A CD&D

While death rate "report cards" indicated low mortality rates after heart bypass surgery, a review of in-hospital deaths in heart bypass patients at Ontario, Canada hospitals found that one-third might have been prevented, researchers report in Circulation, the journal of the American Heart Association (Dallas).

In the largest review of coronary artery bypass graft (CABG) deaths to-date, researchers conducted a retrospective analysis of 347 in-hospital deaths, randomly selected, from nine Ontario hospitals between 1998 and 2003. They analyzed all-cause, risk-adjusted in-hospital deaths after CABG surgery to determine the proportion of potentially preventable in-hospital deaths as a measure for hospital quality of care.

Despite a low risk-adjusted, average mortality range of 1.3% to 3.1% across Ontario hospitals, which is comparable to contemporary data in the U.S., researchers concluded that 111 of the 347 deaths (32%) after CABG might have been prevented.

"These findings underscore the need to find better ways to evaluate hospital performance than our current report card models," said Veena Guru, MD, lead author of the study and a research fellow at Ontario's Institute for Clinical Evaluative Sciences (ICES) and Sunnybrook Health Sciences Center of the University of Toronto. "It's appealing to see public report cards in healthcare as a cure-all. This study shows that we can't just publish post-operative death rates if we want to continue to improve the quality of care."

Researchers conducted the study in a region where, since 1999, hospital bypass mortality rates are publicly reported and mortality rates have steadily improved to less than 2%.

The study's findings have implications for quality of care initiatives that rely only on hospital report cards to monitor and improve quality of care.

In the study, experienced cardiac surgeons, a majority of whom were cardiac surgical division heads, reviewed chart summaries for all CABG deaths over the five years and identified preventable deaths using a standardized tool. Two reviewers looked at each death, and a third reviewer was used when the surgeons disagreed. Researchers estimated preventable deaths for each hospital and compared them to all-cause mortality rates. Both reviewers judged 52 total deaths to have been preventable. One of the two reviewers considered another 114 deaths preventable of which the third reviewer determined 59 were preventable.

Most of the preventable deaths were related to problems that occurred either during surgery or while patients were recovering in intensive care, and many were attributable to lapses in established hospital procedures. Independent of whether the death may have been preventable, both surgeon reviewers identified deviations in perioperative care in 32% of assessments and one reviewer did so in 42% of the assessments.

The analysis also identified quality improvement opportunities for preventable deaths in communication, credentialing, education, quality assurance programs, enhanced resources and retraining.

"Because deaths judged as preventable were more common in patients with lower predicted operative risk, one way to initially focus quality improvement efforts is to look most closely at deaths that are statistically 'unexpected' - i.e., occurring among those who were expected to have uncomplicated post-operative courses and excellent outcomes," said Chris Feindel, MD, a senior cardiac surgeon from the University Health Network in Toronto who participated in the study.

"Mortality rates for coronary bypass surgery have declined in the province of Ontario to less than 1.5 percent according to the most recent performance report card," said Stephen Fremes, MD, senior author of the study and divisional head at Sunnybrook Health Sciences Centre. "The reason for this further decline is uncertain, but the study may have stimulated subsequent quality improvement exercises in the cardiac surgical units in Ontario.

"We identified specific opportunities to improve the care of coronary bypass patients from this investigation," Fremes said. Typical report cards do not provide the necessary detail to direct surgeons where to focus their quality improvement efforts. We hope these findings will stimulate cardiac surgery, and other quality of care initiatives to invest in more detailed audits of adverse events rather than rely solely upon risk-adjusted outcomes report cards to improve outcomes."

In an accompanying editorial, Harlan Krumholz, MD, professor of medicine and epidemiology and public health at Yale University School of Medicine's (New Haven, Connecticut) Center for Outcomes Research and Evaluation, noted that the study indicates a large percentage of CABG deaths appear preventable with optimal care and the rate is probably similar in the U.S.

Noting that the study offers important lessons with implications beyond cardiac surgery, he said that medicine needs to develop a culture in which this type of examination is part of the expectation of every hospital, clinician and patient, "How else will we attain the goal of creating the high-reliability high-performance institutions that we prefer for our practices and that our patients deserve?"

Rate control as effective as rhythm control, says study

The data from an international clinical trial coordinated by the Montreal Heart Institute recently reported in the New England Journal of Medicine, showing that rate control is as effective as rhythm control. The Atrial Fibrillation and Congestive Heart Failure Trial (AF-CHF) was a prospective, multicentrer project involving patients with heart failure and atrial fibrillation.

The trial, launched in 2001, enrolled 1,376 patients at 123 hospital sites in North America, South America, Europe and Israel. The project's goal was to improve treatment with the objective of reducing mortality and morbidity linked with atrial fibrillation and heart failure.

Made possible by a grant of more than $6.5 million from the Canadian Institutes of Health Research (CIHR), this study was directed by Dr. Denis Roy, a cardiologist at the Montreal Heart Institute (MHI) and chair of the department of medicine at the University of Montreal, in collaboration with Dr. Mario Talajic, also a cardiologist at the MHI, and several Canadian researchers and international experts who contributed to this large-scale research project.

Between May 2001 and June 2005, the 1,376 patients were randomly assigned to a rhythm-control strategy these patients receiving electrical shocks and medication to suppress the abnormal rhythm or the simpler strategy of rate-control where two common drugs, beta-blockers and digitalis, are used to prevent rapid heart rates with no specific efforts to regularize the rhythm).

The primary endpoint of the study was cardiovascular mortality. Data management and analysis were performed at the Montreal Heart Institute Coordinating Center (MHICC). The intention-to-treat analysis revealed no difference in the primary endpoint between the two groups.

Cardiovascular death occurred in 182 (27%) patients in the rhythm-control group compared with 175 (25%) in the rate-control arm. Total mortality, worsening heart failure and stroke were similar between the two groups.

Hospitalizations were more frequent in the rhythm-control group, many due to hospitalization for management of atrial fibrillation.

The investigators said that the AF-CHF trial provides importantinformation concerning two widely-used treatment strategies for atrial fibrillation in patients with heart failure.

The routine use of a rhythm-control strategy did not reduce the rate of death in comparison with a rate-control strategy. Furthermore, there were no significant differences in other important outcomes such as worsening heart failure or stroke. The rate-control strategy eliminated the need for repeated cardioversions and reduced rates of hospitalization. In conclusion, the results of this trial suggest that rate-control, should be considered the primary approach for patients with atrial fibrillation and congestive heart failure.

"It is now clear that the rate-control strategy offers a less complex approach for the management of atrial fibrillation and could reduce rates of hospitalization" says Dr. Denis Roy, principal investigator.

"The result of this provocative study challenges the conventional wisdom, and shows that these patients can be conservatively managed, without repeated electric shocks. This will serve as a new goal post for future care of these patients," said Dr. Peter Liu, scientific director of the CIHR Institute of Circulatory and Respiratory Health.

Deficiency in resolution signals can lead to atherosclerosis

When a person develops a sore or a boil, it erupts, drawing to it immune system cells that fight the infection. Then it resolves and flattens into the skin, often leaving behind a mark or a scar.

A similar scenario plays out in the blood vessels. However, when there is a defect in the resolution response the ability of blood vessels to recover from inflammation atherosclerosis or hardening of the arteries can result, said researchers at Baylor College of Medicine (Houston) and Harvard Medical School (Boston) in a report that appeared online in the Journal of the Federation of American Societies for Experimental Biology. The major factor in this disease is a deficiency in the chemical signals that encourage resolution (pro-resolution signals). These signals are produced in the blood vessel where the inflammation occurs, the researchers said.

Chronic inflammation of the artery wall can cause atherosclerosis, a major risk factor for heart disease and heart attack. However, said Dr. Lawrence C.B. Chan, professor of medicine and molecular and cellular biology and chief of the division of division of diabetes, endocrinology and metabolism at BCM, in many instances, the lesions or little sores inside the artery arise and then resolve, often from a very young age. The mystery is why some lesions do not heal.

What he and his colleagues from BCM and Harvard found was that genetically increasing the production of the pro-resolution signals would cool down the inflammation and give the "sores" a chance to heal or the atherosclerosis to slow down. However, genetically clamping down on these signals would fan the fire of inflammation and speed up the progression of atherosclerosis.

"Inflammation is a two-edged sword. If resolution fails and the response gets out of hand there is a never ending civil war in the body," said Dr. Aksam J. Merched, assistant professor of molecular and cellular biology at BCM and lead author of the study. "Continued inflammation draws more macrophages (potent immune system cells) to the site of the inflammation. They produce molecules that turn this into a vicious cycle."

Dr. Charles Serhan of Brigham and Women's Hospital and Harvard Medical School, a key collaborator who first discovered many of the chemical mediators, provided special expertise in understanding the role of the mediators as well as performed analyses that allowed us to measure them accurately, said Chan.

"Resolution is not a passive process," said Chan, who also is the Betty Rutherford Chair for Diabetes Research at BCM. "It is active and produces specific anti-inflammatory mediators that 'cool down' the inflammatory process.

Some natural mediators that 'cool' this inflammation are derived from omega-3 polyunsaturated fatty acids, which are plentiful in fish and are frequently cited for their beneficial effects on the heart. Another kind of mediator is triggered by the anti-inflammation drug aspirin, said Chan.

"The specific chemical mediators that naturally cool down the inflammatory process identified in this study represent a new drug target for anti-atherosclerosis therapy," said Merched.

Mexican-Americans, women at highest risk for SAH stroke

A type of stroke that can strike at any age, and kills one-third of its victims, appears to be more common in women and Mexican-Americans than in non-Hispanic white men, according to a new study from the Stroke Program of the University of Michigan (U-M; Ann Arbor). The type of stroke measured in the study is a ruptured brain aneurysm, called subarachnoid hemorrhage (SAH).In a paper published online June 11 by the journal Neurology, researchers report that women had a 74% greater chance of suffering a type of stroke related to SAH. Mexican-Americans of both genders had a 67% greater chance. SAH accounts for 3% of the 780,000 strokes in the U.S. each year. They result from ruptured aneurysms, arising for unknown reasons at any stage of life.

An SAH is different from intracerebral hemorrhage (ICH), called a "bleeding" stroke, which can also result from a ruptured aneurysm or a misformed blood vessel, called an arteriovenous malformation. Both types of bleeding stroke are somewhat more dangerous than ischemic or "blockage" strokes, which result from a clot or other blockage inside a brain blood vessel.

Ischemic strokes account for more than 85% of U.S. strokes.

The paper, its authors say, attempts to give a "real world" picture of the risk of death from SAH nearly one in three in the geographic region in the study, Nueces County, Texas, where the city of Corpus Christi is located. The region has a large Mexican-American population and does not have a major university health system. (African-Americans and Asian-Americans were included in the initial screening for the study, which reviewed the medical records of 6,550 stroke patients, but their numbers were too small to assess any differences in SAH risk.)

"Physicians and public health officials should help Mexican-Americans and women take steps that might prevent subarachnoid hemorrhage, and other types of stroke that have already been shown to be more common in these two groups," says Lewis Morgenstern, MD, senior author. "Given that Mexican-Americans are the largest and fastest-growing minority group in the United States, it's important to understand how this condition might affect them differently and tailor messages to them."

Morgenstern directs the Stroke Program at the U-M Cardiovascular Center and is a professor of neurology and neurosurgery at the U-M Medical School and professor of epidemiology at the U-M School of Public Health.

The study is the latest report from the BASIC project (for Brain Attack Surveillance in Corpus Christi), an analysis of all strokes and mini-strokes in Nueces County, and detailed analysis of anonymous patient records.The paper is based on data from 107 SAH patients over the age of 44 who experienced their stroke between 2000 and 2006. All of their diagnoses were validated by neurologists who reviewed their records.

The reasons for the differences seen in the study are unclear, because the researchers were able to account and adjust for blood pressure, age, excessive alcohol use, smoking and health insurance status.

In all, 40% of the 107 SAH cases were in non-Hispanic whites, although 52% of the over-45 population in the study area is non-Hispanic white. Meanwhile, 60% of the SAH cases occurred in Mexican Americans, who make up 48% of the population over age 45 in the study area. At the same time, 67.3% of SAH patients were women, though 53.5% of the population in the area is female.

The BASIC study is funded by the National Institute of Neurological Disorders and Stroke.

Report: just 11% of youth athletes survive after SCA

Only one in 110 student athletes who experience sudden cardiac arrest (SCA) survives, according to a new study that examined exercised-related SCA events among youth in the U.S. The study is the first to identify this extremely low survival rate among young athletes and is published in the June edition of Heart Rhythm, the journal of the Heart Rhythm Society (HRS; Washington).

SCA is estimated to claim more than 250,000 lives per year, and more specifically, it is the leading cause of death in young athletes, according to HRS. About one death resulting from SCA occurs every three days in organized youth sports.

"The annual incidence of sudden cardiac death in young athletes is approximately one out of 50,000, and yet there is little knowledge about the survival rates of youth after experiencing an exercise-related sudden cardiac event," said lead author Jonathan Drezner, MD, of the department of family medicine at the University of Washington (Seattle), the study's lead author. "Our study sought to monitor exercise-related sudden death in the U.S. and assess survival trends following exercise-related SCA in the youth."

The study identified exercise-related sudden death events in youth through an online search through public media reports from 2000 to 2006. A total of 486 cases of exercise-related SCA in elementary school, middle school, high school and college students were identified over the seven year period. The average overall survival rate was 11%, ranging from 4% to 21% per year. Of the 486 cases identified, 83% were male,17% female.

"Recognizing this poor survival rate among youth athletes experiencing sudden cardiac arrest will hopefully spark improved efforts towards prevention and emergency planning," said Drezner. "It is critical for organized youth sports to be prepared for cardiac emergencies with strategies such as CPR training for coaches and prompt access to AEDs to protect athletes in their programs should a cardiac event occur."

A way to keep cardio testing on its toe(nail)s, study says

In a first-of-its-kind study, research results show that toenail nicotine levels can help predict risk of heart disease in women. Researchers at the University of California San Diego School of Medicine, in collaboration with colleagues from Harvard University, showed that the higher the level of nicotine in the toenails, the higher the risk of coronary heart disease, no matter the number of cigarettes smoked or level of exposure to second hand smoke. Study results were published in the June print edition of the American Journal of Epidemiology.

"Using toenail nicotine is a novel way to objectively measure exposure to tobacco smoke, and ultimately, to increase our understanding of tobacco-related illnesses," said Wael Al-Delaimy, PhD, department of family and preventive medicine, UC San Diego School of Medicine. "It has advantages over using other biomarkers and could become a useful test to identify high-risk individuals in the future. This would be especially helpful in situations where smoking history is not available or is biased."

Researchers analyzed toenail clippings from 62,641 women, between ages 36 and 61, collected for the Nurse's Health Study cohort. Between 1984 and 1998, 905 women were diagnosed with heart disease and those diagnosed with heart disease averaged double the level of nicotine in their toenails than women without heart disease.

Researchers found no difference in age, body mass index, aspirin use, or history of high cholesterol corresponding to the toenail nicotine levels. Women with the highest toenail nicotine levels were physically less active, had a lower body mass index, drank a higher amount of alcohol, and were more likely to have histories of high blood pressure, diabetes, and family history of heart attack than women with lower levels.

The toenails have an advantage over other existing biomarkers of smoking because they grow more slowly. The levels detected in the nails represent nicotine taken up from blood by nails during growth.

The slow growth rates of toenails provide a more stable estimate of average exposure, which is most relevant for illnesses related to tobacco smoke, such as heart disease. Using toenail samples in epidemiological studies is also an attractive concept because they're easy to collect and store for relatively low cost.

The researchers said that a study limitation is the declining exposure of non-smokers to secondhand smoke and the decline in active smoking nationwide. The measured exposure in 1982 might have misclassified exposure in later years. But Al-Delaimy said, "If anything, such decline in exposure will underestimate the risk we found between toenail nicotine levels and heart disease. That means the risk is possibly even higher than reported."

The Nurses' Health Study was established in 1976, when 121,700 registered female nurses, 30 to 55 years old and residing in one of 11 states, completed a mailed questionnaire regarding medical history and lifestyle factors. This information has been updated every two years since 1976. Cardiovascular risk factors, such as smoking, history of diabetes, hypertension, high cholesterol, and dietary variables, have been updated regularly. In 1982, all participants were asked to collect toenail clippings from their 10 toes and to send them in the provided envelope.

This study was funded by grant 12548 from the Flight Attendants Medical Research Foundation.

STS sees decline in interest in cardiothoracic surgery

The Society of Thoracic Surgeons (STS; Chicago) has issued a warning that there is a growing decline in the number of doctors entering the cardiothoracic surgery field, calling this "dangerous healthcare trend [that] will continue this year for Americans of all ages with heart disease and lung cancer."

The results of the 2008 National Residency Match Program (NRMP), reported on June 11, shows that the number of applicants for cardiothoracic surgery residency positions fell short of those needed for the fifth consecutive year. Only 94 of 118 heart and lung surgery residency positions will be filled, based on this year's Match.

"This dwindling supply of heart and lung surgeons means that Americans with heart disease and lung cancer will soon face a giant hurdle in access to care and, most likely, life-threatening postponements of surgeries," the STS said in a statement.

The situation is made even more serious due to the aging surgeon workforce. The average age of the practicing heart and lung surgeon today is over 55 years, and reports indicate that more than half expect to retire within the next decade.

"We are suffering from a 'brain drain' of increasingly dangerous proportions," said Randolph Chitwood Jr., MD, president of STS. "Heart and lung surgeons are starting to retire, and there aren't enough new generation surgeons to replace them - that could mean compromised patient care in the very near future."

"We all have a family member or friend who has been diagnosed with clogged arteries or other serious heart problems; we've all read about how the rate of lung cancer has increased by 60%," said Chitwood. "Ultimately, everyone is going to be touched by this problem."

Exacerbating the problem is an aging baby boomer population and uncertain outcomes with percutaneous stents. Demand is increasing just as supply is diminishing. Heart disease currently affects 70 million Americans, and lung cancer is the leading cause of cancer deaths in the U.S., killing more Americans annually than breast, prostate, and colon cancers combined.

The Society of Thoracic Surgeons, the largest organization representing heart and lung surgeons worldwide, is calling on Congress to enact reforms that will protect access to surgical care. STS urges Congress to help ensure the availability of cardiothoracic surgical care for future patients by overhauling the price-controlled Medicare physician reimbursement system and allowing market-based adjustments in the economics of the health care delivery system. STS also supports the Higher Education Act (HEA) which includes a provision on loan forgiveness in areas with physicians in short supply.

In brief ...

• Research conducted at the Methodist DeBakey Heart & Vascular Center (Houston) shows that the use of ultrasound contrast agents during stress echocardiograms is safe, these results presented at the 19th annual scientific sessions of the American Society of Echocardiography (Raleigh, North Carolina).The study examined 3,121 consecutive patients who underwent stress echocardiograms from 2002 through 2007 at the hospital. The report comes months after the FDA mandated a black box warning on labels of contrast agents used for cardiovascular ultrasound.

The risk of major adverse effects is no different in patients that received contrast during their stress echocardiogram than in those who did not receive contrast, according to the data. Researchers evaluated demographics, contrast use, hemodynamics, ECG and wall motion changes, symptoms and arrhythmias. Contrast was administered in 1,879 of 3,121 patients (60%). None of the patients receiving an ultrasound contrast agent experienced sustained ventricular tachycardia, ventricular fibrillation, cardiac arrest or death.

• Researchers from the Academic Medical Center in the Netherlands and the University of Wisconsin (Madison) have revealed that fever can trigger life-threatening changes in the electrical activity in the heart of patients with LQT-2, characterized by prolongation of the QT interval n the heart's electrical activity. Via ECG, the researchers measured the electrical activity in the heart over time of two LQT-2 patients with the same HERG mutation (A558P), finding that fever was associated with prolonged QT intervals. When this mutation was introduced into a cultured human cell line, the cells exhibited temperature-dependent characteristics, including altered electrical currents across their cell membranes at high temperatures. The authors conclude that similar changes in electrical currents occur in heart cells at the high temperatures associated with fever, thus a potential trigger of the potentially lethal changes in the electrical activity in the heart of these patients.

• The NIH-National Institute of Neurological Disorders and Stroke and the NIH-National Institute of Child Health and Human Development has awarded $12.4 million, for a study of a physical therapy program for stroke patients who have lost movement in their upper limbs, to Carolee Winstein, director of the Motor Behavior and Neurorehabilitation Laboratory at the the University of Southern California (Los Angeles).

The five-year study is named I-CARE, for Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (I-CARE) Stroke Initiative.