to implant the HeartAssist 5 ventricular assist device, the modern version of the DeBakey VAD. The device augments the pumping function of the left ventricle in an especially effective, gentle and quiet manner. The pump weighs 92 grams and is made of titanium and plastic. It pumps blood from the weakened or failed left ventricle into the aorta.

"Following the 3.5 hour surgery, the patient is doing fine," reports Professor Karck. The 50-year-old woman suffered from heart failure that could not be effectively treated with medication. Since a heart transplant was not an option due to medical reasons, the implanted heart pump will now assist her heart permanently.

Bridging the waiting time for a heart transplant

"The heart pump can also be used as a bridge-to-transplant while the patient waits for a matching donor heart," says Dr. Arjang Ruhparwar, senior registrar in the Department of Cardiac Surgery in Heidelberg. When a donor heart becomes available, the pump and the diseased heart are both removed and replaced by the new donor heart.

The DeBakey VAD was first developed in the 1990s in cooperation with NASA by Professor Michael DeBakey, the renowned American cardiac surgeon at the Baylor College of Medicine in Houston, who died in 2008 at the age of 99. The modern version of the device, the HeartAssist 5, is manufactured by US company MicroMed Cardiovascular. It is considered to be a fifth generation VAD because it can be implanted adjacent to the heart and has an exclusive flow probe that provides direct, accurate measurement of blood flow from the left ventricle to the aorta. The new miniature device is light, easy-to-handle and can be monitored and controlled externally.

Patients can live a normal life at home

"The new device has great advantages - at only 92 g, it is the smallest and lightest approved VAD in Europe that can completely replace the function of the left ventricle and it works very quietly and effectively with a high flow coefficient," explains Professor Karck. Thus, patients are able to live a nearly normal life at home.

In Europe, the HeartAssist 5™ has CE Marks for both adult and pediatric use. In the U.S., the HeartAssist 5, formerly DeBakey VAD® Child, is the only FDA-approved pediatric VAD. A bridge-to-transplant IDE clinical study is currently underway in the U.S. for adults.

Source:
Dr. Matthias Karck
University Hospital Heidelberg

Correct Placement Of Defibrillators Key To Effective Use

2009-07-29T10:06:00.003+02:00

The appropriate placement of automated external defibrillators (AEDs) is critical to optimize their use in public places, according to two studies published in Circulation: Journal of the American Heart Association.

Sudden cardiac arrest is the sudden, abrupt loss of heart function. Without immediate bystander cardiopulmonary resuscitation (CPR), brain death and permanent death start to occur in just four to six minutes after someone experiences cardiac arrest. Cardiac arrest can be reversed by immediate bystander CPR and treatment within a few minutes with an electric shock to allow the heart to restore a normal heartbeat. More than 92 percent of out-of-hospital cardiac arrest victims don't survive to hospital discharge. In cities where bystander CPR and defibrillation is provided within 5 to 7 minutes, the survival rate from out-of-hospital sudden cardiac arrest is as high as 30 percent to 45 percent, according to the American Heart Association.

In one study, researchers found that school-based AED programs have a high rate of survival for students and others on school grounds.

Researchers found that 83 percent of 1,710 U.S. high schools with AED programs that they studied had an established emergency response plan for sudden cardiac arrest. However, only 40 percent practiced and reviewed their plans at least annually with potential school responders.
Of 36 cases of sudden cardiac arrests at the 1,710 schools:
94 percent received bystander CPR,
83 percent received an AED shock and
64 percent survived to hospital discharge including 9 of 14 student athletes and 14 of 22 non students.

Three factors - prompt recognition of sudden cardiac arrest, the presence of a trained rescuer to initiate CPR and access to early defibrillation through on-site AEDs - are critical to improving survival from sudden cardiac arrest in schools, said Jonathan A. Drezner, M.D., lead author of the study and associate professor and team physician in the Department of Family Medicine at the University of Washington-Seattle.

"It is not just about the AEDs - schools must have a comprehensive emergency response plan for sudden cardiac arrest that includes training anticipated responders in CPR and AED use, access to an AED, and practice and review of the response plan," Drezner said.

"It is crucial to recognize that AEDs permit early defibrillation not only in young athletes but also in other individuals who may experience an unexpected sudden cardiac arrest. We found that more than half of sudden cardiac arrest events reported in schools occur in adults working at the school or attending a school event. Schools are a strategic location for AED programs to serve large concentrations of people at risk for sudden cardiac arrest."

In a Danish study, researchers examined strategic placement of AEDs in public urban locations. A significant amount of interest and money is focused on AED deployment and public access defibrillation programs worldwide, but knowledge about where and how widespread AED deployment in the community should be is lacking, said Fredrik Folke, M.D., lead author of the study and a cardiology research fellow at Gentofte University Hospital, Hellerup, in Denmark.

To evaluate whether public AEDs were located where the majority of cardiac arrests occurred, Folke and colleagues digitally marked the exact locations of all arrests on a map and then analyzed the locations of 104 AEDs placed in municipal institutions in Copenhagen, Denmark, from 1994 through 2005. About 25 percent of out-of-hospital cardiac arrests occurred in public places.

According to the cardiac arrest analysis, carefully choosing AED coverage in 10 percent of the city area would provide coverage for about 67 percent of all cardiac arrests occurring in public. The highest rates of cardiac arrest in cities were in high-density public areas such as major train stations, large shopping centers, central bus terminals and sports centers.

"Our findings suggest that public access defibrillation programs should cover the greatest possible number of arrests in public, which is consistent with the recommendations from the American Heart Association," Folke said. "But if AED deployment in the community is driven by local or political initiatives and not on strategic AED placement, there is a high risk of AEDs being placed primarily in low-incidence areas of cardiac arrest and hence low likelihood of the AEDs ever being used."

Placing AEDs in about 10 percent of the city area cost an estimated $41,000 per extra year of a survivor's life - deemed "acceptable" by the researchers. However, unguided AED placement trying to cover the entire city had an estimated cost of $108,700 per extra life year.

In an accompanying editorial, Dianne L. Atkins, M.D., a pediatric cardiologist at the University of Iowa, wrote that the two "informative" studies demonstrate that the mere presence of an AED in the general area of an arrest does not guarantee success. Successful AED programs require immediate bystander CPR and non-equipment components in addition to AED-availability, she said.

"The need for ongoing CPR training, fully-developed and executed emergency plans and links to EMS are vital to the immediate and long-term outcomes of shock delivery," Atkins wrote.

Source:
Kate Lino
American Heart Association

Disparities In Arrhythmias Treatment Across Europe

2009-06-23T21:41:00.003+02:00

The latest statistics regarding the use of pacemakers and implantable cardiac devices in Europe was presented on Sunday 21 June, at EUROPACE 2009, the meeting of the European Heart Rhythm Association (EHRA)1 which takes place in Berlin, Germany from 21 to 24 June.

"One of the roles of a European Association like the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC), is to promote equal access to therapy for all patients across Europe. To do so, the first step is to compile data on the current situation in various ESC membership countries, compare them, and propose actions to move towards harmonization. The current leadership of EHRA agreed on the importance of obtaining as much current information as possible concerning the situation of the practice of electrophysiology in Europe" stressed Wolpert.

Under the leadership of Professors Christian Wolpert from Germany, Panos Vardas from Greece and Josep Brugada from Spain, a group worked to collect the most recent figures. To ensure up to date data, Presidents of the different Working Groups and National Societies were contacted and asked not only to provide data, but also to verify and authorize all the information that became available through various sources.
Wolpert declared that this data is also the point of comparison for the future: " By knowing where we are today, we will be able to benchmark in the future and see how diverse countries evolve. This means that this book must be an ongoing process, with updated information, new and additional data, and the inclusion of information from those countries that have not yet been able to collect and transmit their records."

Explaining the data, Prof Wolpert highlighted certain trends, such as the fact that "more and more, cardiologists represent the majority of implanters while surgeons are decreasingly active in these procedures."
There is a disparate coverage of diseases and treatments within the European Union and the European Society of Cardiology member countries outside of the EU. Some of the countries have no reimbursement e.g. for ICD or pacemaker therapy and the penetration of catheter ablation of atrial fibrillation is very different. Data shows big differences across ESC member countries in:

•Guideline implementation.
•The number of trained physicians and specialised centres
•The number of implantations which seems to depend not only on reimbursement and financial resources, but also to be a function of the number of centres and physicians dedicated to electrophysiology and implantation of devices.
•The numbers of ICD implanting centres range from less than 1 to 6.87 per million citizens.
•Pacemaker therapy is performed in the range of 88 to a maximum of around 1200/ million inhabitants.
•ICD implant rates including CRT-D devices range from approx. 2.5 to 354 per million inhabitants. The data shows an increase for a subset of 16 western and northern European countries around 15% from 2006 to 2007.
•Regarding a potentially different medical consensus in specific countries the use of biventricular pacemakers vs. biventricular ICDs shows a 8:1 ratio at the highest down to 1:1.2 ratio as the lowest.
•In the field of invasive electrophysiology and catheter ablation for supraventricular and ventricular arrhythmias the number of centres available is variable ranging from less than 0.2 to more than 3 centres/ million. The total number of catheter ablations is increasing and reaches a maximum of more than 200/ million in approx. half of the countries. However, there is a strong discrepancy comparing all 35 countries, displaying a wide range from less than 20 to more than 450/ million.
•The same is true for catheter ablation of atrial fibrillation which varies tremendously, linked to reimbursement policies but also to different approaches in the various EP societies.

"As an example, Germany, hosting the EUROPACE meeting this year, has one of the highest implant rates for ICD's in Europe with a total of 1037 centres which implant pacemakers; 200 centres implanting CRT resynchronisation devices and a total of 360 ICD implanting institutions" highlights Prof Wolpert.
"Within the Non-EU ESC member countries, there has been a steady increase of therapy availability and disease coverage, however, there are still many countries that struggle with reimbursement, trained personnel and technical support, which requires a strong effort and leaves much space for improvement. It is the task and the intention of EHRA to support any initiative to improve steadily the situation for these countries in order to reduce the disparities".

Source-Eurekalert

Protecting Kidney Function During Heart Failure

2009-06-18T10:10:00.002+02:00

• Mayo Clinic cardiology researchers have found a peptide that helps preserve and improve kidney function during heart failure, without affecting blood pressure. Earlier variations of this peptide caused blood pressure to drop limiting the potential benefits to the kidneys. The findings appear in the current Proceedings of the National Academy of Sciences.

"Heart failure itself and some of the approaches used to treat it can have detrimental effects on the kidneys," says Mayo cardiologist and lead researcher Robert Simari, M.D. "Our hope is that this compound will help protect kidney function while you're being treated, and possibly shorten your hospital stay and keep you out of the hospital."

This new peptide (a unique link of amino acids) has been tested in the laboratory and in animal models and is expected to move into clinical trials next year.

"One of the biggest additional concerns for patients with heart failure is the health of their kidneys," says Dr. Simari. "The extreme case is that it can lead to the kidneys shutting down completely." Nearly 5 million Americans are living with heart failure, a condition where the heart can't pump enough blood to meet the body's needs. Symptoms include shortness of breath, exercise intolerance and fluid retention. All can occur when heart function is impaired.

Seven Years of Research

The mapping of the human genome (2000-2003) revealed a gene that produces a protein called BNP (B-type natriuretic peptide). BNP was not only useful in diagnosing heart problems, it also proved therapeutic in treating heart failure. Unfortunately, says Dr. Simari, it had limited use because many heart failure patients experience low blood pressure and BNP lowered it further.

The Mayo investigators discovered an alternative splicing (AS) of BNP in messenger RNA (produced by the same gene). When they shortened the amino acid sequence of ASBNP for testing, they found that it had the same therapeutic benefits as BNP, but without the side effects to blood pressure. Positive impacts include increasing the kidney filtration rate, suppressing harmful protein production, and keeping water and salt flowing from the body. Potentially, this new drug would be given by IV to patients who are being treated in the hospital.

"There's an important reduction of kidney function every time one of these acute heart failure episodes happens," says Dr. Simari. "And by stopping one or more of those decrements, we hope there will be an overall improvement in long-term maintenance of kidney function."

Others on the team include Shuchong Pan, M.D., Ph.D., Horng Chen, M.D., Guido Boerrigter, M.D., Candace Lee, Laurel Kleppe, Amir Lerman, M.D., Margaret Redfield, M.D., John Burnett, Jr., M.D., all from Mayo Clinic, and Deborah Dickey, Ph.D., Jennifer Hall, Ph.D., and Lincoln Potter, Ph.D., all from the University of Minnesota. The research was funded by Mayo Clinic, the National Institutes of Health, and Anexon, Inc.

Mayo Clinic and five of the investigators associated with this research have a financial interest in the technology studied in the research. In accordance with the Bayh-Dole Act, that technology has been licensed to Anexon. Mayo Clinic and Drs. R. Simari and Dr. S. Pan have received royalties from the licensing of that technology of greater than the federal threshold for significant financial interest. Drs. J.Burnett, M.Redfield and H.Chen have received royalties less than the federal threshold for significant financial interest. In addition, Mayo Clinic holds an equity position in Anexon.

Source
Mayo Clinic

CAFE-LLA: Statin Therapy Does Not Influence Central Aortic Pressure or Hemodynamics

2009-01-02T23:16:00.003+01:00

December 31, 2008 (Leicester, United Kingdom) — The use of statin therapy in hypertensive patients has no impact on central aortic pressures, pulse-wave augmentation, the augmentation index, pressure amplification, or any other central hemodynamic parameter [1].

These are the findings of the Conduit Artery Function Evaluation-Lipid-Lowering Arm (CAFE-LLA) study, a large-scale, placebo-controlled substudy of the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA) designed to prospectively evaluate the effect of statin therapy on the relationship between brachial and central aortic pressures.

Publishing their findings online December 22, 2008 in Circulation, lead investigator Dr Bryan Williams (University of Leicester, UK) and colleagues state that the "favorable effects of statins in cardiovascular outcomes in hypertensive patients are via mechanisms that are independent of important effects on large-artery function and central pressure."

Looking at Large-Artery Function in ASCOT

Because statins reduce the risk of cardiovascular events in individuals with hypertension, there has been interest in the hypothesis that the lipid-lowering drugs modulate large-artery function and central aortic pressures independent of cholesterol lowering. With this in mind, the researchers assessed the effects of atorvastatin 10 mg daily in 891 patients enrolled in ASCOT-LLA.

Patients were, on average, 63 years old and enrolled in ASCOT if they had untreated hypertension or treated hypertension >140/90 mm Hg and three cardiovascular risk factors but no history of coronary heart disease. To be eligible for ASCOT-LLA, patients had to have total cholesterol concentrations <250 mg/dL and be untreated with any lipid-lowering medication.

After six months, treatment with atorvastatin reduced LDL cholesterol by 32 mg/dL and total cholesterol by 35 mg/dL from baseline, a relative reduction of approximately 33% and 25%, respectively, compared with placebo.

Despite the reductions in LDL- and total-cholesterol levels, atorvastatin did not have any effect on central aortic blood pressure or various hemodynamic measurements. Time-averaged brachial blood pressure was similar in the placebo and atorvastatin-treatment arms, as was the change in aortic-pulse pressure. The augmentation index and heart rate were also unaltered with statin therapy compared with placebo.

"The results of CAFE-LLA are unequivocal," write Williams and colleagues. The clinical-outcome benefits of atorvastatin in treated hypertensive patients are not mediated by direct effects on central aortic pressure and hemodynamics, they write.

Too Little, Too Late, and Too Short

In an editorial accompanying the published study [2], Drs Michel Safar, Athanase Protogerou, and Jacque Blacher (Hotel-Dieu Centre de Diagnostique et Thérapeutique, Paris, France) suggest that the results of the study are surprising, "because arterial stiffening and atherosclerosis, although different diseases, have overlapping processes due to common cardiovascular risk factors and complications."

The editorialists note that several studies have shown, although the results are not entirely consistent, that statins have a beneficial effect on central aortic stiffness, possibly because of pleiotropic effects on atherosclerotic plaques, such as improved endothelial function and increased nitric-oxide bioavailability. The negative results of CAFE-LLA might be partly attributed to a lack of power to evaluate hemodynamic outcomes, but for the most part, they say the findings are a case of "too little, too late, too short."

For example, the 10-mg statin dose used in CAFE-LLA might be too low. Although the dose was chosen because baseline cholesterol levels were only modestly elevated, previous studies have shown reductions of aortic stiffness with higher doses of statins, up to 80 mg of atorvastatin. Regarding too late, vascular damage might have already been established in these patients, given that their age was 63 years upon study entry. And finally, too short, in that longer follow-up is needed to observe significant pressure-independent effects on central hemodynamics.

In their paper, Williams and colleagues echo many of these possible explanations in reconciling the differences between large-artery function, hemodynamics, and plasma cholesterol reductions.

Although CAFE-LLA was not powered to assess statin-mediated differences in central pressures and hemodynamics relative to clinical outcomes, the researchers note that atorvastatin in ASCOT-LLA was associated with significant reductions in cardiovascular events compared with placebo.

Williams B, Lacy PS, Cruickshank JK, et al. Impact of statin therapy on central aortic pressures and hemodynamics. Circulation 2009; 119:53-61. Abstract
Safar ME, Protogerou AD, Blacher J. Statins, central blood pressure, and blood pressure amplification. Circulation 2009; 119:9-12. Abstract
The complete contents of Heartwire, a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.

Source: Heartwire/Medscape

Sucking Out a Coronary Thrombus Before Stenting Seems Worthwhile

2008-09-24T19:24:00.001+02:00

Previous work in The Netherlands has shown that percutaneous coronary intervention (PCI) can induce embolization of atherothrombotic material with resulting impaired myocardial reperfusion, and that thrombus aspiration before stenting can prevent this effect.

In this study, reported in The Lancet in 2008,[1] 12 investigators analyzed, by intention to treat, cardiac death or nonfatal myocardial reinfarction after 1 year in 1060 randomized patients.
In the group treated by conventional PCI, 6.7% suffered cardiac death vs only 3.6% in the thrombus aspiration group; the data for cardiac death or nonfatal reinfarction after 1 year were 5.6% vs 9.9%.
The intuitively sensible action of aspirating thrombus in acute myocardial infarction prior to stenting is supported by data.

This article is selected from Medscape Best Evidence. Dr George Lundberg.

In-Stent Restenosis Best Corrected With Drug-Eluting Stent

2008-08-29T21:46:00.001+02:00

NEW YORK (Reuters Health) Aug 21
- The risk of restenosis is significantly lower when revascularization is achieved with a paclitaxel-eluting stent than by vascular brachytherapy for a bare metal stent in-stent restenosis, according to the 2-year findings of the TAXUS V-ISR multicenter trial.
Dr. Stephen G. Ellis of the Cleveland Clinic in Ohio and colleagues prospectively randomized 396 patients with a bare metal stent restenosis to receive either a Taxus stent or vascular brachytherapy treatment.

Ischemia-driven target lesion revascularization was required less frequently with the paclitaxel-eluting stent than with vascular brachytherapy, with revascularization rates of 5.3% and 10.3% at 9 to 24 months, respectively, the investigators report in the July issue of the European Heart Journal.

At 24 months, ischemia-driven target lesion revascularization was significantly reduced with paclitaxel-eluting stent, with a rate of 10.1% compared with 21.6% for vascular brachytherapy.

There were no significant differences in death, myocardial infarction, or target vessel thrombosis between the two groups after 1 or 2 years.

In an editorial, Dr. Debabrata Mukherjee of the University of Kentucky at Lexington notes that the era of bare metal stent is waning again, while the use of drug-eluting stents is once again becoming the preferred option for in-stent restenosis.

In 2007, the use of drug-eluting stents dropped because of concerns with restenosis. "We have more objective data now to support the use of drug-eluting stents. The key is the use of aspirin and clopidogrel, with their use extended for 1 year," Dr. Mukherjee commented in an interview with Reuters Health.

"The bottom line is that at this point in time, drug-eluting stents implantation (for in-stent restenosis) is best," Dr. Mukherjee asserted. "There are some exceptions, such as diffuse stenosis of the proximal (left anterior descending artery), when bypass surgery would be a better option."

"Still, about one third of patients in the US receive a bare metal stent," Dr. Mukherjee cautioned. "That's a significant population; it's about 100,000 people."

Eur Heart J 2008;29:1595-1596,1625-1634.

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Reuters Health Information 2008. © 2008 Reuters Ltd.

The benefits of thrombus aspiration after heart attack

2008-06-12T19:05:00.001+02:00

SummaryBackground

Percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction can be complicated by spontaneous or angioplasty-induced embolisation of atherothrombotic material. Distal blockage induces microvascular obstruction and can result in less than optimum reperfusion of viable myocardium. The Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS) found that thrombus aspiration resulted in improved myocardial reperfusion compared with conventional PCI, but whether this benefit improves clinical outcome is unknown. We aimed to investigate whether the early efficacy of thrombus aspiration seen in TAPAS translated into clinical benefit after 1 year.

Methods
Patients with ST-elevation myocardial infarction enrolled at the University Medical Centre Groningen were randomly assigned in a 1:1 ratio to either thrombus aspiration or conventional treatment, before undergoing initial coronary angiography. Exclusion criteria were rescue PCI after thrombolysis and known existence of a concomitant disease with life expectancy less than 6 months. Of the 1071 patients enrolled between January, 2005, and December, 2006, vital status at or beyond 1 year after randomisation was available for 1060 (99%). The primary endpoint was cardiac death or non-fatal reinfarction after 1 year, and analysis was by intention to treat. The TAPAS trial is registered with Current Controlled Trials number ISRCTN16716833.

Findings
Cardiac death at 1 year was 3•6% (19 of 535 patients) in the thrombus aspiration group and 6•7% (36 of 536) in the conventional PCI group (hazard ratio [HR] 1•93; 95% CI 1•11–3•37; p=0•020). 1-year cardiac death or non-fatal reinfarction occurred in 5•6% (30 of 535) of patients in the thrombus aspiration group and 9•9% (53 of 536) of patients in the conventional PCI group (HR 1•81; 95% CI 1•16–2•84; p=0•009).

Interpretation
Compared with conventional PCI, thrombus aspiration before stenting of the infarcted artery seems to improve the 1-year clinical outcome after PCI for ST-elevation myocardial infarction.

Funding
Medtronic and the Thorax Centre of the University Medical Centre Groningen.
Affiliations

a. Department of Cardiology, University Medical Centre Groningen, University of Groningen, Netherlands
b. Department of Pathology, University Medical Centre Groningen, University of Groningen, Netherlands
Correspondence to: PJ Vlaar, Department of Cardiology, University Medical Centre Groningen, Thorax Centre, Netherlands

More Heparin Recalls in Europe and US

2008-03-26T18:51:00.001+01:00

March 25, 2008 (London, UK) – The heparin-contamination saga is continuing, with the latest countries to recall products being France, Italy, and Denmark.

The heparin products recalled in France are medicinal products manufactured by Rotexmedica, the same company that supplied the heparin products recalled previously in Germany. These were recalled in Germany because of an association with an increased rate of adverse events. A spokesperson from the European Medicines Agency (EMEA) told heartwire that no additional adverse reactions had been reported in France, but that Rotexmedica was recalling a limited number of batches "because of a suspicion of the presence of a contaminant."

In Italy and Denmark, the recall involves a number of batches of heparin active pharmaceutical ingredient (API) made by the Italian company Opocrin. The EMEA spokesperson said he didn't think these batches of heparin API had made their way into the final heparin medicinal products as yet and were being recalled because the presence of a contaminant had been confirmed. He added: "We presume this is the same contaminant as identified in the US, as it has been detected by the same tests as used in the US, but we have no definite confirmation of the identity of the contaminant found in the Opocrin heparin API as yet."

He added that the heparin medicinal products from Rotexmedica and the heparin API from Opocrin had all been manufactured using products sourced originally from China by four Chinese companies. Rotexmedica's heparin products were sourced from Changzhou Qianhong Biopharmaceutical Co Ltd and Yantai Dongcheng Biopharmaceutical Co Ltd, while Opocrin's heparin API had been sourced from Yantai Dongcheng Biopharmaceutical Co Ltd, Shenzen Hepalink Pharmaceutical Co Ltd, and Shanghai No 1 Biochemical Co Ltd. These appear to be different from the Chinese company to which affected heparin in the US has been traced (Changzhou Scientific Protein Labs).

The EMEA spokesperson explained to heartwire that heparin products were regulated by each individual country in Europe. EMEA, being the centralized medical agency, was just providing an information-sharing role on the issue. He added that as there were many companies supplying heparin in Europe, it was not expected that a heparin shortage would occur.

Another US manufacturer affected

Meanwhile, another US heparin manufacturer has recalled some heparin products because of concern about the contaminant. B Braun Medical is recalling 23 lots of heparin after its supplier, Scientific Protein Laboratories, disclosed that one lot of heparin sodium active pharmaceutical ingredient supplied to B Braun may contain the contaminant implicated in the adverse reactions. To date, B Braun has not received any adverse-event reports related to these products, the company said.

The complete contents of Heartwire, a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.

Source: Heartwire

Handbook of Contrast Echocardiography

2007-10-22T23:00:00.001+02:00

LV Function and Myocardial Perfusion

Ultrasound contrast agents are rapidly becoming an integral part of echocardiography, the most widely used technique to image the heart.
Its demonstrated ability to provide the first images of perfusion in the myocardium have elicited widespread interest in the cardiology community.
This has been accompanied by rapid development of the agents and specialised imaging methods for their detection.
In spite of this, there exist no sources of reference for the practical use of contrast agents in the echocardiography laboratory.
This book is the result of the authors' combined experience in both research into the agents and their associated imaging techniques, and of clinical application of contrast echocardiography in patients over a period of ten years.
Its aim is to provide for the clinical echocardiographer a complete guide and reference for performing and interpreting a contrast echo study. The copious illustrations accompanying the text are supplemented by the generous contributions of more than twenty five worldwide authorities who have provided cases which convincingly demonstrate the general applicability of this new technology. It is available in both printed and electronic formats from this site:

http://www.sunnybrook.utoronto.ca/EchoHandbook/

European Heart Health Charter

2007-08-10T09:53:00.001+02:00

European Heart Health Charter

The European Heart Health Charter has been developed by the European Society of Cardiology and the European Heart Network, in collaboration with the European Commission and WHO Regional Office for Europe, to prevent cardiovascular disease in Europe.

The official ceremony for the launch of the European Heart Health Charter took place on 12 June in Brussels, in the symbolic venue of the European Parliament, in the presence of:

the Health Commissioner Markos Kyprianou,
WHO Deputy Regional Director Dr Menabde and
Dr Georgs Andrejevs, MEP.
The 12 June also saw the launch of a website dedicated to the European Heart Health Charter at:www.heartcharter.eu

The "Charter Community" section allows the sharing of initiatives on heart health promotion with other stakeholders (ie health professionals, health promotion organisations, health authorities, education system, etc) across Europe.

The European Heart Health Charter is the result of a fruitful work process of the Heart Health Charter Steering Group brought together after the Luxembourg Declaration. The Steering Group is composed of members of the ESC, EHN, WHO Regional Office for Europe, European Commission, Directorate-General Health & Consumer Protection, European Association for Cardiovascular Prevention & Rehabilitation and the Joint Prevention Committee.

So far, 14 European health promotion organisations have agreed to support the European Heart Health Charter:

Comité Permanent des Medecins / Standing Committee of European Doctors (CMPE)
European Institute for Women’s Health (EIWH)
ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP)
EuroHealthNet
European Association for Cardiovascular Prevention and Rehabilitation (EACPR)
European Association for the Study of Diabetes (EASD)
European Atherosclerosis Society (EAS)
European Health Management Association (EHMA)
European Men’s Health Forum (EMHF)
European Network for Smoking and Prevention (ENSP)
European Public Health Alliance (EPHA)
European Society of Hypertension (ESH)
International Society on Behavioural Medicine (ISBM)
Wonca Europe

source ESC

Good Outcome With Cardiac Resynchronization Therapy for Heart Failure

2007-02-14T17:44:00.001+01:00

NEW YORK (Reuters Health) Feb 07 - Patients with advanced heart failure and ventricular function delay (QRS duration of 120 ms or greater) who are treated with cardiac resynchronization therapy have a favorable long-term outcome.
"It is unknown whether the magnitude of survival benefits conferred by cardiac resynchronization therapy in a daily practice scenario is comparable to what has been observed in randomized controlled trials and whether this benefit is sustained over the long term," Dr. Angelo Auricchio, of University Hospital, Magdeburg, Germany, and colleagues write.

To investigate, the researchers examined the long-term outcome of 1303 consecutive heart failure patients with prolonged QRS duration treated with cardiac resynchronization therapy alone (44%) or with implantable cardioverter-defibrillator backup.
The researchers evaluated the cumulative event-free survival using a combined end point of death from any cause, urgent heart transplantation, or implantation of a left ventricular assist device. The team also assessed the cumulative incidence of competing events, including heart failure, sudden cardiac death and non-cardiac death. The results are published in the January 15th issue of the American Journal of Cardiology.

At 1- and 5-year follow-up, the cumulative event-free survival was 92% and 56%, respectively. The cumulative incidence of heart failure, sudden cardiac death and death from other causes was 25.1%, 9.5% and 8.8%.
Results of multivariable analysis revealed an association between treatment with a combined device and a nonsignificant 20% lower mortality.

"Patients treated with a combined device had a significantly lower incidence of sudden cardiac death than patients treated with CRT alone (HR 0.04, p < 0.002)," Dr. Auricchio's team writes. "Only two sudden deaths occurred in the 726 patients treated with a combined device...compared with 34 of 572 patients...treated with a resynchronization device alone."
Source: Reuters-Am J Cardiol 2007;99:232-238.

Effects of intravenous sildenafil on hemodynamics and cardiac sympathetic activity in chronic human heart failure

2006-11-29T23:16:00.001+01:00

Abstract
Background
Erectile dysfunction is common in patients with chronic heart failure and sildenafil is an effective treatment option in this population. Sildenafil has been reported to increase sympathetic outflow in normal volunteers. To date, experience with sildenafil in patients with congestive heart failure is limited and the impact of phosphodiesterase-5 inhibition on sympathetic activity in this population has not been evaluated.

Methods and results
10 patients with heart failure (ejection fraction 23 ± 3%) were studied. Generalized and cardiac sympathetic activity responses to an intravenous infusion of sildenafil were measured by the norepinephrine spillover method. In response to sildenafil, there was a significant reduction in mean pulmonary artery (− 26 ± 5%, P < 0.01) and mean arterial pressures (− 8 ± 1%, P < 0.01). These hemodynamic responses were accompanied by a 22 ± 5% reduction in cardiac norepinephrine spillover (P < 0.02) but no change in total body norepinephrine spillover.

Conclusions
The acute administration of sildenafil is associated with a modest reduction in systemic arterial blood pressure and a more substantial reduction in pulmonary arterial pressure. These hemodynamic changes are observed in the absence of systemic sympathetic activation and are associated with a reduction in cardiac norepinephrine spillover in patients with chronic heart failure. These observations are relevant given the high prevalence of erectile dysfunction in this patient population.

Keywords: Autonomic nervous system; Heart failure; Sildenafil

Abdul Al-Hesayena, John S. Florasa and John D. Parker,
Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, University of Toronto, Ontario, Canada M5G 1X5

Corresponding author. Mount Sinai and University Health Network Hospitals, University of Toronto, 600 University Avenue, Suite 1609, Toronto, Ontario, Canada M5G 1X5. Tel.: +1 416 586 4794; fax: +1 416 586 8413.

European Journal of Heart Failure
Volume 8, Issue 8 , December 2006, Pages 864-868

Pleural flap to prevent lobar torsion: a novel technique

2006-11-16T19:27:00.001+01:00

Abstract
Lobar torsion is reported as very rare but sometimes catastrophic complication if overlooked during the early postoperative period following a lobectomy, though it is totally preventable. In this novel technique, a piece of parietal pleural flap is harvested from the posterior wall of the chest using a hook diathermy while keeping its upper border as close to the apex as possible. Finally, distal end of the flap is secured to the upper edge of the lobe using a fine monofilament absorbable suture. This procedure not only protects the lobe from rotation but also maintains continuous expansion of the lung in the early postoperative period and may, therefore, be a good option to prevent such a serious complication in selected patients following a lobectomy.
Keywords: Lobectomy; Lobar torsion; Patient safety; Perioperative care; Postoperative complications
Corresponding author. Address: Hakki Yeten Cad. 17/12, Şişli 80200, Istanbul, Turkey. Tel.: +90 212 296 1680; fax: +90 212 247 4122.

FDA Announces Recall of Respironics Ventilator

2006-05-17T18:06:00.001+02:00

The US Food and Drug Administration (FDA) and Respironics California, Inc, have notified healthcare professionals regarding the class 1 recall of a mechanical ventilator (PLV Continuum Ventilator [PLVC I]) due to the potential for device failure resulting in serious injury or death.
The problem has been linked to a design flaw that can cause breakage of lead wires in the air flow valve during use, according to an alert sent Friday from MedWatch, the FDA's safety information and adverse event reporting program.
In a news release, the company notes that no adverse events or injuries have been reported as a result of the flaw. .The FDA advises that patients be safely transferred from the device to a different comparable patient support device. If a suitable ventilator is not available, arrangements for a substitute device can be made by contacting the company by phone at 1-760-918-7328.
The ventilator is used in homes and in institutional and portable settings to provide invasive and noninvasive ventilation for pediatric and adult patients weighing 5 kg or more; it is not intended for use as an emergency transport ventilator.

source: Medscape

New impotence treatment

2006-02-23T14:15:00.001+01:00

Medical Europe started a new adventure.
Although not in the erectile dysfunction field, we decided to give this new product a chance.
Due to vascular problems, a lot of men are suffering of ED, which is a sad situation according to themselves.
An estimated 40% of men in the age above 40 face this problem.
Younger men also, 25% of the men between 25-40 years of age.
The only "convienient"solution at the moment is Viagra and other medication in the same range.
But they have side effects and work for a few hours.
This new product is a solution for longer time, maybe for years.
Clinical reseach has been done and show 61.1% increase of erection.
The problem could be, that a lot of doctors reject this solution because , in their point of view, this is an alternative solution.
Medical Europe does not agree with this attitude.
The only important reason for using this product is; will it cure ED. and it does!
not only ED, but also libido-loss, both in men and women.
So, what is important? help people? or reject this solution anyhow.
For Medical Europe only 1 thing is important; Potency works!
Have a look for further information: http://www.optipotency.com

Clinical trials update from the American Heart Association: REPAIR-AMI, ASTAMI, JELIS, MEGA, REVIVE-II, SURVIVE, and PROACTIVE

2005-12-31T11:09:00.001+01:00

Abstract
This article provides information and a commentary on trials presented at the American Heart Association meeting held in November 2005, relevant to the pathophysiology, prevention and treatment of heart failure. All reports should be considered as preliminary data, as analyses may change in the final publication.

In REPAIR-AMI an improvement in ejection fraction was observed in post-MI patients following infusion of bone marrow stem cells. However, the ASTAMI study showed no benefit of stem cell implantation in a similar patient cohort.
The JELIS study reported a reduction in major coronary events in patients receiving statins plus fish oil compared to statins alone.
MEGA showed that low dose statins in a low risk population reduce the incidence of major cardiovascular events.
Two studies of levosimendan in acute heart failure gave conflicting results, in the REVIVE-II study levosimendan was reported to have a superior effect on the composite primary outcome compared to placebo, however, in SURVIVE despite a trend to early benefit with levosimendan, there was no difference in effect on long-term outcome versus dobutamine.
The PROACTIVE study showed encouraging results for the use of pioglitazone in post-myocardial infarction patients with concomitant type 2 diabetes.
source:
European Journal of Heart Failure Volume 8, Issue 1 , January 2006, Pages 105-110

EU approval HeartMate 11

2005-12-01T19:44:00.001+01:00

Next-Generation Cardiac Assist Device (HeartMate II) for Long-term Cardiac Support in EU
On Nov. 7, the European Commission approved a next-generation left ventricular assist system (LVAS; HeartMate II, made by Thoratec Corporation) to provide long-term support for patients in advanced-stage heart failure.
The continuous-flow implantable device is approximately one fifth the size of the company's HeartMate XVE product (which is approved for use in the United States) and may be used in a broader range of body sizes.
It is designed to have a much longer functional life and operate more quietly compared with currently approved pulsatile devices.
The approval was based on data from the first 20 patients implanted with the device in a European study and a US phase 1 clinical trial (HeartMate II Axial Flow LVAS: Suitability for Advanced Congestive Heart Failure). The data reflected more than 7,900 days of cumulative support with individual use ranging from 1 to 717 days.
Results from the phase 1 trial in 34 patients (median support, 160 days; range, 6 - 562 days) showed that 43% of 14 patients supported by the device for 3 months or longer improved by 3 New York Heart Association functional classes. In addition, 75% of patients demonstrated improved exercise capacity compared with baseline, as evaluated by increases in walking distance.
No device-related deaths or pump failures were reported, and 2 pump-related infections occurred.
According to a company news release, the device's potential for restoring hemodynamic function may render it suitable for use in a wider range of advanced-stage heart failure patients to significantly improve their survival and quality of life.
The device is currently undergoing a pivotal clinical trial in the United States for both destination therapy (DT) and bridge-to-transplantation (BTT) indications. Thus far, 102 patients have been enrolled in the study. The DT group (n = 50) will be evaluated on survival, rate of neurologic events, and device reliability in a 2-year composite end point; the primary end point of the BTT group (n = 52) will be rate of survival to transplantation.
source: medscape

New portal online about clinical trials worldwide.

2005-09-28T19:56:00.001+02:00

A new portal (www.ifpma.org/clinicaltrials), established by the International Federation of Pharmaceutical Manufacturers and Associations, links available online information about clinical trials worldwide.

New Guidelines Target Postoperative Atrial Fibrillation

2005-08-09T20:09:00.001+02:00

The American College of Chest Physicians on Monday released the first evidence-based guidelines to address the prevention and management of atrial fibrillation (AF) after cardiac surgery.
"Over one third of patents suffer from AF after cardiac surgery, which is associated with a higher risk of operative morbidity, increased hospital stay, and increased hospital cost," guideline co-chair Dr. Peter P. McKeown, from the VA Medical Center in Asheville, North Carolina, said in an ACCP statement. "Although previous guidelines have focused on the management of chronic AF, our guidelines are the first to address AF associated with cardiac surgery," he added.
The guidelines, which appear in the August issue of Chest, stem from a systematic review of randomized controlled trials and offer specific recommendations on a number of relevant topics, such as the use of cardiac pacing and anticoagulation therapy.
In their analysis, the researchers conclude that beta-blockers are superior to calcium channel blockers in preventing postoperative AF as well as controlling the ventricular rate.
The guidelines advise against the routine use of magnesium and digitalis for preventing AF after cardiac surgery. Amiodarone, however, is a suitable choice for patients with contraindications to beta-blockers or when sinus rhythm control is needed.
Atrial pacing was found to reduce the occurrence of AF after cardiac surgery and further analysis indicated that biatrial pacing was preferable to single atrial pacing.
To help prevent AF during intraoperative procedures, the guidelines recommend the use of mild hypothermia and heparin-coated circuits. To prevent postoperative thromboembolism, cautious anticoagulation therapy is indicated if the AF persists for longer than 48 hours.
"The development and implementation of clinical practice guidelines allow clinicians to practice medicine based on the highest quality of data available," Dr. Paul A. Kvale, President of the American College of Chest Physicians, said in the statement.
Chest 2005;125:1S-8S.
Source: Reuter