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Cardiology speCialMngmnt o cronc trl brlltonstrtg or prvnton o CVd
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Fdg-peT n bt cncpoC ut
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The MagaziNe For healThCare deCisioN Maker
Week news updates onwww.ihe-onine.com
Volume 35 Issue 4IHE Sepember 2009
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Te dramatic incr
ease in the average
lie expectancy o
the Western popula
tion over the last ewdecades is generally
attributed to the pro
vision o basic inrastructure eatures
such as clean water and ecient drains
as well as to steady medical and surgi
cal advances in the treatment o many
previously atal diseases. In the con
text o the increase in lie expectancy,
it is an all the more sobering act that
today some obese young adults will
lose up to 20 years o lie expectancy
i they dont drastically reduce their
weight. Despite the huge press atten tion that is directed to healthy living
and the desirability o maintaining
a reasonable weight, the acts show
that, especially in certain lower socio
economic classes, there is a stubborn
increase in the rates o obesity. It
seems that voluntary eorts to modiy
diets and liestyle have very little eect
on what can now best be described as
an obesity epidemic. All this is part
o the background to the dramatic
increase in the numbers o bariatric
surgical interventions that are now
being undertaken specically to causeweight loss.
Currently bariatric surgery or weight
loss is recommended or patients with
BMIs o at least 40 or with patients
whose BMI is 35 but who have seri
ous coexisting medical conditions. Te
other part o the explanation is that now
outdated bariatric surgical procedures
have been replaced by much improved
and saer laparoscopic procedures. O
course even such improved techniques
are not risk ree; the question is what is
the exact level o risk. Te precise level
o short term saety associated with the
various generally used bariatric surgi
cal procedures has been addressed by
a recently published study, namely the
Longitudinal Assessment o Bariatric
Surgery, LABS, (New England Journal
o Medicine July 2009; 361;5: 520).
Te overall death rate in patients under
going bariatric surgery was ound to be
0.3%, and 4.1% o patients had major
complications. Tese data are very sim
ilar to those seen in other major opera
tions. Unortunately, designed as it was
or the study o short term saety, thetrial did not allow hard conclusions as
to precisely which surgical procedures
were the best. Likewise the real ques
tion, namely do the clinical outcomes
justiy the risk, was not addressed by
the trial. Other data do exist howeverwhich suggest that remarkable long
term improvements can be achieved
with bariatric surgery, e.g. the Swed
ish Obese Subject (SOS) study which
showed a 23.7% reduction in mortal
ity while yet other case controlled
studies showed improvements as great
as 40% in long term mortality in
patients undergoing bariatric surgery.
It is tempting to combine the separate
saety and outcome studies to comeup with the conclusion that bariatric
surgery should be actively encouraged
and perhaps extended to slightly less
obese patients. Already the question
now being asked is whether society
can aord such surgical approaches or
what is aer all a condition that could
otherwise be solved by dietary sel
control and lie style changes. Given
the huge costs incurred by not treat
ing obesity, the real question should becan we aord not to extend bariatric
surgery, the one approach that seems
to be eective?
Baiaic sugey: he sluin he besiy epiemic?
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ISSN 1471-2806
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6 Issue N4 Sept. 2009
Worldwide, breast cancer is the most common
malignant neoplasm in woman, with its high inci
dence and associated mortality making the diseasea correspondingly important public health prob
lem. According to the GLOBOCAN database o
the International Agency or Research in Cancer
(IARC) data, the global incidence o breast cancer in
2002 was as high as 1,151,298 cases with the disease
being responsible or as many as 410, 712 deaths .
Positron emission tomography (PE) is one o
the techniques used in the diagnosis o breast
cancer. Tis relatively non invasive, exploratory
technique provides physiological inormation
on the uptake o glucose and its metabolism. Te
technique involves the injection o a radioactive
tracer, usually fuorodeoxyglucose (FDG), thatemits positrons. Although in itsel not a new tech
nique, PE is o growing interest as a means o
oncological imaging.
Diagnosis o primary tumoursTe ability o FDG PE to diagnosis primary
tumours in women suspected o having breast can
cer appears to vary widely, with sensitivities ranging
rom 48% to 95.7%. Te sensitivity o the technique
appears to be lower when the tumours are small (
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Issue N4 Sept. 20097
Te regional uptake o FDG has been reported to be
reduced in tumours that respond to the rst cycle o
chemotherapy, and to become signicantly reduced
aer the second cycle (P
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reecing he impance he subjecan he inees in i, he numbe pee-
eviewe papes cveing pin--caeesing is huge, such an exen ha iis equenly ifcul healhcae p-essinals keep up wih he lieaue.
As a special sevice u eaes, IHEpesens a selecin lieaue absacs,chsen by u eiial ba as beingpaiculaly why aenin.
Use saliva-base nan-bichip ess acue mycaial inacin a hepin cae: a easibiliy suy.
Floriano PN et al.Clin Chem 2009; 55(8): 1530-8.
Tis paper investigated the easibility and util
ity o saliva as an alternative diagnostic fuid or
identiying biomarkers o acute myocardial in
arction (AMI). Luminex and lab on a chip meth
ods were used to assay 21 proteins in serum and
unstimulated whole saliva obtained rom 41 AMI
patients within 48 hours o chest pain onset and
rom 43 apparently healthy controls. Data were
analysed to evaluate the diagnostic utility o each
biomarker, or combinations o biomarkers, or
AMI screening.Both established and novel cardiac biomarkers
demonstrated signicant dierences in concen
trations between patients with AMI and controls
without AMI. Te saliva based biomarker panel
o C reactive protein, myoglobin and myeloper
oxidase exhibited signicant diagnostic capability
and, in conjunction with ECG, enabled eective
screening or AMI comparable to that o the panel
(brain natriuretic peptide, troponin I, creatine
kinase MB, myoglobin), ar exceeding the screen
ing capacity o ECG alone. Tese whole saliva
tests were adapted to a novel lab on a chip plat
orm or proo o principle screens or AMI. Te
authors conclude that as a complement to ECG,
saliva based tests within lab on a chip systems
may provide a convenient and rapid screening
method or cardiac events in prehospital stages
or AMI patients.
Peicin an managemen bleeing in caiac sugey.
Despotis G et al.J romb Haemost 2009; 7 Suppl 1: 111-7.
Excessive bleeding aer cardiac surgery can result
in increased morbidity and mortality related totransusion and hypoperusion related injuries
to critical organ systems. Te objective o this
study was to review mechanisms that result in
bleeding aer cardiac surgery as well as current
and emerging interventions to reduce bleedingand transusion. Te authors demonstrated that
point o care tests o haemostatic unction can
acilitate the optimal management o excessive
bleeding and reduce transusion by acilitating
administration o specic pharmacological or
transusion based therapy and by allowing phy
sicians to better dierentiate between microvas
cular bleeding and surgical bleeding. Te authors
consider that while emerging interventions such
as recombinant FVIIa have the potential to reduce
bleeding and transusion related sequelae and
may be lie saving, nevertheless randomised, con
trolled trials are needed to conrm saety beorethey can be used as either rst line therapies or
bleeding or bleeding prophylaxis. Careul investi
gation o the role o new interventions is essential
since the ability to reduce use o blood products,
to decrease operative time and/or re explora
tion rates has important implications or overall
patient saety and healthcare costs.
Pin--cae assessmen aniplaeleagens in he peipeaive pei:a eview.
Gibbs NM.
Anaesth Intensive Care 2009; 37(3): 354-69.
Te aim o this paper was to review the strengths
and limitations o current point o care tech
niques or the detection o antiplatelet drug eects.
Te review was based on a Medline search or arti
cles with key words related to platelet unction
tests, point o care, and anaesthesia, published
in English between January 1996 and September
2008.Te authors ound that global assessments o
haemostasis are not specic or platelet unction
and are essentially insensitive to cyclooxygenase
inhibitors and P2Y12 antagonists. Global assess
ments o platelet unction are more specic or
platelet unction, but also have limited sensitivity
or cyclooxygenase inhibitors and P2Y12 antago
nists. Te newer devices developed specically or
the assessment o antiplatelet drugs, such as Platelet
Mapping, the Impact Cone and Platelet Analyser
and the VeriyNow, are more promising, but are
not as sensitive as laboratory platelet aggregom
etry. All three categories o devices detect G(p)
II(b)/III(a) antagonist activity, but not all provide
quantitative assessments or monitoring therapy.
Te limitations appeared to be related to the com
plexity o platelet unction, the multiple pathways
o platelet activation, the wide interpatient variabil
ity in platelet responses and the interdependencebetween platelets and other aspects o coagulation.
Te authors conclude that the strengths and
limitations o point o care devices should be
appreciated beore they are used to assist clinical
decision making in the perioperative period.
the limiains pin--caeesing panemic inuenza:wha clinicians an public healh
pessinals nee knw.
Hatchette TF et al.Can J Public Health. 2009; 100(3): 204-7
Many governments have made signicant unding
commitments to infuenza vaccine developmen
and antiviral stockpiling. Te authors consider that
while these are essential components o a response
to pandemics, rapid and accurate diagnostic testing
remains an oen neglected cornerstone o pandemic
infuenza preparedness. Te benets and drawbacks
o dierent infuenza tests in both seasonal and
pandemic settings need to be understood. Culturehas been the traditional gold standard or infuenza
diagnosis but requires rom 1 10 days to generate a
positive result, compared to nucleic acid detection
methods such as real time reverse transcriptase
polymerase chain reaction (R PCR). Although the
currently available rapid antigen detection kits can
generate results in less than 30 minutes, their sensi
tivity is suboptimal and they are not recommended
or the detection o novel infuenza viruses. Te
authors conclude that until point o care (POC)
tests are improved, the best option or pandemic
infuenza preparation is the enhancement o nucleic
acid based testing capabilities.
Point-o-care testing in microbiologythe advantages and disadvantages oimmunochromatographic test strips.
Strenburg E, Junker R.Dtsch Arztebl Int. 2009; 106(4): 48-54.
his study describes the current technical status
o Point o Care esting (POC), giving some
examples, and summarises the speciic advan
tages and disadvantages o the POC approach
in microbiology. he conclusions are that the
test systems available today are technically
mature and oer good to very good perorm
ance. For HIV, malaria, group A streptococci
and legionellae, POC, when indicated, is on a
par with conventional procedures. he inor
mation yielded by rapid tests or pneumococc
and or inluenza tends to be supplementary in
nature. he rapid test or group B streptococc
is unsuitable or routine use because its sensi
tivity is still too low compared with bacteria
culture. POC can be successul only i the tests
are perormed correctly by trained personnel
quality management procedures are ollowed
and the severity o illness and the epidemiolog
ical circumstances are taken into account wheninterpreting the results.
LItErAtUrE rEVIEW Issue N4 Sept. 2009 8
Pin--cae esing
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Issue N4 Sept. 200911PoINt-oF-CArE: NEWS IN BrIEF
Point-o-care test or long termprognosis o patients with chronicliver disease
Researchers at the Hadassah Hebrew University
Medical Centre in Israel have developed an eec
tive new tool or assessing the prognosis o patients
with chronic liver disease, which could have impor
tant implications in determining which patients
are the most appropriate candidates or liver trans
plantation. Previously, prognosis in patients with
chronic liver disease has been determined by usinga combination o blood tests.
Studying 575 patients with varying types and
degrees o liver disease, the investigators showed
that a rapid, non invasive 13C Methacetin breath
test could predict which patients would develop
complications that would aect their prognosis.
Te test can also be used in acute liver disease
to determine liver unction on a daily basis and
determine how well therapy is working.
Researchers believe that the accuracy o the test,
and its capacity to assess liver unction, makes the
breath test a potentially powerul new tool in pre
dicting prognosis o liver related complications,
prioritising patients or organ transplantation andpredicting their ability to survive surgery.
www.hadassah.org.il/english
Point-o-care tests and training incommunication skills can help cutover-prescribing o antibiotics
In a major new clinical trial, published in the
British Medical Journal, a team o researchers
rom Cardi Universitys School o Medicine,
together with researchers rom the Maastricht
University Medical Centre in the Netherlands,
ound that those General Practitioners in pri
mary care who made use o a simple point
o care blood test, and those who underwent
training in advanced communications skills,
prescribed ewer antibiotics or lower respira
tory tract inections, which requently do notrespond to antibiotics.
As the problem o bacteria resistant to antibiotic
treatment grows, researchers are seeking ways
to improve the quality o antibiotic prescribing.
Prescribing antibiotics only when patients will
clearly benet reduces the pressure that drives
antibiotic resistance. Te clinical trial thereore
sought to evaluate ways that antibiotic prescrib
ing could be reduced without adversely aecting
patient recovery or satisaction with care. Te trialevaluated an illness ocussed approach, where
clinicians seek to better understand the patients
illness experience and communicate more eec
tively about management, and a disease ocussed
approach, where clinicians ocus on diagnosis, in
this case, a simple point o care test or C reac
tive protein (NycoCard II Reader; Axis Shield,
Norway). A result can be available within three
minutes, using a drop o blood obtained by n
ger prick. Te value o C reactive protein in ruling
out serious bacterial inection was emphasised.
Te trial randomised 20 general practices in the
Netherlands, where 40 GPs managed 431 patientswith lower respiratory tract inection.
Te results showed that 54% o GPs practising
according to usual care prescribed antibiotics,
whereas 27% o those who had been trained in the
advanced communication and 31% o the GPs who
used the point o care blood test methods did so.
Only 23% o GPs who were trained in the advanced
communication skills and who used the blood test
prescribed antibiotics. Importantly, the results also
showed that prescribing ewer antibiotics did not
mean that patients were unwell or longer. Patient
recovery and satisaction with care were not
compromised by GPs not prescribing antibiotics.
www.cardi.ac.uk
Point-o-care nanosensors or HIVdiagnosis and monitoring to bedevelopedTe London Centre or Nanotechnology will
develop a new device to enable people living with
HIV to monitor their own health and the eec
tiveness o their treatments, thanks to a 2 mil
lion EPSRC (Engineering and Physical Sciences
Research Council) grant. Te device will will act
as an early warning system to alert patients o the
need to seek medical help i the virus is resisting
anti retroviral treatments. It could also be o real
benet to doctors in developing countries who
urgently need rapid and aordable ways to diag
nose and monitor their patients.
Researchers rom the London Centre or Nanote
chnology, a joint venture between UCL (University
College London) and Imperial College London,
and their research partners have been awarded
the Nanotechnology or Healthcare grant rom
the EPSRCs Grand Challenge Competition. Te
research will bring biomedical engineers, physi
cists, chemists, virologists and clinicians together
to create the device, which will use nano canti
lever arrays to measure HIV and other protein
markers that can indicate a rise in the level o thevirus and the bodys response to it. Messages will
be displayed on an built in screen, giving patients
access to clear, immediate advice. For example
they could be told that their condition remains
stable i levels o virus do not change, or they
could be told to make an appointment to see thei
doctor i the virus begins to fare up. Te project
will be carried out over the next three years, with
the promise o additional unding.
www3.imperial.ac.uk
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A nvel caiacPEt imaging agen
d M. Yu &d S.P. rbinsn
Page 14
the assessmen healhcae pemanc
in CVd pevenind A. Lazzini &d S. Lazzini
Page 16
Managemen aecnl in chnicaial fbillain
d t. Niklaiu &P. K.S.Channe
Page 20
Cardiology SpecialSelection o peer-reviewed
cardiology literature SEPTEMBER2009
Cardiology
SpecialSeveal he laes cp ecenly-publishe pee-eviewe aicles in hescienifc an meical lieaue elae cailgy seem likely be pa-icula impance. In his egula lie-aue absacing sevice, IHE pviessummaies selece key papes inhe fel.
Relation between modifableliestyle actors and lietime risko heart ailure.
by djuss L et al.
JAMA 2009; 302(4): 394 - 400
Heart ailure is now recognised as the leading cause
o acute hospital admission and the most prevalent
chronic cardiovascular condition. Whats worse,
mortality rates aer the onset o heart ailure remain
high, ranging rom 20 50 per cent, despite improve
ments in medical and surgical management. In the
context o this bleak situation the recent results o a
huge long running prospective cohort study (1982
2008) involving no ewer than 20,900 men are very
encouraging in that the results show that adoption
o healthy lie style actors can signicantly reduce
the risk o heart ailure. Carried out by a group rom
the Brigham and Womens Hospital, Harvard Medi
cal School, the study assessed six modiable liestyle
actors: body weight, smoking, exercise, alcohol
intake, consumption o breakast cereals and con
sumption o ruits and vegetables on the lietime risk
o heart ailure. It was ound that men who exercised
regularly, drank moderately, did not smoke, were
not overweight, and had a diet that included cereal,
ruits and vegetables had a highly signicant lowerlietime risk o heart ailure.
High heart rate as predictor oessential hypertension.
by tjugen tB et al.
Prog Cardiovasc Dis 2009; 52(1): 20-5.
High heart rate has proven to be a strong pre
dictor or cardiovascular disease and a predictor
o the development o essential hypertension.
Because heart rate is highly infuenced by many
actors such as anxiety and physical activity,it is sometimes dicult to interpret the value
o heart rate measurement in individual per
sons. Tis article rom a team at the Cardiology
Department, Oslo University Hospital reviews
the debate as to whether heart rate itsel is a risk
actor or development o hypertension or just
a marker or sympathetic overactivation. What
ever the answer, the presence o elevated heart
rate in both hyperkinetic and hypertensive sub
jects makes it an interesting and easy measurable
prognostic marker.
Dual antiplatelet therapy and
antithrombotic treatment:recommendations and controversies.
by Byniaski L,et al.Cardiol J 2009; 16(2): 179-89.
Dual antiplatelet therapy is currently recom
mended or all patients with acute coronary
syndromes, independently o whether they are
receiving pharmacological treatment or under
going percutaneous coronary intervention.
Antiplatelet agents are the cornerstone o phar
macological treatment in interventional cardi
ology. However, there is a clear need or ran
domised trials to assess the treatment strategy
o dual antiplatelet therapy in patients who also
need long term antithrombotic treatment (such
as those with atrial ibrillation, prosthetic heart
valve, mitral valve regurgitation or stenosis,
deep vein thrombosis, pulmonary embolism,
or pulmonary hypertension). In this paper the
authors discuss trials and analyses on the use o
dual antiplatelet treatment in combination with
antithrombotic therapy in particular diseases,
with a ocus on the risk o haemorrhagic events
connected with this treatment, as well as recent
guidelines o the European Society o Cardiol
ogy, the American College o Cardiology, andthe American Heart Association.
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14 Issue N4 Sept. 2009 CArdIoLoGY
Cardiac imaging procedures such as echocardi
ography, computer tomography (C), magnetic
resonance imaging (MRI) and nuclear imaging
are non invasive and readily accepted by patients.Imaging with C and MRI provides excellent ana
tomical inormation. However, nuclear imaging
presents an opportunity to examine changes at
the molecular, cellular and organ levels, including
perusion, metabolism and viability in the heart.
Nuclear imaging can be used to detect cardiac
changes allowing early diagnosis beore clinical
symptoms are evident, to evaluate the eectiveness
o treatment and to predict disease progression.
Nuclear myocardialperusion imagingNuclear myocardial perusion imaging (MPI)
is carried out to assess alterations in perusionassociated with coronary heart disease such as
myocardial inarction (non reversible perusion
deect) and ischaemia (reversible perusion
deect). MPI under rest and stress conditions has
been increasingly utilised over the past decade [1,
2]. Currently, it is dominated by three MPI agents:99mc sestamibi, 99mc tetroosmin and 201Tallium
(201l), used with single photon emission com
puted tomography (SPEC). Although the value
o perusion imaging with these agents to guide
clinical decisions has been proven, some limita
tions exist. Tese include lack o accurate attenu
ation correction, poor image quality in obese
patients, and, in the case o 201l, redistribution.
Most importantly, the myocardial uptake o these
SPEC agents is proportional to regional blood
fow under resting condition. However under
stress conditions, the uptake plateaus at regional
myocardial blood fow above 2 mL/min/g. Tus,
SPEC imaging with these perusion agents has
the potential to underestimate myocardial blood
fow under stress conditions (the roll o phe
nomenon). Tis underestimation compromises
the capability o these agents to detect mild
coronary artery stenosis.
MPI with positron emission tomography (PE)has emerged as an accurate alternative to SPEC.
PE has several signicant advantages over
SPEC, including higher spatial resolution, accu
rate attenuation correction and the capability to
quantiy myocardial perusion into mL/min/gtissue. However, the current PE MPI tracers
(82rubidium chloride, 13nitrogen ammonia and15oxygen water) all have a short isotopic hal
lie requiring on site production (cyclotron or
generator), thus limiting the duration o dynamic
imaging and/or causing a low signal to noise ratio
(particularly with 82Rubidium, whose hal lie is
1.3 min). Tus, an ideal MPI agent should have
myocardial uptake that is proportional to bloodfow, even at high fow rates under stress condi
tions, and be a PE emitter with a hal lie that
allows central unit dose distribution.
A novel myocardial perusionimaging agentDeveloped as a PE based MPI agent, BMS747158
is an 18F labelled 2,5 disubstituted pyridazinone
that binds the highly abundant mitochondria
complex I o the myocardium. It has been [3]
With a hal lie o 110 minutes this 18F labelled
agent can be radiosynthesised centrally and deliv
ered to hospitals. Cardiac imaging in rats, rabbitspigs, nonhuman primates and human subjects
with this agent shows high myocardium uptake
and allows accurate identication o the perusion
decit area [3, 4, 5]. More importantly, in an iso
lated heart preparation, the myocardial extrac
tion o the new agent is higher and correlates bet
ter with fow at a wide range o fow rates than
currently available SPEC MPI agents, such as99mc sestamibi and 201thallium [Figure 1].
In a recent study in pigs, the myocardial perusion
measured by PE imaging with BMS747158 cor
related well with fow as quantied by the micro
sphere technique, the gold standard or fow quan tication, both at rest and stress conditions [4]
Tese ndings suggest that this agent possesses
an improved chemical prole with less roll
o than is observed with the current SPEC
MPI agents.
Cardiac imaging withBMS747158 and FDG undervarious experimental conditionsFluorodeoxyglucose (FDG) is an 18F labelled
glucose analogue that is a substrate or glucose
transporters. It has been used with cardiac PE
imaging to assess myocardial metabolism and
tissue viability. Cardiac images o FDG have
been used in conjunction with perusion agent
images to identiy viable tissue in myocardia
perusion deicit regions (mismatch) [6]. he
mismatch is helpul in predicting the beneicia
eect o surgical revascularisation in patients
with myocardial perusion deect.
In a recently published study [7], the impacts
o eeding state and anaesthetic use on cardiac
imaging and uptake o BMS747158 and FDG
were compared in rats. Rats were either ed
with a normal diet (control group) or were ood
deprived or 20 hours (asted group) and wereanaesthetised either with sodium pentobarbita
A nvel caiac PEt imaging agenFluexyglucse (FdG) is a well-esablishe PEt imaging agen use in cail-gy assess evaluain mycaial meablism an viabiliy. Hweve inake an anesheics use have been shwn aec he upake by he he hea
of FDG. A novel cardiac PET imaging agent (BMS747158) is being developed toassess mycaial peusin in iagnsis an pgnsis cnay hea isease.the new imaging agen has been shwn have a bee imaging pfle han hecuenly available SPECt agens. Unlike FdG, he image qualiy is n aece by inake an use anaesheics.
by d Ming Yu an d Simn P. rbinsn
Figure 1. Upper panel: representative cardiactomographic images o BMS747158 in control ratsand rats with coronary ligation and in a nonhumanprimate. Images are presented in cardiac short-axis
(doughnut shaped) and long-axis (horse shoe shaped)views. The myocardium is clear in the rats and theprimate and there is easy identication o perusion
decit areas in rats with coronary ligation.Lower panel: heart uptake o BMS747158 com-pared to the currently available perusion imaging
agents 201Thalium and 99mTc-sestamibi, ollowingincreasing coronary perusion low rates in an isolated
rabbit heart preparation. It can be seen that the
correlation with perusion fow o the heart uptake oBMS747158 is better than with the other two agents.
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Issue N4 Sept. 200915
(control group) or ketamine and xylazine (xyla
zine group). Blood glucose levels were 12210
mg/dL in the control group and about 25% lower
in the ood deprived group. Anaesthesia with
pentobarbital did not change the blood glucose
levels; however, ketamine and xylazine markedly
increased the levels by 215% at 60 minutes aer
injection. Cardiac imaging with FDG showed
clear myocardium in the control rats, but the
heart was barely visible in the asted rats [Fig
ure 2]. Te heart uptake o FDG was also mark
edly lower in the rats anaesthetised with keta
mine and xylazine. In contrast, imaging with
BMS747158 demonstrated a well dened myo cardium with minimal background intererence
under all experimental conditions.
FDG transport into cardiac myocytes, like glu
cose, is regulated by the transmembrane glucose
gradient and the insulin regulated glucose trans
porter on cell membranes. Te apparently para
doxical nding o low FDG heart uptake at both
low (asted group) and high (xylazine group)
blood glucose levels (i.e. low and high transmem
brane glucose gradient) could be the consequence
o insulin. Food deprivation lowers plasma glu
cose and insulin levels, and consequently the
insulin regulated transporter unction in the
myocardium is decreased. In contrast, xylazine
has been reported to act as an 2 agonist and
inhibit the secretion o insulin rom the pancreas
[8]. Tis results in reduced insulin levels and low
insulin regulated glucose transporter unction,
which causes a decreased FDG heart uptake
and elevated blood glucose levels. However, the
consistent uptake o BMS747158 independent
o eeding status and anaesthesia use in rats sug
gests this perusion agent will not be infuenced
clinically by these physiological alterations.
Under ischaemic conditions, the heart uptake oglucose increases in anaerobic regions that are
viable, not necrotic, [9]. he mismatch o dam
aged areas detected by cardiac imaging with a
perusion agent like 99mc sestamibi and FDG
has been used to identiy viable tissue in the
perusion deicit area. Identiication o viable
tissue is critical or determination o a revas
cularisation procedure in patient care. With
enhanced spatial resolution and quantiication
capability o PE, imaging with BMS747158and FDG should provide greater accuracy than
the current SPEC agents or the determination
o tissue viability in ischaemic regions.
Prospect and conclusionBMS747158 is currently in phase II clinical
trial as a PE based MPI. As compared to cur
rently available SPEC agents, heart uptake o
the new agent correlates better with perusion
low at cardiac stress conditions, which may
enable better detection o mild coronary ste
nosis. Moreover, the agent exploits the advan
tage o PE technology over SPEC. With PEperusion quantiication, the new agent may
allow diagnosis o balanced 3 vessel disease
in the heart which has been a limitation or
SPEC imaging. With PE attenuation correc
tion, the agent may also permit more accurate
determination o perusion deects with mini
mal intererence o attenuation artiacts. With
the enhanced image quality shown in pre and
clinical studies, the agent may enable better
delineation o the let ventricular wall to acili
tate generation o anatomical and unctional
inormation. Indeed, unctional inormation,
like the ejection raction measured by nuclear
MPI has been shown to correlate closely withthat measured by cardiac MRI.
In summary, FDG has been used with PE
imaging to assess myocardial metabolism and
tissue viability. Feeding status and anaesthesia
have been demonstrated to inluence the heart
uptake o FDG. BMS747158 is a new genera
tion o MPI agent or PE imaging. In con
trast to FDG, the physiological changes do not
inluence heart uptake. Due to the improved
imaging proile, clinical use o this MPI agent
in the near uture should provide better diag
nostic and prognostic inormation or heart
disease stratiication.
Reerences1. Clark AN, Beller GA. he present role o nuclear
cardiology in clinical practice. Q J Nucl Med Mol
Imaging 2005; 49(1): 43 58.
2. Beller GA, Bergmann SR. Myocardial perusion
imaging agents: SPEC and PE. J Nucl Cardiol
2004; 11(1): 71 86.
3. Yu M, Guaraldi M, Mistry M et al. BMS 747158
02: a novel PE myocardial perusion imaging
agent. J Nucl Cardiol 2007; 14(6): 789 798.
4. Nekolla SG, Reder S, Saraste A et al. Evaluation
o the novel myocardial perusion positron emission tomography tracer 18F BMS 747158 02:
comparison to 13N ammonia and validation with
microspheres in a pig model. Circulation 2009
119(17): 2333 2342.
5. Maddahi J, Schiepers C, Czernin J et al. Fris
human study o BMS747158, a novel F 18 labelled
tracer or myocardial perusion imaging. J Nuc
Med 2008; 49(Supplement 1): 70P.
6. Beller GA. Assessment o myocardial perusion
and metabolism or assessment o myocardial via
bility. Q J Nucl Med 1996; 40(1): 55 67.
7. Yu M, Guaraldi M, Bozek J et al. Eects o ood
intake and anesthetic on cardiac imaging and
uptake o BMS747158 02 in comparison with
FDG. J Nucl Cardiol 2009.
8. Abdel el Motal SM, Sharp GW. Inhibition o glu
cose induced insulin release by xylazine. Endo
crinology 1985; 116(6): 2337 2340.
9. Schwaiger M, Neese RA, Araujo L et al. Sustained
nonoxidative glucose utilization and depletion o
glycogen in reperused canine myocardium. J Am
Coll Cardiol 1989; 13(3): 745 754.
The authorsMing Yu, MD PhD and Simon P. Robinson, PhD
Discovery Research
Lantheus Medical Imaging
331 Treble Cove Rd
N. Billerica, MA 01862, USA
e-mail: [email protected]
Tel: 1-978-671-8142
e-mail: [email protected]
www.ihe-online.com & search 45317
Figure 2. Representative cardiac short-axis imageso BMS747158 in comparison with FDG in rats
under control and ood deprived (asted) conditions.Cardiac images o FDG were clear in the control rat,but barely visible in the ood deprived rat. In contrast,the myocardium is well dened when imaged with
BMS747158 under both conditions.
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16 Issue N4 Sept. 2009 CArdIoLoGY
In recent years interest in and the attention given
to the prevention o cardiovascular diseases haveincreased exponentially. Tis is o course due not
only to the direct relevance and eect o cardio
vascular disease on the health and well being o
individuals but also to the signicant eects that
CVD has on the global economy [1, 2].
Research and studies carried out by the World
Health Organisation (WHO), show that CVD is
currently one o the major causes o death and
disability throughout the world. It has been esti
mated that between 2006 and 2015, deaths due to
cardiovascular diseases are expected to increase
by 8,5%; this is in stark contrast to the predicted
trend over the same period or deaths rom otherpathologies such as inectious diseases, nutri
tional deciencies, and maternal and perinatal
conditions, which are estimated to decline by 3%.
Data in the scientic literature show clearly that,
when present in the same subject, the combination
o most o the individual risk actors results in a
multiplicative increase in the overall risk associ
ated with cardiovascular disease (CVR) [3, 4, 5].
Research has also established that risk reduction
programmes are eective i individuals adhere
to the recommended or prescribed regimes [6].
Unortunately, however there is a requent lack o
compliance with such risk reduction programmes.
Burke et al [7] estimated that 50% o individuals
withdraw rom cardiac rehabilitation programmes
within the rst year, and that 50% o hyperten
sion patients discontinue their medication within
the rst year o treatment. Tere is also a signi
catively high rate o relapse in smoking cessation
programmes: about 79% o participants abandon
the programmes in the rst six months.
Efciency, eectiveness and quality:the main goals o a well-structuredtherapy processIn most Western countries expenditure on healthcare amounts to a large percentage o national
Gross Domestic Product (GDP). In addition,
healthcare related expenditure is increasing ata worrying rate [Figure 1]. Te nancial impact
o all this highlights the importance o the need
to manage healthcare and healthcare resources
using established management criteria, including
the introduction o perormance measurements.
Concepts such as eciency, eectiveness, equity
and quality have become amiliar in healthcare
organisations and those who work or them. Te
importance o these concepts is set to increase in
the near uture. Several rameworks have been
developed or ormulating guidelines to identiythe most suitable tools and measures to evaluate
healthcare perormance [8, 9]. Such a task is not
easy, since methodologically it is dicult to estab
lish a precise economic evaluation o the nan
cial burden on the community that is caused by
chronic diseases such as CVDs.
Starting rom the well known structure process
outcome model [10], we agree with the sugges
tion rom several authors o the need to widen
the concept o the disease cure process. Tus
the concept should not be limited to the cure
o acute diseases and to secondary preventionactivities, but should also include primary pre
vention and health promotion activities in th
community [11, 12]. While the concepts o health
and healthcare are separated rom a semantic
and pragmatic point o view, they are o course
strictly interrelated, with one o the major points
o contact between the two concepts being pri
mary disease prevention activities developed in
an attempt to modiy behaviours and liestyles
Many healthcare system providers believe that
Cuenly, inees in he pevenin caivascula iseases (CVd) an heaenin pai his hugely impan subjec by eseaches, physicians, plicy-makes an healh ganisains is inceasing expnenially. In many cunieshee is als a wying incease in healhcae expeniue elae CVd. In tus-cany, Ialy pil pjecs have been evelpe aime a pevening an eamencaivascula iseases.
by d A. Lazzini an d S. Lazzini
Figure 1. Total expenditure on health as a percentage o GDP. in selected countries.Source: OECD Fact book 2009
twas he assessmen healhcaepemance: CVd pevenin
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8/7/2019 IHE Sept09
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Issue N4 Sept. 200917
the most cost eective approach in the long run
lies in such prevention activities with the inevita
ble associated consequence o the need to adjust
health related behaviours.
One innovative model is the Chronic Care Model
(CCM), which describes some o the changes
in the structure and process that are needed to
improve the outcome in patients with chronicdisease [13, 14]. Te basic idea is that healthcare
systems can reach objectives in terms o:
a) eectiveness i they support the development
o getting patients better inormed and more
interested (sel management support);
b) eciency i they have proactive healthcare
teams (delivery system design);
c) quality i they avour interactions between the
various parties (decision support and clinical
inormation systems);
d) equity resulting rom the previous three
objectives.
From an organisational point o view, increases
in the eiciency o the system can be achieved
by changing rom a reactive approach, based on
the treatment and resolution o acute events,
to a proactive approach, based on prevention
strategies aimed at completely avoiding disease
or delaying its progression. his means that the
global assessment o CVR, inluenced as it is by
the simultaneous actions o many actors, will
replace the consideration o single risk actors.
In this context the general practitioner should
thereore ocus on carrying out primary preven tive actions aimed at reducing overall CVR. It is
evident that such an approach necessitates the
inorming patients so as to create sel awareness
o the health risks incurred by dangerous behav
iours and lie styles, thus enabling patients to
more eectively control their own health or ill
ness (sel management support). Such an activ
ity is not always easy, because patients sometimes
do not accept suggestions about their behaviour
and liestyles; in some cases communication
between the general practitioner and the patient
may cease altogether.
he Chronic Care Model implies an approach
centred on patients but moving rom a tradi
tional unctional approach based on specialisa
tion and separation, to a perspective based on
systems in which general practitioners, special
ists and paramedical personnel work together
as a unique team, with the common aim o
guaranteeing a more eicient and eicacious
health service.
In the practical implementation phase o such a
model in the real world, inormation and com
munication technologies (ICs) play a vital role
since by using IC it is possible to assess theoverall CVR associated with each patient. he
work load o each o the teams involved could
be eased through the creation o a medical card
or each patient on a health platorm, with the
possibility o it being shared on the web. Te
overall process could thus be simplied and
costs reduced by eliminating duplicated activi
ties and organising patient history and medical
chronology. Healthcare teams with access to the
database could also contact patients with specicneeds, deliver a planned therapy to them, receive
eedback on the perormance and exploit patient
reminder systems. Integrated management is the
vital platorm needed to improve the eciency,
eectiveness and quality o the cure process in
patients with CVDs.
An integrated approach tocardiovascular disease:the pilot projects o the Tuscanyregional health systemhe current Italian projects or the prevention
and cure o CVD are centred on changes in theconcept o health assistance rom a traditional
disease cure based model, which is physician
centred and ocused on acute therapy and is
characterised by a reactive approach to an
innovative model. his is chronic cure based,
patient centred, and the treatment is delivered
by a healthcare team. his model requires a net
work approach, where the dierent parts o the
system connect through mechanisms enabling
knowledge and inormation sharing.
In most Italian regions, the prevention and
treatment o CVD are still divided among sev
eral players with dierent competences andoperative responsibilities in dierent organisa
tional structures [15, 16]. A distinctive eature
o the uscany healthcare system is the atten
tion given to the prevention and cure o CVD,
with the relevant activities being considered as
a unique and integrated process.
he 2008 2010 uscan strategic health plan is
based on the awareness that, while the roles and
unctions o dierent personnel are observed
and recognised, the mutuality and interde
pendence o all relevant personnel is necessary
in order to achieve the inal results.
he main lines o action adopted by uscany to
manage CVDs in an integrated way are based
on two strictly correlated activities:
a) the assessment o CVR
b) the development o new organisational mod
els based on a network approach.
he strategies or lowering the risk actors are
ocused on i) the population level and ii) the
individual level.
At the population level, the lines o action are
based on the assumption that because a large
part o the population is exposed to a moderatelevel o CV global risk, an overall improvement
in liestyle would cause a signiicant reduction
in the probability o incurring CVD. he under
lying objective is to modiy dangerous behav
iours and liestyles, consequently reducing
the risk o CVDs.
At the individual level the policy is instead
aimed at identiying subjects who have a higher
probability o CVD, and thereby organis ing a preventive approach aimed at averting
the disease.
As ar as the assessment o individual risk is
concerned, uscany is widely recognised or
its achievement in the integrated assessment
o CVR using a pilot project called VIRC. his
was set up at the Institute o Clinical Physiol
ogy o Pisa and was based on the establishmen
o a clinical database that was accessible on the
web enabling the medical data relevant to the
management o patients in the ield o multi
disciplinary prevention o CVD to be viewedand assessed.
he calculation o CVR takes into considera
tion a number o variables, which, as well as the
usual risk actors related to liestyle, include
a series o other linked actors. he variables
considered include social economical actors,
physiological anamnesis; basic clinical indica
tors, psychosocial actors, amily anamnesis
and a complete report o past diseases.
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18 Issue N4 Sept. 2009 CArdIoLoGY
With regard to CVD, uscany has also encour
aged projects which bring about a deeper inte
gration between the dierent parties involved
in the process o prevention and cure [17, 18].
he major innovation related to the applica
tion o the CCM in Italy is the new and central
role played by primary prevention in the cure
o some chronic diseases. Cardiac decompen
sation has been considered o importance inCVR, and a series o standard processes has
been proposed, based on homogeneous char
acteristics that ollow the NYHA classiica
tion o such pathology. he horizontal model
speciies six major parties: the patient, the gen
eral practitioner, the cardiologist, the hospital
attendants, the dietician and the medical dis
trict. Within the model, the dierent parties are
linked transversally, and attention is paid to the
dierent contributions they oer to the patient.
he result is that the approach is matrix based,
with the tasks and unctions assigned to the
dierent parties changing on the basis o thepatients decompensation class. he various
roles played can be increased or reduced based
on a standardised therapy process.
For each therapy process, a patient drivenperspective is adopted, rom which theresponsibilities o the dierent parties areestablished In this perspective is the singleclinical demand: to require activities andresources. Particular attention is given totreatment traceability, which can be achievedby the electronic clinical medical card sharedbetween the parties, or by simpliication o
the process o admission to therapy.
ConclusionsTis paper has analysed the role played by car
diovascular prevention activities starting rom
the consideration that the healthcare expenditure
has been increasing dramatically in most o the
industrialised countries.
Te most consistent margins o action appear to
be linked to a reorganisation o prevention sys
tems [19]. Most o the healthcare systems opted
or a preventive welare model based on the spe
cialisation o their operators; this empowered the
systems, which could then achieve a precise artic
ulation o competencies and responsibilities. Tis
kind o model presupposes a vertical approach,
while the uture trends related to the adoption o
the CCM involve a horizontal perspective [20].
Reerences1. World Health Organization, Preventing Chronic Dis
eases: A Vital Investment, Geneva, Switzerland, 2005
2. Sassi F, Hurst J. he prevention o liestyle related
chronic diseases: an economic ramework, OECD
Health Working Papers, N.32, 2008
3. Grundy SM, Pasternak R, Greenland P, Smith S,
Fuster V. Assessment o Cardiovascular Risk by Useo Multiple Risk Factor Assessment Equations.
Circulation 1999; 100(13): 1481 92.
4. Wood D, De Backer G, Faergeman O, Graham I,
Mancia G, Pyrl K. Prevention o coronary heart
disease in clinical practice: Recommendations o
the Second Joint ask Force o European and other
Societies on Coronary Prevention. Atherosclerosis
1998; 140(2): 199 270.
5. Blane D et al. Association o Cardiovascular Dis
ease Risk Factors with Socioeconomic Position
During Childhood and During Adulthood. British
Medical Journal 1996; 313(7070):1434 8.
6. Burke LE, Dunbar Jacob J. Adherence to medica
tion, diet, and activity recommendations: From
assessment to maintenance. Journal o Cardiovas
cular Nursing 1995; 9(2): 62 79.
7. Burke LE, Dunbar Jacob JM, Hill MN. Compliance
with cardiovascular disease prevention strategies:
A review o the research. Annals o Behavioral
Medicine 1997; 19(3): 239 263.
8. WHO, Primary Health Care: a ramework or
uture strategic directions, Geneva: WHO, 2003.
9. Sibthorpe B. A proposed conceptual rameworkor perormance assessment in primary health
care, Canberra: Australian Primary Health Care
Research Institute, 2004.
10. Donabedian A. he quality o medical care.
Science 1978;200:85664.
11. Gakidou EE, Murray CJ, Frenk J. Deining and
Measuring Health Inequality: an Approach Based
on the Distribution o Health Expectancy. Bul
letin o the World Health Organization 2000;
78(1):42 54.
12. Homarcher M, Oxley H, Rusticelli E. Improved
health system perormance through better care
coordination OECD Health Working Papers,
N.30, 200713. Wagner EH, Davis C, Schaeer J et al. A survey o
leading chronic disease management programs: are
they consistent with the literature? Managing Care
Quarterly 1999; 7: 56 66.
14. Wagner EH. Chronic Disease Management: What
will it take to improve care or chronic illness?
Eective Clinical Practice 1998; 1(1): 2 4.
15. Del Bene L. Criteri e strumenti per il controllo
gestionale nelle aziende sanitarie, 2000, Milan
Giur.
16. Del Vecchio M. Le aziende sanitarie tra specializ
zazione organizzativa, deintegrazione istituzionale e
relazioni di rete pubblica, in Anessi Pessina, Cant
eds. Laziendalizzazione della sanit in Italia OASI
Report 2003, Milan, Egea.
17. Marin L. Dinamiche competitive ed equilibrio
economico nelle aziende sanitarie, 2001, Milan
Giur.
18. Grandori A. Knowledge governance mechanism
and the theory o the rms. Working paper 2003
University o Modena e Reggio Emilia.
19. Porter ME. A strategy or health Care Reorm
oward a value based System, Te New England
Journal o Medicine 2009; 10: 1056. Massachusett
medical society.
20. Anselmi L. Il processo di trasormazione della pub
blica amministrazione, Il percorso aziendale 1995
orin, Giappichelli.
The authorsArianna Lazzini, PhD,Researcher, Department o Social,
Cognitive and Quantitative Sciences,
University o Modena and Reggio Emilia,
Viale Allegri 9,
Reggio Emilia 42100,
Italy
e-mail: [email protected]
Simone Lazzini, PhD,
Researcher, Department o Business
Administration E. Giannessi ,
Via C. Ridol 10,
Pisa 56124,Italy
e-mail: [email protected]
Comments on this article?Feel free to post them at
www.ihe-online.com/comment/CCM
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Tis atlas provides
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Te basic principles o oesophageal surgery as
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20 Issue N4 Sept. 2009 CArdIoLoGY
Recent guidelines in rate control
managementAtrial brillation (AF) is the commonest cardiacarrhythmia and its incidence increases with age.
Considering that the population is ageing it is
important that treatment be sae and eective in
the elderly. Guidelines are usually based on clinical
trial evidence derived rom younger and healthier
participants. Tis evidence is not always directly
transerable to elderly patients. In this age group
the most common therapeutic strategy or AF is
rate control in combination with anticoagulation.
In June 2006, the UK National Institute o Clinical
Excellence (NICE) published new guidelines or
heart rate control in patients with chronic AF [1].Tese guidelines depart rom historical practice
by recommending that, instead o digoxin the pre
erred initial monotherapy in all patients, except
in predominantly sedentary patients, should be
adrenoceptor blockers or rate limiting cal
cium antagonists. Similarly, the revised 2006
joint American College o Cardiology/American
Heart Association/European Society o Cardiol
ogy (ACC/AHA/ESC) guidelines recommend the
use o blockers or calcium antagonists alone to
control heart rate [2]. Digoxin is recommended
in patients with heart ailure, le ventricular
dysunction or or sedentary individuals.
We have reviewed the clinical trial evidence and
challenge the saety o recent guidelines.
Treatment aims o rate control inchronic AFOptimal rate control in AF is dicult to dene.
It is aimed at reducing heart rate (HR) at rest and
exercise in order to prevent tachycardia induced
cardiomyopathy. It also aims to control heart rate
variability throughout the day (maximum minus
minimum HR) without causing excessive brady
cardia or pauses. From a clinical perspective,
treatment aims are to improve survival, symp
toms, exercise tolerance and quality o lie. Side eects o medication need to be weighed against
their benets. Co morbidities, such as hyperten
sion, heart ailure, ischaemic heart disease, val vular heart disease and peripheral vascular dis
ease, are also taken into account when selecting
appropriate rate limiting therapies.
Systematic review o the evidence inrate control managementWe have systematically reviewed the literature or
trials o digoxin, blockers or calcium antago
nists alone or in combination or managing rate
control in chronic AF [3]. Forty six trials met
eligibility criteria, o which 36 were randomised
controlled trials, one a cross over non ran
domised study, one a case control study and eight
were observational trials. Te published studiesare small, with the largest one recruiting 136 par
ticipants. Tey are also heterogeneous in protocol
design and drug dosages. Some studies employ
24 hour HR recordings while others utilise exer
cise testing. Side eects and symptom control are
not consistently reported. Te mean age across
studies ranges rom 48 74 years. We perormed a
qualitative analysis describing the evidence avail
able or blockers and calcium antagonists rst
as monotherapy and then as combination therapy
with digoxin.
DigoxinDigoxin has traditionally been used or rate con trol in AF. It acts primarily by exerting a vago
mimetic infuence on the atrio ventricular (AV)
node and has a positive inotropic eect, which is
benecial in patients with heart ailure. It has ew
side eects and a long hal lie, allowing once daily
dosing. However, digoxin has a fat dose response
curve and a narrow therapeutic index oen lead
ing to the use o sub therapeutic doses. It is less
eective at controlling heart rate during exercise
and in states o increased sympathetic activation
[4]. Channer et al ound that doubling serum
digoxin concentration improved HR control
but not HR variability, and daytime pauses weresignicantly prolonged [5].
-blockers alone and in combinationwith digoxin blockers have heterogeneous eects on HR con
trol depending on their specicity or the recep
tor and concomitant agonist activity. en studies
assessed blockers as monotherapy in control
ling HR in chronic AF. Only one study ound that
blockers improved resting HR compared to dig
oxin, while our studies ound improved exercise
HR. wo studies report improvement in exercise
tolerance with blockers alone while six ound no
change. Nineteen studies tried the combination o
blocker with digoxin. Combination treatment
resulted in improved HR control at rest and exer cise. However, the eect on exercise tolerance was
inconsistent with ve studies reporting deteriora
tion in exercise capacity, three reporting improve
ment and ten reporting no change. Khand et a
reported on the use o carvedilol in 47 patients
with AF and heart ailure [6]. When used alone
carvedilol did not improve HR or exercise toler
ance compared to digoxin. Withdrawal o digoxin
in these patients resulted in worsening heart ail
ure with deleterious eects. In the same study the
combination o digoxin with carvedilol improved
HR as well as le ventricular ejection raction.
Side eects o blockers reported in these stud ies include heart ailure, intermittent claudica
tion, arrhythmia, postural dizziness and bron
chospasm. wo studies reported worsening hear
ailure on withdrawal o digoxin [6, 7].
Diltiazem and verapamil alone andin combination with digoxinFive studies evaluated diltiazem as monotherapy
in HR control. When compared to digoxin
diltiazem was better at controlling exercise HR
but exercise capacity was not improved. Combi
nation o diltiazem with digoxin improved resting
and exercise HR, as well as 24 hour HR control.
Exercise tolerance was shown to improve in two o
eight studies. Maragno et alound that the com
bination o diltiazem with digoxin provided bet
ter mean 24 hour HR control compared to either
drug alone [8]. In two studies, HR control at rest
and exercise, as well as exercise tolerance, were al
improved when the combination o digoxin and
diltiazem was compared to digoxin alone [9, 10].
Seven studies examined monotherapy with
verapamil and three ound improved exercis
HR compared to digoxin. In two studies there
was improvement in exercise tolerance [11, 12]
When the combination o verapamil with digoxinwas assessed most trials ound improvement in
Aial fbillain is he ms cmmnly encunee ahyhmia in cailgy.recen guielines have ecmmene ha insea igxin, mnheapy wih -blckes ae-limiing calcium anagniss shul be fs-line eamen aecnl in chnic aial fbillain. We have eviewe he evience an un hacmbinain eamen igxin wih a -blcke calcium anagnis is meeecive an sae.
by d t. Niklaiu an P. K. S. Channe
Managemen ae cnl in chnicaial fbillain
-
8/7/2019 IHE Sept09
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Issue N4 Sept. 200921
resting and exercise HR compared to digoxin.
Tree studies also ound improvement in exercise
capacity, while our showed no change.
Diltiazem and verapamil have negative inotropic
eects and are also associated with signicant side
eects. Verapamil also reduces the clearance o dig
oxin resulting in higher digoxin concentrations. In
a study by Roth et al, 75% o participants showedat least one adverse reaction to diltiazem [13]. In
the same study one patient with mild heart ailure
developed worsening heart ailure aer discontinu
ation o digoxin while receiving diltiazem 360mg/
day. Side eects o verapamil in the studies included
bradycardia, deranged liver unction tests, impo
tence, peripheral oedema, arrhythmia and heart ail
ure. In a study by Schwartz et al, two patients with
a previous history o heart ailure decompensated
aer commencing verapamil treatment [14].
Conclusions
Digoxin has been the mainstay o treatment ormany years in patients with chronic AF, and new
treatment recommendations should be sae and
evidence based. Te evidence on managing rate
control comes rom small studies with varied
methodologies. A review o the literature shows
that the combination o digoxin with a blocker
improves HR control at rest and exercise
compared to digoxin alone.
However, there is also evidence that blockers
may worsen exercise capacity and need to be used
cautiously. Te combination o digoxin with a
non dihydropyridine calcium antagonist results in
improved HR at rest, exercise and over 24 hours
compared to digoxin. It may also improve exercisecapacity. Side eects o blockers and calcium
antagonists are dose related. Combining these
drugs with digoxin has a synergistic eect on rate
control and allows smaller doses to be used. Large
randomised trials directly comparing treatment
options with an emphasis on symptom control, exer
cise capacity and quality o lie are needed to inorm
uture practice. We recommend that combination
treatment with digoxin and a blocker or calcium
antagonist should be rst line management.
Reerences1. National Collaboration Centre or Chronic Conditions.
Atrial brillation: national clinical guideline or man
agement in primary and secondary care. London: Royal
College o Physicians, 2006.
2. Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB,
Ellenbogen KA, et al. ACC/AHA/ESC 2006 guidelines
or the management o patients with atrial brillation
executive summary: a report o the American College
o Cardiology/American Heart Association ask Force
on Practice Guidelines and the European Society o
Cardiology Committee or Practice Guidelines (Writing
Committee to Revise the 2001 Guidelines or the Man
agement o Patients With Atrial Fibrillation). J Am Coll
Cardiol 2006;48(4):854 906.
3. Nikolaidou , Channer KS. Chronic atrial brillation: a
systematic review o medical heart rate control manage
ment. Postgrad Med J 2009;85(1004):303 12.4. Koh KK, Kwon KS, Park HB, Baik SH, Park SJ, Lee KH,
et al. Ecacy and saety o digoxin alone and in combi
nation with low dose diltiazem or betaxolol to control
ventricular rate in chronic atrial brillation. Am J Car
diol 1995;75(1):88 90.
5. Channer KS, Papouchado M, James MA, Pitcher DW,
Rees JR. owards improved control o atrial brillation.
Eur Heart J 1987;8(2):141 7.
6. Khand AU, Rankin AC, Martin W, Taylor J, Gemmell I,
Cleland JG. Carvedilol alone or in combination with dig
oxin or the management o atrial fbrillation in patients
with heart ailure? J Am Coll Cardiol 2003;42(11):1944 51.
7. Lawson Matthew PJ, McLean KA, Dent M, Austin
CA, Channer KS. Xamoterol improves the control ochronic atrial brillation in elderly patients. Age Ageing
1995;24(4):321 5.
8. Maragno I, Santostasi G, Gaion RM, rento M, Grion
AM, Miraglia G,et al. Low and medium dose diltiazem
in chronic atrial brillation: comparison with digoxin
and correlation with drug plasma levels. Am Heart J
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9. Koh KK, Song JH, Kwon KS, Park HB, Baik SH, Park
YS, et al. Comparative study o ecacy and saety o
low dose diltiazem or betaxolol in combination with
digoxin to control ventricular rate in chronic atria
brillation: randomized crossover study. Int J Cardio
1995;52(2):167 74.
10. Lundstrom , Ryden L. Ventricular rate control and
exercise perormance in chronic atrial brillation
eects o diltiazem and verapamil. J Am Coll Cardio
1990;16(1):86 90.
11. suneda , Yamashita , Fukunami M, Kumagai K
Niwano S, Okumura K, et al. Rate control and quality
o lie in patients with permanent atrial brillation: the
Quality o Lie and Atrial Fibrillation (QOLAF) Study
Circ J 2006;70(8):965 70.
12. Pomret SM, Beasley CR, Challenor V, Holgate S. Rela
tive ecacy o oral verapamil and digoxin alone and in
combination or the treatment o patients with chronic
atrial brillation. Clin Sci (Lond) 1988;74(4):351 7.
13. Roth A, Harrison E, Mitani G, Cohen J, Rahimtoola
SH, Elkayam U. Ecacy and saety o medium and
high dose diltiazem alone and in combination withdigoxin or control o heart rate at rest and during exer
cise in patients with chronic atrial brillation. Circula
tion 1986;73(2):316 24.
14. Schwartz JB, Keee D, Kates RE, Kirsten E, Harrison
DC. Acute and chronic pharmacodynamic interaction
o verapamil and digoxin in atrial brillation. Circula
tion 1982;65(6):1163 70.
The authorsDr eodora Nikolaidou MRCP(UK) MBChB
(corresponding author)
Research Fellow
Royal Hallamshire Hospital
Glossop Road, Shefeld S10 2JFUK
Proessor Kevin S Channer MD FRCP
Consultant Cardiologist and Physician
Royal Hallamshire Hospital
Glossop Road, Shefeld S10 2JF
UK
New web-base cailgy PACS
Most current cardiology
service providers are ham
pered by the need or phy
sicians to log onto multiple
systems to review patient
images and data; accessing
prior exams rom DVD
or tape libraries is time
consuming and inecient. Tese actors can lead to delayed diagnosis and
treatment. o address such issues, Carestream Health has launched a new web
based cardiology PACS that oers a single integrated platorm or diagnosis,
image review and reporting or echocardiography, cardiac catheterisation and
nuclear cardiology procedures as well as electrocardiogram management. Te
new cardiology PACS system enables providers to consolidate isolated cardiac
lab systems into a centralised solution to achieve both greater eciency and
lower costs. Te PACS client also enables productive reading o cardiology data
rom any on site or o site networked PC. Clinicians benet rom a convenient
and productive review o multiple cardiac studies and resultsalong with easy
access to prior exams. Te new cardiology PACS oers structured reporting
templates or all cardiovascular applications (cath, echo, vascular and nuclear)
with point and click access to pre dened statements along with digital sig
natures. Tere are comprehensive measurement tools or echocardiography
applications, including the ability to import measurements taken at the modal
ity. An ECG management solution includes a time saving worklist and the abil
ity to integrate to multi vendor ECG carts. Also available are catheterisation
reporting tools such as coronary tree annotations or stenosis, stent and gra
locations to eliminate dictation and provide a single tool or reporting o echo,
cardiac cath and nuclear cardiology. In addition, there are many nuclear car
diology eatures, including web based gated SPEC wall motion review, a 3D
cine and localiser tool, as well as viewing and reporting tools.
CareStream HealtHrchs, nY, USa
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8/7/2019 IHE Sept09
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www.medicalfair.cz
MEDICAL FAIR BRNO CENTRAL EUROPE
REHAPROTEXInternational Fair for Medical Technology, Rehabilitation and Healthcare
20.23. 10. 2009Brno Exhibition Centre, CZ
Supported by Messe Dsseldorf
Organizer of MEDICA and REHACARE BVV Trade Fairs Brno
Vstavit 1
647 00 Brno
Czech Republica
Tel.: +420 541 152 818
Fax: +420 541 153 063
www.medicalfair.cz
Third largest fair on European continent of a high standard of quality guaranteed by its association with the MEDICA
Group chain - the trade fair company Messe Dsseldorf.
One of the most important specialist fairs of medical technology, equipment of hospitals, healthcare centers
and subsequent rehabilitation incl. prosthetics in the area of EU new and member countries
The REHAPROTEX segment it presented a broad assortment of compensation, prosthetic, orthopedic and rehabilita-
tion equipment and is unrivalled in the Central-European area.
A number of specialised conferences, seminars and international congresses will be held during MEDICAL FAIR Brno
which will be attended by more than 5,000 specialists from the Czech Republic and other countries
16-year tradition of medical fairs in Brno!
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8/7/2019 IHE Sept09
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ProdUCt NEWS Issue N4 Sept. 200923
Point-o-care ultrasound systemA versatile tool or vascular and endovascular
surgeons, the M urbo point o care ultrasound
system oers high quality rapid imaging or both
clinical assessments and ultrasound guided pro
cedures. Te system allows abdominal, nerve,
vascular, cardiac, venous access, pelvic and
supercial imaging. Excellent image quality is
obtained with sharp contrast resolution and
clear tissue delineation. With SonoHD imaging
technology, enhanced colour fow and soon an
optional new SonoRemote control, the M urbo
has 16 times the processing power o the compa
nys previous generation model and still weighs just around 3 kg. Te system
boots in seconds rom a cold start and has been drop tested rom a metre.
It is simple to use and clean, as a sealed, fuid resistant interace allows
thorough disinection.
SonoSite ltd
Hch, Hs, UKwww.ihe-online.com & search 45328
Multi-beam OCT scannerUsing the high resolution capability
o Michelson Diagnostics proprietary
technology, the VivoSight multi beam
OC scanner provides state o the
art images o skin and other surace
tissue through the use o a compact
ergonomically designed hand held
probe. Te probe is designed or useon external tissue, such as or imaging
skin microstructure, with an isotropic resolution o better than 10 m to a
depth o up to 2 mm. Scan rates vary rom 6.5 ps to 35 ps depending on the
scan width, which, in turn, can be varied up to 5 mm. Te probe has ull x y
scanning capability enabling rapid capture o 3D IFF ormat image stacks
up to 5 mm x 5 mm, with a pixel size o 4 m. A specially designed adjusta
ble stand o enables image capture rom awkward locations without subject
discomort. Te soware is designed to be quick and easy to understand and
use, and does not require an in depth understanding o OC.
miCHelSon diagnoStiCS ltd
o, K, UK
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Wireless technology platormWith the introduction o Mortara Instruments Wireless Acquisition Module
(WAM) or resting ECG, a new go wireless technology platorm is avail
able. Te platorm is comprised o Mortaras proprietary technology that is
specically designed to oer an equivalent or lower cost alternative to wired
designs in ECG applications. Te technology is optimised or diagnostic
ECG acquisition with simple conguration, long battery lie and robus
transmission protocols to be integrated into a wide array o ECG acquisi
tion products. Te WAM is the rst go wireless product or resting ECG
acquisition to be introduced, and is a high delity diagnostic ECG acquisi
tion module with integrated go wireless capabilities enabling transmission
to Mortara ELI electrocardiographs. At the touch o a button an ECG can
be acquired or rhythm strip initiated. Te wireless capability eliminates thetraditional expensive and bulky ECG cable and allows caregivers greater
reedom o movement while acquiring electrocardiograms. Te WAM
is targeted to simply replace traditional patient cable designs.
mortara inStrUment, inC.
mwuk, Wi, USa
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FroNt CoVEr ProdUCt
Optical navigation system or minimally-invasivesurgical procedures
Physicians increasingly
use modern navigation
technologies or surgi
cal interventions. TeCappa C Nav rom Sie
mens Healthcare oers
an optical navigation
system that is especially
suitable or spinal as
well as trauma surgery.
Te new navigation system enables surgeons to perorm interven
tions with greater saety and precision. Additionally, the method
minimises radiation exposure to the patient as well as the OR sta.
Precision is a substantial pre condition in the OR in general, and espe
cially or spinal and trauma surgery and orthopaedics. In spinal surgery
the new method helps to accurately position pedicle screws in the spine;
in orthopaedics navigation technology is used to support online visualisa tion during stabilisation o degenerated bones. Prior to the operation, the
surgeon creates a 3D X ray data set o the region o interest. Tis data set
is used like a map or orientation during surgical intervention. Te sur
geon navigates during the operation by using optical tracking via a special
stereo camera, and is able to use the navigation system easily by him/her
sel via a sterile user interace. Te surgical instruments and patients body
region o interest are provided with dierently arranged small refecting
marker spheres. Te camera continuously acquires the position o these
spheres and inorms the navigation system o their location. Tis enables
the surgeon to proceed with even greater accuracy during the operation
by virtually testing the length o the screws, or example. In addition, the
ability to continuously check the progress and results o an operation may
prevent the need or a second surgical intervention. Cappa C Nav is opti
mally tailored or the mobile C arm Arcadis Orbic 3D and, i needed, canbe retrotted or these systems.
SiemenS ag
e, gy
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8/7/2019 IHE Sept09
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ProdUCt NEWS Issue N4 Sept. 2009 24
Small but powerul patient monitor
Te new LieWindow Lite monitor rom Digicare
Biomedical echnology is small in size but big in
perormance. Designed with only world class vital
signs modules, the new system delivers unprec
edented perormance and reliability. Several
options o measurement modules are available;
these congurable, upgradable, additional mod
ules can be installed at any time. Te operation
o the monitor by touch screen is intuitive and all
monitored vital signs are stored and can be trans erred to clinical inormation systems. Connec
tion to the companys central monitoring station
is totally wireless or up to 16 bedside monitors.
Remote viewing and control is possible.
digiCare BiomediCal
teCHnologY, inC.
By Bch, Fl, USa
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Improved nuclear cardiologyperormanceGE Healthcares recently launched nuclear car diology platorm based on Alcyone technol
ogy combines cadmium zinc telluride (CZ)
detectors, ocused pin hole collimation, 3D
reconstruction and stationary data acquisi
tion, to improve worklow, dose management,
and overall image quality. he new Alcyone
technology will be available on GE Healthcares
Discovery NM 530c and Discovery NM/C
570c systems. Alcyones heightened sensitiv
ity and zero equipment motion improves both
image quality and energy resolution, ena
bling the potential or new clinical applica
tions including 3D dynamic acquisitions and
simultaneous dual isotope imaging.
With conventional nuclear cardiac imaging,
patients must hold their arms above their heador two scans that take between 15 20 minutes
each. With the Discovery NM 530c, the scan
ning time is reduced to 3 5 minutes or each
scan. his reduction in time can mean less
pain or the patients caused by the uncomort
able position, and can also reduce the likeli
hood o any patient movement caused by such
pain, which can result in artiacts in the scan.
he Discovery NM/C 570c can perorm a
complete cardiac scan in less than ive minutes
including myocardial perusion imaging (MPI),
Computed omographic Angiography (CA),
and calcium scoring (CaSC).
ge HealtHCare
Chf S gs, UK
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Demand-compatible resuscitatorTe proven COM
BIBAG resuscita
tor rom Wein
mann can now
be used with a
demand valve.
Patients can now
receive 100% oxy
gen via the resus
citator. ried and
tested over the
years, the COM
BIBAG eatures practical recessed grips or use
in paediatrics. Te smaller volumes are appro
priate or the ventilation o small children.Use
o the same resuscitator or adults and children
saves space in the emergency case or backpack.
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FroNt CoVEr ProdUCtComplete MR-based prostatepackage
Oering a new imaging and intervention
option or patients with elevated and/or
rising PSA levels, the irst complete MR
based solution or the analysis, planning
and interventional biopsy o prostate cases
has been introduced to the market by the UScompany Invivo. he new system has been
developed over the past ive years through
close collaboration between the company
and selected prestigious clinical centres
throughout the world. Extensive evaluation
o the sotware, with its comprehensive set
o advanced prostate image visualisation