Registration and management of smoking behaviour in patients with coronary heart disease. The EUROASPIRE survey

AIMS

To establish to what extent smoking status and its management is recorded in coronary patients' medical records, and to investigate their motivation to change smoking behaviour.

METHODS

In EUROASPIRE, a survey on secondary prevention in 21 hospitals in the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, Slovenia and Spain, data were collected from records of 4863 consecutive patients =<70 years of age, with previous (>6 months) admission for coronary bypass operation, angioplasty, myocardial infarction or ischaemia. Of these, 3569 patients were interviewed 1.6 years following their index hospitalization.

RESULTS

Of the 82% of patients whose pre-hospitalization smoking behaviour was known, 34% were smokers. Documentation was significantly better in younger patients, in males and patients requiring angioplasty or bypass operation. In only 35% of 1364 smokers was the smoking habit recorded again after discharge from hospital At the time of the interview, 554 of the interviewed patients were still smoking. In over 90% of the smokers, advice to quit smoking was reported at interview. A positive relationship was found between receiving advice and seeking help to stop smoking, between receiving advice to stop smoking and attempting to stop, as well as between seeking help and attempting to stop.

CONCLUSION

In almost 20% of coronary patients, smoking habits are not documented in medical records, and in only 35% of the smoking patients is smoking status documented at the follow-up. After a cardiac event requiring hospitalization as many as 50% of patients continue their smoking habit and so there is further potential to reduce the risk of recurrent coronary disease. Advice to stop smoking motivates patients to seek help and to attempt to stop smoking. Physicians repeated advice to stop smoking is important and smoking status should always be documented at follow-up.

Anticoagulant properties, clinical efficacy and safety of efegatran, a direct thrombin inhibitor, in patients with unstable angina

AIMS

Thrombin plays a key role in the clinical syndrome of unstable angina. We investigated the safety and efficacy of five dose levels of efegatran sulphate, a direct thrombin inhibitor, compared to heparin in patients with unstable angina.

METHODS

Four hundred and thirty-two patients with unstable angina were enrolled. Five dose levels of efegatran were studied sequentially, ranging from 0.105 mg. kg(-1). h(-1)to 1.2 mg. kg(-1). h(-1)over 48 h. Safety was assessed clinically, with reference to bleeding and by measuring clinical laboratory parameters. Efficacy was assessed by the number of patients experiencing any episode of recurrent ischaemia as measured by computer-assisted continuous ECG ischaemia monitoring. Clinical end-points were: episodes of recurrent angina, myocardial infarction, coronary intervention (PTCA or CABG), and death.

RESULTS

Efegatran demonstrated dose dependent ex-vivo anticoagulant activity with the highest dose level of 1.2 mg. kg(-1). h(-1)resulting in steady state mean activated partial thromboplastin time values of approximately three times baseline. Thrombin time was also increased. Neither of the efegatran doses studied were able to suppress myocardial ischaemia during continuous ECG ischaemia monitoring to a greater extent than that seen with heparin. There were no statistically significant differences in clinical outcome or major bleeding between the efegatran and heparin groups. Minor bleeding and thrombophlebitis occurred more frequently in the efegatran treated patients.

CONCLUSION

Administration of efegatran sulphate at levels of at least 0.63 mg. kg(-1). h(-1)provided an anti-thrombotic effect which is at least comparable to an activated partial thromboplastin time adjusted heparin infusion. There was no excess of major bleeding. The level of thrombin inhibition by efegatran, as measured by activated partial thromboplastin time, appeared to be more stable than with heparin. Thus, like other thrombin inhibitors, efegatran sulphate is easier to administer than heparin. However, no clinical benefits of efegatran over heparin were apparent.

Age at natural menopause in a population-based screening cohort: the role of menarche, fecundity, and lifestyle factors

OBJECTIVE

To verify whether a population-based hypothesis (age at menarche and age at natural menopause have an inverse relationship) also applies at the level of the individual and to investigate what other factors predict age at natural menopause.

DESIGN

Prospective cohort study (the Doorlopend Onderzoek Morbiditeit/Mortaliteit [DOM] project).

SETTING

Prevention Breast Cancer Screening Centre, Utrecht, The Netherlands.

PATIENT(S)

A cohort of 3,756 Dutch women, born between 1911 and 1925, participating in a population-based breast cancer screening program, who experienced a natural menopause. Three samples of women were studied: a sample who did not use oral contraceptives (OCs) (n = 3,347), a sample of OC users (n = 409), and a combined sample of OC users and nonusers (n = 3,756).

MAIN OUTCOME MEASURE(S)

Age at menopause and menarche, fertility patterns, OC use, height, weight, smoking, and demographic variables.

RESULT(S)

No relation was found between age at menarche and age at natural menopause. The total percentage of variance in age at natural menopause explained by multiple regression including all factors was minimal, ranging from 1.3% to 9.7% in OC users. Linear regression analysis indicated a slight secular trend in age at menopause.

CONCLUSION(S)

Frisch's hypothesis could not be corroborated at the individual level. These results suggest that age at menarche and menopause should be treated as independent risk factors for breast cancer. Modification of age at menopause by lifestyle factors (except possibly for OC use) appears minimal.

Cardiac depression after experimental air embolism in pigs: role of addition of a surface-active agent

OBJECTIVE

Air bubbles entering the coronary artery may have harmful effects on cardiac function. From the physical point of view it is the relatively high surface tension of the blood-air interface which causes bubbles to trap in small vessels. The aim of the present study was to reduce depression of myocardial function from air embolism by lowering the surface tension of air bubbles.

METHODS

The effect of using antifoam as a surface-tension-reducing agent on air bubble entrapment and cardiac function was investigated in 6 anesthetized pigs (27 +/- 1 kg) and analyzed using a two-compartment diffusion model. Air bubbles with a diameter of 150 microns were selectively injected into the left anterior descending coronary artery (LADCA) in a carrying fluid in the presence or absence of antifoam. Myocardial systolic segment shortening in the LADCA region (SS-LADCA) was measured by sonomicrometry. Presence of emboli was detected by measuring the amount of reverberation of ultrasound scattered by trapped air bubbles.

RESULTS

SS-LADCA transiently decreased after injections of air bubbles in both the absence and presence of antifoam. However, in the presence of antifoam the regional depression recovered to normal sooner, the average depth of the depression was reduced, and bubbles from the embolized area cleared faster. These observations can be explained by a model derived from Laplace's law.

Estimated gain in life expectancy. A simple tool to select optimal reperfusion treatment in individual patients with evolving myocardial infarction

Currently several modes of reperfusion therapy for acute myocardial infarction are available. Streptokinase, accelerated alteplase and direct angioplasty are the most frequently used. These options are increasingly effective, but are also increasingly complex and costly. Since, unfortunately, physicians are often restricted by budget limitations, choices must be made in clinical practice to provide optimal therapy to individual patients. In order to guide such decision making, we developed a model to predict the expected benefit of therapy in terms of gain in life expectancy. Patients' life expectancy will decrease after infarction. Part of this loss can be prevented by early reperfusion therapy. The clinical benefit of therapy ranges from negligible gain in patients with small infarcts treated relatively late to an expected gain of more than 2 years in patients with extensive infarction treated within 3 h of onset of symptoms. The expected benefits are presented in a set of tables and depend on age, previous infarction, estimated infarct size, treatment delay and intracranial bleeding risk. With the help of these table, resources will be allocated in such a manner that patients who will benefit the most will receive the most effective therapy. Patients with similar expected treatment benefit will be offered the same mode of therapy. Future life years were discounted at 5% per year. The arbitrary thresholds currently applied for decision making at the Thoraxcenter are: no reperfusion therapy when the estimated gain in discounted life expectancy was < 1 month, streptokinase for 1-4 months and accelerated alteplase for a gain > or = 5 months. Direct angioplasty is recommended in patients with an estimated gain > or = 12 months, and in patients with an increased risk of intracranial bleeding. In this way, approximately 80% of our patients will be treated with thrombolytics (40% streptokinase and 40% accelerated alteplase), while in 10% direct angioplasty will be initiated. Patients with small infarcts presenting late will not receive reperfusion therapy. These threshold values have been chosen arbitrarily, and different thresholds may be selected in other centres. However, the developed model would guarantee that treatment decisions are made in a consistent manner, to provide optimal therapy for patients with evolving myocardial infarction, in spite of limited resources.

[Quality of life following coronary surgery and balloon angioplasty; more chest pain and social inhibition following angioplasty]

OBJECTIVE

To determine the differences in quality of life between patients who had a coronary artery bypass graft (CABG) and patients who had a percutaneous transluminal coronary angioplasty (PTCA).

DESIGN

Comparative and prospective study.

SETTING

Rotterdam, the Netherlands.

METHOD

91 patients with multi-vessel coronary disease who had been randomised to CABG (n = 37) or PTCA (n = 54), as participants in the CABRI study (Coronary angioplasty or bypass revascularisation investigation) completed several psychological questionnaires. Besides, the severity of angina pectoris after the procedure was estimated using the Canadian Cardiovascular Society score. In a subpopulation of 36 patients (CABG:14; PTCA:22) the quality of life just before the intervention was measured, also using psychological questionnaires.

RESULTS

A significant difference in angina pectoris was found between the two groups. The PTCA group experienced more chest pain (p < 0.01), at an average of 2.6 years after the intervention. The quality of life aspects did not differ between the two groups, except for 'social inhibition' (p < 0.05): the PTCA group experienced more problems and had less energy (p < 0.01). No significant differences between the PTCA and CABG groups were found regarding to the change in quality of life caused by the intervention.

CONCLUSION

The persistent angina pectoris and social inhibition among patients who have had a PTCA need further study.

[Tertiary crowding in the lower front teeth. Two observations]

Tertiary crowding, especially in the lower dentition, is shortly discussed. Two cases are illustrated that show the uncertainty regarding the often stated influence of the third molars in this respect.

Abnormal left ventricular early diastolic filling during dobutamine stress Doppler echocardiography is a sensitive indicator of significant coronary artery disease

OBJECTIVES

This study was designed to assess changes in Doppler indexes of left ventricular ejection and filling in response to high dose (40 micrograms/kg body weight per min) dobutamine stress and their utility in detection of coronary artery disease compared with that of new wall motion abnormalities.

METHODS

Ten patients with a low likelihood of coronary artery disease served as a control group, and 23 patients with documented single-vessel coronary artery disease underwent baseline and peak dobutamine echocardiographic and Doppler studies.

RESULTS

In both groups dobutamine induced similar increases in heart rate and systolic blood pressure. During the test, 14 patients had new wall motion abnormalities, 13 had angina, and 7 had electrocardiographic ST segment changes. No markers of ischemia occurred in the control subjects. Dobutamine induced qualitatively similar changes from baseline to peak dobutamine stress in control subjects and patients in peak aortic velocity (46% vs. 42%, p = NS), average aortic acceleration (61% vs. 43%, p = 0.03) and systolic time-velocity integral (7% vs. 2%, p = NS). Dobutamine caused marked increases in control subjects and decreases in patients in peak early filling velocity (E) (33% vs. -22%, p < 0.0001) and average E acceleration (76% vs. -28%, p < 0.0001). The response of Doppler early filling indexes to dobutamine stress was abnormal in all patients. There was no overlap in the percent change from baseline to peak dobutamine stress between control subjects and patients for E and E acceleration.

CONCLUSIONS

During dobutamine stress testing, an abnormal response of Doppler indexes of left ventricular early filling is a more sensitive marker of significant single-vessel coronary disease than are new wall motion abnormalities, and it is far superior to the response of Doppler ejection variables as a predictor of coronary artery disease.

Effect of arterial blood pressure and ventilation gases on cardiac depression induced by coronary air embolism

In this study the time course of cardiac depression after selective intracoronary injection of air bubbles was investigated in six anesthetized pigs (30 +/- 2 kg) with different mixtures of ventilation gases and different mean arterial blood pressures (MAP). Air bubbles of 150 microns diam were injected into the left anterior descending coronary artery (LADCA) in a volume of 2 microliters/kg body wt. In each animal an injection of air bubbles was applied during ventilation with N2-O2 and a MAP of 77 +/- 3 mmHg (N2-O2/low pressure) or 111 +/- 3 mmHg (N2-O2/high pressure) and during ventilation with pure O2 and a MAP of 77 +/- 3 mmHg (O2/low pressure) or 110 +/- 3 mmHg (O2/high pressure). Systemic hemodynamic variables such as left ventricular pressure, its peak first derivatives, and MAP changed < 10% after injection of air bubbles. During N2-O2/low pressure, systolic segment length shortening in the LADCA region (SS-LADCA) decreased from baseline and did not return to baseline within the 10 min after injection of air bubbles. During N2-O2/high pressure and O2/low pressure, SS-LADCA was decreased between 60 and 120 s, whereas for O2/high pressure this period was from 60 to 90 s. By calculating the time integral of the deviation from baseline of SS-LADCA, it could be demonstrated that the depression of regional myocardial function was less severe during O2/high pressure and O2/low pressure than during N2-O2/low pressure. We conclude that, when coronary air embolism occurs during hypertension and during ventilation with pure O2 instead of a normal N2-O2 mixture, the resulting depression of regional myocardial function is reduced.

Temporary tricuspid valve detachment in closure of congenital ventricular septal defect

In a consecutive series of 149 patients with congenital ventricular septal defect (VSD), temporary tricuspid valve detachment was applied in 39 (detached group) to facilitate the transatrial approach for closure of the defect. Baseline characteristics showed that, preoperatively, the detached group were younger (1.3 +/- 2.3 vs. 3.5 +/- 4.1 years, P = 0.002), shorter (0.67 +/- 0.20 vs 0.87 +/- 0.34 m, P = 0.001), lighter (6.9 +/- 5.4 vs 13.5 +/- 12.0 kg, P < 0.002), and had a higher mean right atrial pressure (6 +/- 2 vs 4 +/- 3 mm Hg, P < 0.003), mean end-diastolic right ventricular pressure (10 +/- 3 vs 8 +/- 3 mm Hg, P < 0.01) and mean pulmonary vascular resistance (267 +/- 202 vs 170 +/- 131 dyn s cm-5, P < 0.02) on cardiac catheterization. At surgery the aortic cross-clamp time was longer (48 +/- 17 vs 39 +/- 15 min, P = 0.003). Seven patients died (2 detached, 5 not-detached), from causes not related to either tricuspid detachment or VSD closure. Follow-up was complete with a mean duration of 2.0 years (range 0.1-5.5). All 142 survivors were investigated by echocardiography, which showed normal tricuspid valve function in all but 29 patients who had trivial regurgitation (6 detached, 23 not-detached). There was no tricuspid stenosis. In 30 patients (8 detached, 22 not-detached) a trivial residual VSD could be detected. One reoperation (not-detached) was performed 12.5 months after the initial surgery for recurrent VSD.(ABSTRACT TRUNCATED AT 250 WORDS)

[The treatment of myocardial infarction during the hospital stage and shortly thereafter: now and 10 years ago]

OBJECTIVE

Comparison between the early and the late eighties of the application of thrombolysis and revascularisation in the acute phase of a myocardial infarction.

LOCATION

University Hospital, Rotterdam.

DESIGN

Prospective with historical comparison.

METHODS

All patients admitted between May 1987 and May 1990 with a myocardial infarction and aged up to 71 years were included (n = 430). Numbers of procedures and survival during the following year were compared with data of patients admitted from 1981 to the end of 1983 (n = 706).

RESULTS

In 1981-1983 thrombolytics were administered to 9% of the patients, in 1987-1990 to 40%. Revascularisation procedures during the next year were performed in 17% and 50% of the patients respectively. Hospital mortality decreased from 14% to 10% (p < 0.05), one-year survival increased from 75% to 83% (p < 0.05). For patients from 1987-1990 one-year survival was higher after thrombolysis treatment: 90% versus 78% without (p < 0.01), and after revascularisation: 94% versus 87% without (p < 0.01).

CONCLUSION

Compared with 1981-1983 the treatment is at present more directed towards reperfusion and revascularisation of the ischaemic myocardium, resulting in invasive treatment in 50% of the patients now as opposed to 25% in the early eighties. The survival rate during the first year has improved.

[Treatments of Class II-patients with headgear]

Treatments with headgears are illustrated. Some theoretical aspects are discussed. A correct period of wear, as well as a reserve in magnitude of forces is strongly advocated.

[Spontaneous corrections and orthodontic treatment]

Spontaneous corrections in orthodontic anomalies can sometimes be expected, when all hindrances are eliminated, and the relevant teeth are given every freedom. Although there seems to be no exact explanation for the corrections some speculations are presented. Advantages and disadvantages are discussed.

Perceptions of dentofacial morphology by laypersons, general dentists, and orthodontists

Line drawings of facial profiles and color photographs of dentitions were evaluated subjectively by 1,150 parents, 72 general practictioners of dentistry, and 54 orthodontists with regard to the normality and abnormality in dentofacial morphology and the need for orthodontic treatment. A significant difference was found between the evaluations of the parents and the professional groups in ten of the 11 facial profiles and in seven of the 11 photographs of dentitions. In general, the parents considered more of the examples acceptable and not requiring orthodontic treatment than did the professional groups. The dentists and orthodontists deviated significantly in their ratings onjy in their judgement of "ugly duckling" example (picture 22, higher abnormal rating by the dentists) and the profile example 10 (higher abnormal rating by orthodontists). number of orthondontists may have associated the conditions in picture 10 with a Class II, Division 2 malocclusion and, as such, scored it abnormal.

Effect of soft tissues on radiographic measurements of the head

Measurements on standardized lateral radiographs of monkey heads and subsequently of the dried skulls did not show statistically significant differences. The error of the method in the heads was on the average six times greater for the linear dimensions and four times greater for the angular dimensions than those in the skulls.