February 14th, 2011
How Hospitals View Cardiology Groups
Westby G Fisher, MD
CardioExchange welcomes this guest post, reprinted with permission, from Dr. Westby Fisher, an electrophysiologist practicing at NorthShore University HealthSystem in Evanston, Illinois, and a Clinical Associate Professor of Medicine at University of Chicago’s Pritzker School of Medicine. This piece originally appeared on his blog, Dr. Wes.
It is no surprise that hospitals are acquiring cardiology and primary care groups in droves lately, as described in this article from Becker’s Hospital Review. It seems that, for now, there is a signficant financial incentive for hospitals to do so, but doctors, and especially cardiologists, should read the tea leaves, exemplified by this advice to hospitals in another article:
While hospitals are limited to paying fair market value for practices, they can gain an edge over competing hospitals by offering longer employment contract terms or better electronic medical record systems and management services. If hospitals move forward with a transaction, Ms. Kaplan suggests they limit employment contracts to no more than two years if possible and rebase compensation annually based on productivity.
“In healthcare you shouldn’t assume anything is permanent,” says Ms. Kaplan. She cautions that the revenue increases that are currently available to hospitals through expanding outpatient cardiology services may not last forever, which is why she urges hospitals to limit employment contracts and other agreements to only a few years. Doing so will afford an “out” for the hospital if the service line goes from a money-maker to a money pit.
-Wes
February 11th, 2011
SCAST Trial Provides No Support for Blood Pressure Lowering in Acute Stroke
Larry Husten, PHD
Lowering blood pressure with an angiotensin-receptor blocker in patients with acute stroke and hypertension produces no benefits, according to a new study presented at the International Stroke Conference and published simultaneously online in the Lancet. In the Scandinavian Candesartan Acute Stroke Trial (SCAST), investigators randomized 2029 acute stroke patients in 9 north European countries who had a systolic blood pressure of 140 mm Hg or higher to candesartan or placebo.
At 6 months, the rate of vascular death, MI, or stroke was not significantly different between the two groups (120 events in the candesartan group versus 111 events in the placebo group, p=0.52). In addition, functional outcome at 6 months as assessed by the modified Rankin Scale was not significantly different between the groups, though a trend suggested a worse outcome in the candesartan group (p=0.048).
The investigators concluded that unless other ongoing trials suggest otherwise, “we see no place for routine blood-pressure lowering treatment in the acute phase of stroke.”
In an accompanying comment, Graeme Hankey writes that the results of the trial, taken with the results of previous trials, suggest that “pharmacologically lowering blood pressure does not have an overall beneficial effect on functional outcome” and that therefore “clinicians should… not be prescribing blood-pressure-lowering drugs within the first week of acute stroke in routine practice.”
February 10th, 2011
What’s Keeping Us from Using FFR?
Richard A. Lange, MD, MBA and L. David Hillis, MD
A recent study of PCI in subjects with multivessel CAD showed that procedure costs were lower when a management strategy based on the results of fractional flow reserve (FFR) measurements was employed. The FFR-based strategy resulted in fewer stents used, which more than offset the cost of the FFR pressure wire.
Even though FFR-guided PCI has been shown to improve outcomes, it appears to be underutilized. We want to know how often you use FFR when angiography demonstrates a coronary stenosis of “intermediate” severity (i.e., < 75% narrowing).
If you don’t use FFR in most cases, is it because FFR (1) prolongs the procedure, (2) is of questionable benefit, or (3) is too costly? Or, do you have another reason and if so, what is it?
February 10th, 2011
Apixaban Better Than Aspirin for Stroke Prevention in AF Patients Unable to Take Warfarin
Larry Husten, PHD
A new trial presented at the American Stroke Association’s International Stroke Conference and published online in the New England Journal of Medicine demonstrates that the novel factor Xa inhibitor apixaban is better than aspirin for the prevention of stroke in AF patients who are unable to take warfarin. Stuart Connolly and investigators in the AVERROES (Apixaban Versus Acetylsalicylic Acid [ASA] to Prevent Strokes) trial randomized 5599 AF patients who were deemed by their physicians to be unsuitable for vitamin K antagonist therapy to either apixaban (5 mg twice daily) or aspirin (81-324 mg per day). Results of the trial were first presented last year at the ESC.
AVERROES was stopped early by the data and safety monitoring committee after they observed “a clear benefit in favor of apixaban.” Stroke or systemic embolism, the primary outcome of the trial, occurred in 51 patients receiving apixaban compared to 113 receiving aspirin. Here are the rates per year and hazard ratios of the important endpoints:
- Primary outcome: 1.6% per year in the apixaban group versus 3.7% in the aspirin group (HR 0.45; 95% CI 0.32-0.62, p<0.001)
- Death: 3.5% per year versus 4.4% (HR 0.79, 95% CI 0.62-1.02, p=0.07)
- Major bleeding: 1.4% per year versus 1.2% (HR 1.13, 95% CI 0.74-1.75, p=0.57)
- First hospitalization for cardiovascular cause: 12.6% per year versus 15.9% (p<0.001)
The authors calculated that treating 1000 patients for 1 year with apixaban instead of aspirin would prevent 21 strokes or systemic emboli, 9 deaths, and 33 hospitalizations for cardiovascular causes, but would cause 2 additional major bleeds.
The AVERROES investigators pointed out that warfarin is not taken by one-third of patients who are considered “ideal candidates” for the drug: “The reluctance of patients to use a vitamin K antagonist is not surprising, given the inconvenience of INR monitoring, the lifestyle changes required, and the real and perceived difficulties associated with warfarin therapy.”
A separate trial, ARISTOTLE, a direct comparison of warfarin and apixaban in AF, is scheduled to be completed in April of this year.
February 9th, 2011
Trial Finds Benefit in Wireless Pulmonary Artery Monitoring in HF
Larry Husten, PHD
Results of a new trial suggest that an implanted device that provides continuous wireless sensing of pulmonary artery pressures can reduce hospitalizations in patients with heart failure (HF). In a report published online in the Lancet, William Abraham and members of the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Patients) Trial Study Group randomized 550 patients with NYHA class III HF to receive either the CardioMEMS heart sensor or conventional therapy.
After six months, there were 83 HF-related hospitalizations in the treatment group versus 120 in the control group — a 30% reduction. At 15 months, the reduction in HF-related hospitalizations reached 39%. There were no pressure-sensor failures and 8 patients had a complication related to the device.
The authors concluded that the “trial represents the first positive, randomized, adequately powered clinical trial of implantable hemodynamic monitoring in patients with moderately symptomatic HF. The addition of information about pulmonary artery pressure to clinical signs and symptoms allows for improved HF management and leads to a reduction in HF-related hospitalizations.”
In an accompanying comment, Henry Krum wrote that “the CardioMEMS device seems to be a simple but ingenious piece of bioengineering. Its simplicity lies in its smallness and ability to derive and transmit clinically useful data (continuous pulmonary artery pressures), via an implantation procedure that seems to add very little in terms of time or risk to that of standard right-heart catheterization.” Nevertheless, he questioned whether there should be “rapid uptake” of the device and said that “we are still some way off” from “widespread or routine” use of the device.
February 8th, 2011
FDA Approves First Pacemaker Designed For Use with MRI
Larry Husten, PHD
The FDA has approved Medtronic’s Revo MRI SureScan Pacing System, the first pacemaker designed for safe use during MRI exams. Here is Medtronic’s description in a press release of how the pacemaker differs from traditional pacemakers:
“The pacemaker system includes hardware modifications to the device and leads that are designed to reduce or eliminate several hazards produced by the MRI environment. In addition, since MRI scanners may cause other current pacemakers to misinterpret MRI-generated electrical noise and withhold pacing therapy or deliver unnecessary pacing therapy, this new pacemaker includes a proprietary SureScan feature that sets the device into an appropriate mode for the MRI environment.”
“FDA’s approval of the Revo pacemaker represents an important step forward toward greater device innovation,” said Jeffrey Shuren, director of the FDA’s Center for Devices and Radiological Health, in an FDA press release. “Those patients who meet the parameters for the device will be able to maintain their critical cardiac therapy while benefiting from the precise diagnostic capability of an MRI.”
According to Medtronic, every year about 200,000 pacemaker patients in the U.S. are forced to skip a medically indicated MRI exam.
February 8th, 2011
Biomarker Levels Post-CABG Strongly Linked to Mortality
Larry Husten, PHD
Creatine kinase (CK-MB) and troponin levels obtained in the first day after CABG are a strong predictor of long-term mortality, according to a new report appearing in JAMA. Michael Domanski and colleagues analyzed data from 7 studies that included 18,908 patients who underwent CABG and for whom data on biomarkers and mortality were available. Mortality was closely correlated with peak CK-MB levels: the 30-day death rate ranged from 0.63% for those with a CK-MB ratio below 1 to 7.06% for those with a CK-MB ratio over 20. In a multivariate model, CK-MB was the strongest predictor of mortality and persisted out to 1 year.
Here is the increase in relative risk by CK-MB category (relative to those with CK MB <1):
- CK-MB ratio 1 to <5: 1.69 RR
- CK-MB ratio 5 to <10: 2.98 RR
- CK-MB ratio 10 to <20: 4.47 RR
- CK-MB ratio 20 to <40: 8.73 RR
- CK-MB ratio >40: 27.01 RR
“Although enzyme elevations are common following CABG surgery, our data make clear that the long-term prognosis is worse for patients who experience even a small elevation of CK-MB than those who do not experience such a increase,” the authors wrote.
February 7th, 2011
The Fellowship Training Blog Moves Into the Trenches
James De Lemos, MD
Andy and I would like to formally welcome John Ryan, who is a second year fellow at the University of Chicago Medical Center, to the Fellowship Training blog at CardioExchange. John has already made several contributions to the blog. Many of you will remember his blogs at the AHA meeting, where he introduced us to his favorite restaurants and shared his experiences of presenting for the first time at a major scientific conference. We’re delighted to have a regular forum for John’s unique perspectives on fellowship training, as well as for a fellow’s perspective on the major happenings in modern cardiology. John will assume the role of co-moderator with Andy and me, and he will be posting regularly to the Fellowship Training pages.
We know that John’s contribution will help broaden our coverage. What would you like to see on the Fellowship Training blog?
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