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Biomedical subjects

M Pfisterer

Publications and source records attributed to M Pfisterer.

At least 19 recordsLinked to original sources
PubMed2006

Rationale and design of ACTIVE: the atrial fibrillation clopidogrel trial with irbesartan for prevention of vascular events.

BACKGROUND: Atrial fibrillation (AF) is the most frequently occurring cardiac arrhythmia with often serious clinical consequences. Many patients have contraindications to anticoagulation, and it is often underused in clinical practice. The addition of clopidogrel to aspirin (ASA) has been shown to reduce vascular events in a number of high-risk populations. Irbesartan is an angiotensin receptor-blocking agent that reduces blood pressure and has other vascular protective effects. METHODS AND RESULTS: ACTIVE W is a noninferiority trial of clopidogrel plus ASA versus oral anticoagulation in patients with AF and at least 1 risk factor for stroke. ACTIVE A is a double-blind, placebo-controlled trial of clopidogrel in patients with AF and with at least 1 risk factor for stroke who receive ASA because they have a contraindication for oral anticoagulation or because they are unwilling to take an oral anticoagulant. ACTIVE I is a partial factorial, double-blind, placebo-controlled trial of irbesartan in patients participating in ACTIVE A or ACTIVE W. The primary outcomes of these studies are composites of vascular events. A total of 14000 patients will be enrolled in these trials. CONCLUSIONS: ACTIVE is the largest trial yet conducted in AF. Its results will lead to a new understanding of the role of combined antiplatelet therapy and the role of blood pressure lowering with an angiotensin II receptor blocker in patients with AF.

Aged↗
PubMed2006

Substantial intraindividual variability of BNP concentrations in patients with hypertension.

Plasma concentrations of B-type natriuretic peptides (BNP) independently predict the risk of death and cardiovascular events. In the present study, we investigated the intraindividual variability of BNP concentrations, a potential confounder of risk prediction. Consecutive outpatients with blood pressure (BP) values of at least 140/90 mm Hg and not taking BP lowering therapy were asked to participate. Exclusion criteria were renal insufficiency, structural heart disease on echocardiography, except left ventricular hypertrophy and any other severe concomitant illness. Plasma BNP levels were determined on two different days using the same assay. In total, 77 patients were included. Mean age was 54+/-12 years, 55% were male and mean systolic/diastolic BP was 163+/-16/96+/-8 mm Hg. Mean creatinine was 70+/-14 micromol/l. The median interval between the two BNP assays was 10 days (interquartile range 1-23 days). Median BNP concentrations were 17 and 16 pg/ml for the first and second visit, respectively (P=0.48). However, there was a wide range of differences in BNP values among individual patients, 34 patients (44%) having an absolute difference of at least 10 pg/ml. When patients were categorized according to tertiles of BNP levels, 25 (32%) changed from one tertile at the first visit to another at the second visit. In conclusion, these data indicate that BNP levels may be used on a population level. However, the high intraindividual variability seems to preclude useful risk stratification in the individual patient. Care should be taken in the interpretation of single BNP values below the currently accepted thresholds for heart failure.

Disease Progression↗
PubMed2005

Selection bias of elderly patients with chronic angina referred for catheterization.

BACKGROUND: Registry patients are generally older and more sick than patients enrolled in trials questioning the generalizability of trial results. We assessed whether such a selection bias also exists in elderly patients with chronic angina referred for catheterization. METHODS AND RESULTS: All 119 patients age>or=75 years with Trial of Invasive versus Medical Therapy in the Elderly (TIME) inclusion but no major exclusion criteria referred for catheterization during the TIME trial inclusion period in four TIME centers were registered and followed-up for one year. Registry patients differed from the 188 trial patients in the same hospitals in that they were younger, somewhat more frequently male, with less antianginal drugs and studied more often after acute chest pain at rest but with more comorbidities than study patients. Left ventricular ejection fraction and vessel disease were similar. One year mortality was 11.4% in registry and 9.6% in invasive TIME patients but differences disappeared after adjustment for baseline differences. Symptomatic status after one year was similar too. CONCLUSIONS: In elderly patients with chronic angina, a bias in the selection for invasive management exists which seems different from that reported in younger patient settings. After adjustment for these selection factors, however, one-year outcome was remarkably similar in registry and trial patients.

Aged↗
PubMed2005

[Physical exercise in old age].

For the prevention of diseases and especially functional deficits in old age, physical activity is a simple, practicable and successful method. With increasing age and frailty or in rehabilitation training, these activities have to be more and more individualized and medically supervised. The paper defines from today's viewpoint suitable activities and the amount of training necessary. Finally, the need for research about physical training in geriatric medicine is pointed out.

Aged↗
PubMed2005

Predictors of long-term mortality and cardiac events in patients with known or suspected coronary artery disease who survive major non-cardiac surgery.

The aim of this prospective study was to assess predictors of long-term outcome in patients with documented or suspected coronary artery disease who survive major non-cardiac surgery. The impact of patients' comorbidities, pre-operative heart rate variability and postoperative increase in cardiac troponin I on all-cause mortality and major cardiac events within 2 years was explored using multivariable logistic regression. Six of 173 patients died within the first month after surgery and were excluded from the study. Thirty-four of 167 patients (20%) died 1-24 months after surgery. Independent predictors of all-cause mortality were history of congestive heart failure (odds ratio 6.4 [95%, confidence interval 1.7-24]), pre-operatively depressed heart rate variability (odds ratio 6.4 [95%, confidence interval 1.9-21]), and age > 70 years (odds ratio 4.5 [95%, confidence interval 1.2-16]). In contrast, postoperative elevation of cardiac troponin I did not independently predict all-cause mortality or major cardiac events.

Aged↗
PubMed2005

The use of B-type natriuretic peptide in the management of elderly patients with acute dyspnoea.

OBJECTIVES: The aim of this study was to define the impact of B-type natriuretic peptide (BNP) levels on the management of elderly patients presenting with acute dyspnoea. DESIGN: We performed a prospective randomized controlled study in 269 elderly patients at least 70 years of age included in the B-type natriuretic peptide for Acute Shortness of breath Evaluation (BASEL) study. Patients were randomly assigned to a diagnostic strategy with (n = 136, BNP group) or without (n = 133, control group) the use of BNP levels provided by a rapid bedside assay. The time to discharge and the total cost of treatment were the primary end-points. RESULTS: Amongst elderly patients, baseline characteristics were well matched between both groups. The use of BNP levels significantly reduced the time to discharge (median 9.0 in the BNP group versus 11.0 days in the control group; P = 0.029). Total treatment cost was $5381 (95% CI, 4482-6280) in the BNP group when compared with $7411 (95% CI, 6180-8642; P = 0.009) in the control group. In addition, a significant reduction in 30-day mortality was observed (9% in the BNP group versus 17% in the control group; P = 0.039). CONCLUSIONS: Used in conjunction with other clinical information, rapid measurement of BNP in the emergency department improved the management of elderly patients presenting with acute dyspnoea and thereby reduced the time to discharge and the total treatment cost. In addition, BNP testing seemed to reduce 30-day mortality.

Acute Disease↗
PubMed2002

[Diagnosis and risk stratification of acute coronary syndrome in general practice and in the hospital].

Acute coronary syndromes usually present as acute chest pain but a manifestation with atypical symptoms or entirely without symptoms makes rapid diagnosis of this potentially lethal syndrome difficult and may lead to delay of the appropriate therapy. The role of the practitioner in this situation is complex since early exclusion of an acute coronary syndrome may be very difficult with the means available in a private practice; on the other hand the early hours which are critical for early therapy may be lost in a private practice. In the early phase of an acute coronary syndrome, diagnoses and risk stratification are based primarily on history, clinical presentation, ECG and biological markers. In the hospital, the time course of these parameters, functional tests for diagnosis and risk stratification as well as determination of left ventricular function and coronary angiography have additional relevance. Recent developments are the availability of highly sensitive and specific biological markers (Troponins), the new classification in acute coronary syndrome with and without ST-elevation and the identification of inflammatory processes in the coronary artery, which have added importantly to our understanding of the acute coronary syndrome. The availability of very early therapy and the possibilities of telemedicine have the potential to influence the pre-hospital diagnostic strategy and management of acute coronary syndromes.

Angina, Unstable↗
PubMed2002

[Which patients with acute coronary syndrome without ST segment elevation should be handled invasively/interventionally when?].

Until recently the therapeutic approach in patients with acute coronary syndrome without ST-segment elevation focused on medical stabilization. Usually cardiac catheterization and revascularisation were performed later only if the stabilized patient had provoked ischemia. Since angioplasty became safer with the introduction of coronary stents, and since new potent antithrombotic agents (i.e. tienopyridines or glycoprotein-receptorIIb/IIIa-antagonists) have been developed, early angioplasty has become much more effective. Moreover major progress has been made in risk-stratification, which allow an individual therapeutic strategy for each patient according to his risk-status. We discuss the most important randomised clinical trials comparing a conservative versus an invasive strategy and introduce a new algorithm for risk-stratification und therapy in acute coronary syndromes without ST-elevation.

Angina, Unstable↗
PubMed2002

Safety and efficacy of abciximab combined with dalteparin in treatment of acute coronary syndromes.

AIMS: The safety and efficacy of abciximab in addition to low-molecular-weight-heparin as the primary medical treatment of acute coronary syndromes has not previously been investigated. METHODS AND RESULTS: The GUSTO IV-ACS trial included 7800 patients with chest pain and either ST-segment depression or a positive troponin test. They were randomized to abciximab for 24 h, 48 h or placebo. In the dalteparin substudy, 974 patients received 5 days of s.c. dalteparin, instead of a 48 h infusion of unfractionated heparin (UFH). Major and minor bleedings were more frequent for abciximab (24 and 48 h combined) than placebo both in the dalteparin (abciximab 5.0% vs placebo 1.8% P<0.05) and in the UFH cohort (3.8% vs 1.8% P<0.001). However, stroke rates were low, < or = 0.6%. At 30 days there were no significant differences in the rate of death or MI, either in the dalteparin (abciximab 9.6% vs placebo 11.3%: O.R. 0.85; 95% C.I. 0.58-1.25) or in the UFH cohort (8.5% vs 7.6%: O.R.; 1.12: 0.95-1.34). CONCLUSION: Treatment with abciximab, aspirin and s.c. dalteparin is associated with a low risk of major side effects and is as safe as the combination of abciximab and UFH. Without early coronary intervention there is no indication for abciximab treatment.

Abciximab↗
PubMed2001

Evidence for age-based rationing in a Swiss university hospital.

AIM: To test the hypothesis that rationing of medical management mainly based on age exists in our health care system today. METHODS: We studied 303 consecutive patients hospitalised for acute coronary syndrome (ACS) and 163 consecutive patients hospitalised with congestive heart failure (CHF). They were divided into two age groups; patients aged less than 75 years and those equal to or older than 75 years. RESULTS: Our main findings were a significant underuse of stress tests (p < 0.001) and coronary angiography (p < 0.0001) in elderly patients with ACS and a significant underuse of echocardiography (p < 0.0001) in patients with CHF of the same age group. In patients with ACS, there was also a trend towards underuse of statins in elderly patients with hypercholesterolaemia. In addition, we noted that the use of beta-blockers in ACS and of ACE inhibitors in CHF was better than in previous published studies but that many patients were still not treated according to evidence based medicine. CONCLUSION: The lower rates of diagnostic tests performed and the lower statin use observed in elderly patients suggest "hidden" rationing of health care in elderly patients.

Age Factors↗
PubMed2001

[Are we treating coronary heart disease and heart failure appropriately in the clinic and ambulatory care? Secondary prevention and drug therapy 1998].

We examined retrospectively 186 patients with acute coronary syndrome (ACS) and 163 patients with cardiac insufficiency (CHF) regarding secondary prevention in hospital or externally. Of the Inhospital-patients with ACS 99% had antithrombotic medicaments (AT), 73% betablockers and 73% a statin. CHF-patients had ACEH in 69%. Externally 120 patients with known coronary heart disease (CHD) received in 91% AT, 66% betablocker, 30% statins and 111 CHF-patients in 49% ACEH. Compared to other studies medical therapy ameliorated in CHD and CHF either stationary and ambulatory. The reasons for low prescription of statins may be due to short time since positive results occurred and to the expensive costs in the setting of pressure because of high cost in health system.

Adrenergic beta-Antagonists↗
PubMed2001

Benefit of glycoprotein IIb/IIIa inhibition in patients with acute coronary syndromes and troponin t-positive status: the paragon-B troponin T substudy.

BACKGROUND: Troponin T (TnT) is valuable for short- and long-term risk stratification of patients with acute coronary syndromes (ACS). It also may predict which ACS patients will benefit from glycoprotein (GP) IIb/IIIa blockade. METHODS AND RESULTS: We prospectively studied 1160 patients with non-ST-segment elevation ACS randomized in PARAGON-B to receive lamifiban, an intravenous GP IIb/IIIa antagonist, or placebo. TnT levels were obtained before study treatment began and 24 to 72 hours later; assays were performed by a blinded core laboratory. At baseline, 40.2% of patients were TnT-positive (>/=0.1 ng/mL); these patients were older and more often male or smokers. Patients positive at baseline had a significantly higher rate of the primary end point (composite of death, myocardial [re]infarction, or severe recurrent ischemia at 30 days; odds ratio, 1.5; 95% CI, 1.1 to 2.1) than those who were TnT-negative. Lamifiban was associated with significant reduction in the primary end point (from 19.4% to 11.0%, P=0.01) among TnT-positive patients but not among TnT-negative patients (11.2% for placebo versus 10.8% for lamifiban, P=0.86; P=0.08 for test of interaction between TnT status and treatment assignment). This pattern held for the end points of death alone and death or myocardial (re)infarction at 30 days. Peak TnT level at 48 hours did not differ with lamifiban treatment. CONCLUSIONS: TnT predicts poor short-term outcomes in non-ST-segment elevation ACS. Treatment benefit with lamifiban is limited almost exclusively to TnT-positive patients, reducing 30-day adverse outcomes to a rate nearly identical to that of negative patients.

Acetates↗
PubMed2001

Comparison of 99mTc-sestamibi lung/heart ratio, transient ischaemic dilation and perfusion defect size for the identification of severe and extensive coronary artery disease.

The ability to identify patients with severe coronary artery disease (CAD) by analysis of perfusion defects is limited. The lung/heart ratio (LHR) and transient ischaemic dilatation (TID) have been used for this purpose in thallium-201 scintigraphy. The value of these parameters in technetium-99m sestamibi single-photon emission tomography (SPET) imaging is controversial. In this study, therefore, we determined TID and LHR in a single-day rest/stress 99mTc-sestamibi SPET perfusion protocol and compared these measurements with perfusion defect size (PDS) and angiographic severity of CAD. Severe CAD was defined as >75% left main coronary stenosis and/or >90% proximal left anterior descending artery stenosis and/or >90% proximal stenosis in the left circumflex and right coronary arteries. LHR was determined from a stress anterior planar image recorded < or =6 min after exercise. TID ratio was derived from automatically calculated left ventricular rest/stress volumes, and PDS was measured based on semi-automated computer software (CEqual). Diagnostic accuracy and predictive values were compared between 22 patients with severe and 98 patients without severe CAD. LHRs showed a higher sensitivity (73%) for the assessment of severe CAD as compared to PDS and TID ratio (41% and 23% respectively, P<0.01), whereas specificity was highest for TID ratio [95%, P<0.01 when compared to PDS (84%) and LHR (82%)]. It is concluded that increased LHR in 99mTc-sestamibi myocardial perfusion imaging seems to yield good diagnostic accuracy in the detection of patients with severe CAD and may be derived from a single-day rest/stress study.

Coronary Circulation↗